HospitalInspections.org

Based on policy and procedure review, medical record review, security log review, incident report review, code blue sheet review, staff and physician interviews, the hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to ensure a safe environment for inpatients and behavioral health patients; failed to maintain an organized and effective quality assessment and improvement program; and failed to have an organized nursing service to meet patient care and safety needs.

The findings included:

1. The facility's staff failed to ensure a safe environment by failing to monitor, identify, and report a patients change in condition; failing to escalate notification of a disconnected telemetry lead for resolution; and failing to ensure a safe environment for behavioral health patients that was free of contraband items available for patient use.

~cross refer to 482.13(c)(2) Patients' Rights Standard: Care in Safe Setting Tag A0144

2. The hospital's leadership failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients by failing to have systems in place to ensure adverse events were tracked and analyzed and services were performed in a safe manner.

~cross refer to 482.21 QAPI Standard: Tag A0286

3. The hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to patients.

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

Based on policy and procedure review, medical record review, security log review, code blue sheet review, incident report review, staff and physician interviews, the facility's staff failed to promote and protect patients' rights by failing to ensure a safe environment by failing to monitor and identify a post-fall patients' change in condition during the use of chemical restraints; failing to escalate notification of a disconnected telemetry lead for resolution; and failing to prevent contraband items from being available to a behavioral health patient.

The findings include:

1. The facility's staff failed to ensure a safe environment by failing to monitor, identify, and report a patients change in condition in 1 of 1 post-fall patients reviewed (Patient #3).

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting Tag A0144

2. The facility's nursing staff failed to ensure a safe environment by failing to escalate notification of a disconnected telemetry lead for resolution in 1 of 2 telemetry monitored patients (Patient #13).

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting Tag A0144

3. The facility staff failed to ensure a safe environment by failing to search a behavioral health patient to prevent contraband items from being available for patient use in 1 of 1 behavioral health patient record reviewed (Patient #22).

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting Tag A0144

Based on review of facility policy, medical record review, code blue sheet review, incident report review, interviews with physicians and staff, the facility staff failed to ensure a safe environment for patient care by failing to monitor, identify, and report a patients change in condition in 1 of 1 post-fall patients reviewed (Patient #3); to escalate notification of a disconnected telemetry lead for resolution in 1 of 2 telemetry monitored patients (Patient #13); monitor a behavioral health patient at high risk for suicide in 1 of 1 behavioral health patient record reviewed (Patient #22).

The findings included:

1. Review of facility policy "Falls Prevention Policy, 14.5" last revised 07/2020 revealed "... Definitions: Swarm: A 10-15 minute safety huddle that takes place at the nurses station as closely as possible to the time of the fall...Post Fall Management: Assess for any injury,(abrasion, contusion, laceration, fracture, head injury); Obtain vital signs and record; Assess for change in range of motion; Notify MD(Medical Doctor) and enter a note in the EMR (electronic medical record) under "Critical Lab/Provider/MRT (Medical Response Team) notification stating the MD was notified of the fall; Notify Charge Nurse, Director, Administrative Supervisor, and family as appropriate. Conduct a "SWARM"at the nursing station as soon as possible after the fall, once the patient has been assessed and safety has been insured...Fall is reported to Quality/Risk Management by entering occurrence in the Safety Incident/ Occurrence Reporting System (RL Solutions) for each fall and near fall...The Director is responsible for ensuring a Learning from Defects or RCA(root cause analysis) is conducted on all falls with injury..."

Review of facility policy "Restraint and Seclusion Policy" last revised 11/2021 revealed "... Monitoring & Documentation: A. When a chemical restraint is used there is an increased risk for patient monitoring and assessment to ensure safety and no harm was caused to the patient. Documentation should include this assessment as well as the patient's response and any adjustments made. Assessments should be documented every 15 minutes times four. Vital signs are monitored every 30 minutes times two, then every 1 hour times three...C. Only hospital personnel who have received training and demonstrated competency will document information related to the use of chemical restraints..."

Closed medical record review of Patient #3 revealed a 70 year old male admitted to the facility on 01/17/2022 for diagnoses including acute respiratory failure with hypoxia and COVID-19. Review of physician orders on 01/17/2022 at 1426 vital signs to be performed every 4 hours and continuous pulse oximetry. Review of "Provider Progress Note" on 01/22/2022 at 1354 revealed "He was found on the floor by nursing staff on 01/21 with laceration to his occipital (back of head). Stat CT (cat scan) did not show any acute intracranial bleed. This morning he has been more confused, agitated, disoriented. Could not provide a history..." Review of the medical record revealed no fall documentation by nursing staff. Review of physician orders on 01/21/2022 at 1542 revealed neuro (Neurologic check- evaluated brain and nervous system functioning) checks to be performed every 4 hours. Review of neuro checks revealed they were completed on 01/21/2022 at 1540, 1940, 2340 and on 01/22/2022 (8 hours 50 minutes later) at 0830, 1210 and last performed at 1610. Review of physician orders on 01/22/2022 at 1723 revealed an order for "Restraints Violent Chemical" and acknowledged by RN #6 (Registered Nurse) at 1737. Review of Patient #3's medication administration record revealed Geodon (violent chemical restraint ordered-antipsychotic medication) 20 mg given IM (intramuscularly) in left upper arm at 1733. Review of Nursing Note at 1744 revealed "Pt (patient) increasingly confused from last night, RN had this pt Tuesday and Wednesday pt was alert/oriented. Pt condition has drastically changed. Per report from night shift pt fell 01/21/2022 and hit his head. Pt had to get CT, Pt was very restless trying to get out of bed. RN called MD about change of condition. MD put in orders for Haldol, Ativan and Morphine pt still continues to get out of bed. MD put in new orders for Geodon IM." Record review revealed vital signs were obtained on 01/22/2022 at 0830 BP (blood pressure)168/79, Pulse 76 and pulse oximetry 90% on 4/L min(liters per minute); at 1610 (7 hours 40 minutes later) BP 168/79 (no documented pulse) , pulse oximetry 90 % on 4L/min; at 1718 BP 150/122, Pulse 102 and pulse oximetry 93% and at 2000 BP 202/80, Pulse 115 and pulse oximetry 92%. Record review revealed no further documentation of monitoring vital signs or neuro assessments. Record review revealed Patient #3 was found unresponsive on 01/23/2022 at 0300 (7 hours after last documented vital signs, and 10 hours 50 minutes after last documented neuro check) and pronounced deceased at 0334 (10 hours and 1 minute following the chemical restraint).

Interview on 05/18/2022 at 1135 with RN #6 revealed she recalled and cared for Patient #3 on the day shift (7am-7pm) on 01/22/2022. Interview revealed she forgot to document monitoring and assessments of Patient #3. Interview revealed she was aware of the 15 minute assessment requirement with chemical restraints after administration. Interview revealed she did not report the elevated blood pressure to the physician because sometimes administered medications can "bring down" the blood pressure.

Interview on 05/18/2022 at 1410 with MD #26 revealed he recalled Patient #3. Interview revealed he was notified of the patient's fall and ordered the CT Scan and Neuro checks. Interview revealed he also was notified of him getting out of bed and ordered the chemical restraints. Interview revealed no one made him aware of the the vital sign changes. Interview revealed the nurses do typically notify him if there is a change in condition.

Interview on 05/18/2022 with RN #27 revealed he was the preceptor and charge nurse for RN #28. Interview revealed RN #28 was in her last 2 days of orientation and was the primary nurse for Patient #3 on the night of 01/22/2022. Interview revealed he recalled the night of 01/22/22. Interview revealed he was walking by Patient #3's room, RN #28 was in the room setting up a respiratory treatment when he recalled Patient #3 "looking gray." Interview revealed he approached the patient and he was unresponsive, left the room to call for the medical response team. Interview revealed the medical response team arrived and CPR was started. Interview revealed he did not call for help from the room because the nurses station was not far away from Patient #3's room.

RN #28 (the night shift nurse on 0/22/2022) was not available for interview and has separated from the facility.


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2. Review of the policy titled "Policy and Procedure for Central (Remote) Monitoring in the Medical/Surgical Areas" with revision date of 10/2020, revealed "PURPOSE: To provide cardiac monitoring services to adult patients under the care of the primary care provider in the Medical/Surgical and Telemetry areas of the hospital outside of the Intensive Care Unit to define the roles and responsibilities pertaining to remote cardiac monitoring....12. The MT (monitor technician) will notify the charge nurse or primary care nurse of any needed battery or electrode changes utilizing the regular phone system. MT calls for battery changes or lead placement should be responded to immediately."

Review of History and Physical dated 03/22/2022 at 1249 revealed Patient #13 was a 60-year-old male admitted on 03/22/2022 for shortness of breath for the last 3 months and increased lower body swelling. Past medical history for Patient #13 revealed he had insulin-dependent diabetes, primary hypertension, COPD (Chronic Obstructive Pulmonary Disease), gout, daily alcohol use disorder, and CAD (Coronary Artery Disease) with 1 stent. Review of the physician orders dated 03/22/2022 at 1249 for Patient #13 revealed "Bed Type: Telemetry--Includes CCM" (Continuous cardiac monitoring). Review of RN #10's hourly rounding note dated 03/24/2022 at 0302 revealed "Alert, Oriented. Are you having pain? No." Review of MT (monitor technician) #11 note dated 03/24/2022 at 0309 (7 minutes after RN #10's hourly rounding) revealed "pt (patient) off monitor/leads off. Name of Nurse Notified: (RN #10)." Review revealed Patient #13 was found unresponsive by a clinical technician (phlebotomist) without telemetry leads in place at 0320, 11 minutes after RN #10 received phone call of leads being off. Review of discharge summary dated 03/24/2022 at 0741 written by MD #8 revealed Patient #13 was "noted to not have monitor in place. Upon evaluation by nursing staff patient was found unresponsive and pulseless. CODE BLUE (emergency team arrived) was initiated to include CPR (Cardiopulmonary resuscitation--act of performing chest compressions and ventilation) the code without successful return of circulation. About 32 minutes and after unsuccessful repeat defibrillation, patient's time of death was called...." Review revealed Patient #13's time of death was 0351.

Review of the Code Blue sheet dated 03/24/2022 revealed Code Blue was initiated at 0321, 13 minutes after MT #11 notified RN #10 (primary RN) that Patient #13's telemetry leads were off.

Interview on 05/19/2022 at 0850 with RN #10, the primary nurse for Patient #13 and charge nurse for the shift, remembered Patient #13. Interview revealed RN #10 was sitting at the desk documenting when MT #11 phoned RN #10 of Patient #13's leads being disconnected. Interview revealed RN #10 remained at the desk and did not immediately enter the room. Interview revealed Clinical technician #13 entered the room a few minutes later to collect the routine morning labs. Interview revealed CNA (Certified Nursing assistant) #17 was asked to come into the room by Clinical Technician #13. Interview revealed CNA #17 screamed out to RN #10 who was at the desk. RN #10 then entered the room. Interview revealed CPR was started and a code blue was activated using the code blue button in Patient #13's room.

Interview on 05/18/2022 at 1935 with Clinical technician #13 revealed she found the Patient #13 unresponsive when entering to collect blood sample. Interview revealed Patient #13 was not connected to the telemetry box. Interview revealed Clinical technician #13 called to CNA #17. Interview revealed CNA #17 called to the desk for RN #10. Interview revealed RN #10 entered the room and began CPR after pressing the code blue button in the room.

Interview on 05/19/2022 at 0837 with MT #11 revealed the leads were off Patient #13 and she notified RN #10 via phone at 0309. Interview revealed the nurse should have replaced the leads or troubleshoot immediately. Interview revealed there was no documentation that the leads were replaced on Patient #13. Interview revealed if the primary nurse did not respond immediately, the charge nurse was called to troubleshoot the telemetry box. Interview revealed the house supervisor should also be notified if there was no response. Interview revealed MT #11 did not escalate notification of Patient #13's leads being off beyond RN #10.

Interview on 05/19/2022 at 0915 with MT #15, employed 5 years, revealed if the primary nurse did not resolve the telemetry issue immediately, another phone call was made to the charge nurse and the house supervisor within 5 minutes. Interview revealed MT #15 had previously entered patients` rooms to resolve some telemetry box concerns.

Interview on 05/19/2022 at 0920 with MT #16, employed 1 year, revealed if the primary nurse did not resolve the telemetry issue immediately, MT #16 waited 30 minutes to 1 hour before another phone call was made to the nurse.

Interview on 05/19/2022 at 1420 with Supervisor #14 revealed if the primary nurse was busy and unable to resolve the telemetry box issue immediately, another staff member should have been called. Interview revealed immediate response was not seen in Patient #13. Interview revealed policy was not followed.


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3. Review of the facility's policy titled "Guidelines for the Behavioral Health Patient in the Emergency Department and the Emergency Department Crisis Stabilization Unit (CSU)" effective December 2021 revealed "...The Emergency Department will take reasonable measures to assess and ensure patients presenting with suicidal...ideation...has a positive suicide screening in triage, poses an imminent harm to self...are subject to the following safety measures...PROCEDURE/RESPONSIBILITIES: A. Security should be called to assist with collecting personal affects and to ensure patient is free of contraband...2. For non-ambulatory (EMS arrivals) patients this should occur in the assigned treatment room or other designated area...B. Patient's person and belongings should be wanded for contraband, weapons, or items not allowed in the department and placed in paper scrubs as soon as possible... C. The patient...are not allowed to have the following items in their care environment:...Lighters...cell phones...Controlled medications..."

Review on 05/17/2022 of a closed medical record revealed Patient #22 was a 41-year-old male that arrived to the hospital on 04/18/2022 at 1356 via EMS (emergency medical service) with the stated complaint "Pt presents by EMS stating he wants to take a bunch of pills to end his life..." Medical record review revealed Patient #22 had a history of manic depression and multiple suicide attempts. Medical record review revealed at 1425 Registered Nurse (RN) #17 triaged Patient #22 and documented he was a "High Risk" for suicide based on the "Columbia Suicide Severity Rating Scale" (suicide ideation rating scale). Review of an "Emergency Department Note" signed by RN #17 on 04/18/2022 at 1435 revealed "...charge nurse aware of pt, will be placed in room when available..."

Review of an "Emergency Department Note" signed by Certified Nursing Assistant (CNA) #19 on 04/18/2022 at 1617 (2 hours, 21 minutes after Patient #22's arrival to the ED) revealed "Received a call from...with Mobile Crisis letting staff know the patient called him and said he got his pills back and was going to take them all. Staff alerted the RN in triage and Charge Nurse." Review of an "Emergency Department Note" signed by the charge nurse (RN #18) on 04/18/2022 at 1625 (2 hours, 29 minutes after arrival to ED) revealed "Patient locked himself in lobby bathroom with his home meds which were given to him by EMS which was unknown to this RN. Security notified immediately and to bathroom to unlock door..." Medical record review revealed on 04/18/2022 at 1715, Patient #22 was placed in room #13 in the emergency department. Medical record review revealed on 04/18/2022 at 1858 (5 hours, 2 minutes after Patient #22's arrival to the ED), RN #18 and an emergency department paramedic (EMT #20) inventoried Patient #22's personal belongings and signed the "Disposition of Valuables" form.

Review of an "Emergency Department Note" signed by RN #18 on 04/19/2022 at 1315 revealed "Odor of cigarette smoke noted coming from ED bathroom...Staff responded and found door to be locked. Patient refusing to come to door and refusing to unlock same. Security called to unlock door. Upon entering the bathroom, patient found sitting on the toilet and strong odor of smoke noted. Wheelchair removed from bathroom and searched. Pill bottle found with several random pills, cigarettes, lighter, and cellphone all under wheelchair seat..." Medical record review revealed on 04/19/2022 at 2202, Patient #22 was discharged to jail/detention facility.

Review of the "Behavioral Health Wanding/Secured Items Log" dated 04/15/2022 through 04/21/2022 failed to reveal evidence Patient #22 was wanded by the hospital's security officers.

Interview on 05/18/2022 at 1322 with RN #17 revealed she triaged Patient #22 when he presented to the ED. Interview revealed Patient #22 arrived to the ED with his personal wheelchair. Interview revealed RN #17 notified the charge nurse (RN #18) that Patient #22 was a high risk for suicide based on the screening tool. Interview revealed RN #17 did not call security to wand or search Patient #22 for contraband prior to sending him back to the waiting room.

Interview on 05/18/2022 at 1137 with RN #18 revealed she was the charge nurse on 04/18/2022 in the emergency department. Interview revealed there were no beds available when Patient #22 came into the ED. Interview revealed Patient #22 was not searched prior to being sent back to the lobby of the ED to wait for a bed. Interview revealed Patient #22 was later placed in an ED room during the evening on 04/18/2022. Interview revealed RN #18 and EMT #20 searched Patient #22 and recorded the items found on the inventory sheet. Interview revealed RN #18 searched the pockets of Patient #22's wheelchair, but "missed" the contraband items.

Interview on 05/18/2022 at 1325 with the interim Safety and Security Supervisor revealed patients are only wanded when the ED staff call security to request they wand a patient. Interview revealed the security officers have no way to identify which patients need to be wanded until notified by the staff. Interview revealed the ED staff did not contact security to request assistance in wanding Patient #22 when he presented to the ED on 04/18/2022.

Interview on 05/18/2022 at 1500 with the interim Emergency Department Director revealed patients that were identified as high risk for suicide in triage should be dressed in blue paper scrubs and searched and wanded while in triage. Interview revealed the triage nurse and charge nurse did not follow the hospital's policy.

An interview was requested with EMT #20 who was unavailable for interview.

Based on facility policy and procedure, medical record review, staff interviews, and employee training record review, the facility's staff failed to monitor a patient during the use of chemical restraints in 1 of 2 patients sampled. (Patient #3)

The findings include:

Review of facility policy "Restraint and Seclusion Policy" last revised 11/2021 revealed "... Monitoring & Documentation: A. When a chemical restraint is used there is an increased risk for patient monitoring and assessment to ensure safety and no harm was caused to the patient. Documentation should include this assessment as well as the patient's response and any adjustments made. Assessments should be documented every 15 minutes times four. Vital signs are monitored every 30 minutes times two, then every 1 hour times three...C. Only hospital personnel who have received training and demonstrated competency will document information related to the use of chemical restraints..."

Closed medical record review of Patient #3 revealed a 70 year old male admitted to the facility on 01/17/2022 for diagnoses including acute respiratory failure with hypoxia and COVID-19. Review of physician orders on 01/17/2022 at 1426 vital signs to be performed every 4 hours and continuous pulse oximetry. Review of "Provider Progress Note" on 01/22/2022 at 1354 revealed "He was found on the floor by nursing staff on 01/21 with laceration to his occipital (back of head). Stat CT (cat scan) did not show any acute intracranial bleed. This morning he has been more confused, agitated, disoriented. Could not provide a history..." Review of the medical record revealed no fall documentation by nursing staff. Review of physician orders on 01/21/2022 at 1542 revealed neuro (Neurologic check- evaluated brain and nervous system functioning) checks to be performed every 4 hours. Review of neuro checks revealed they were completed on 01/21/2022 at 1540, 1940, 2340 and on 01/22/2022 (8 hours 50 minutes later) at 0830, 1210 and last performed at 1610. Review of physician orders on 01/22/2022 at 1723 revealed an order for "Restraints Violent Chemical" and acknowledged by RN #6 (Registered Nurse) at 1737. Review of Patient #3's medication administration record revealed Geodon (violent chemical restraint ordered-antipsychotic medication) 20 mg given IM (intramuscularly) in left upper arm at 1733. Review of Nursing Note at 1744 revealed "Pt (patient) increasingly confused from last night, RN had this pt Tuesday and Wednesday pt was alert/oriented. Pt condition has drastically changed. Per report from night shift pt fell 01/21/2022 and hit his head. Pt had to get CT, Pt was very restless trying to get out of bed. RN called MD about change of condition. MD put in orders for Haldol, Ativan and Morphine pt still continues to get out of bed. MD put in new orders for Geodon IM." Record review revealed vital signs were obtained on 01/22/2022 at 0830 BP (blood pressure)168/79, Pulse 76 and pulse oximetry 90% on 4/L min(liters per minute); at 1610 (7 hours 40 minutes later) BP 168/79 (no documented pulse) , pulse oximetry 90 % on 4L/min; at 1718 BP 150/122, Pulse 102 and pulse oximetry 93% and at 2000 BP 202/80, Pulse 115 and pulse oximetry 92%. Record review revealed no further documentation of monitoring vital signs or neuro assessments. Record review revealed Patient #3 was found unresponsive on 01/23/2022 at 0300 (7 hours after last documented vital signs, and 10 hours 50 minutes after last documented neuro check) and pronounced deceased at 0334 (10 hours and 1 minute following the chemical restraint).

Interview on 05/18/2022 at 1135 with RN #6 revealed she recalled and cared for Patient #3 on the day shift (7am-7pm) on 01/22/2022. Interview revealed she forgot to document monitoring and assessments of Patient #3. Interview revealed she was aware of the 15 minute assessment requirement with chemical restraints after administration. Interview revealed she did not report the elevated blood pressure to the physician because sometimes administered medications can "bring down" the blood pressure.

Interview on 05/18/2022 at 1410 with MD #26 revealed he recalled Patient #3. Interview revealed he was notified of the patient's fall and ordered the CT Scan and Neuro checks. Interview revealed he also was notified of him getting out of bed and ordered the chemical restraints.

Review of RN #6 training records on 05/19/2022 revealed she completed restraint and seclusion training in 09/2021.

Based on policy review, closed medical record review, and staff interview the hospital failed to report the death of 1 of 1 sampled patients that died within 24 hours of restraint to CMS (Centers for Medicare and Medicaid) by the close of business the next business day following knowledge of the patient's death (Patient #3).

The findings include:

Review of facility policy "Restraint and Seclusion Policy" last revised 11/2021 revealed "Restraint-related deaths and Reporting Requirements: As required in 482.13(g), Centers for Medicare and Medicaid Services (CMS) is notified of any death associated with the use of seclusion or restraint no later than the close of business on the next business day following the knowledge if the patient's death...The following scenarios require reporting:... Each death that occurs while a patient is in a restraint or seclusion; Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion..."

Closed medical record review of Patient #3 revealed a 70 year old male admitted to the facility on 01/17/2022 for diagnoses including acute respiratory failure with hypoxia and COVID-19. Review of Patient #3's physician orders on 01/22/2022 at 1723 revealed "Restraints Violent Chemical" and acknowledged by RN #6 at 1737. Review of Patient #3's medication administration record revealed Geodon (antipsychotic medication) 20 mg given IM (intramuscularly) in left upper arm at 1733. Record review revealed Patient #3 was found unresponsive on 01/23/2022 at 0300 and pronounced deceased at 0334 (10 hours 1 minute after administration of a chemical restraint).

Interview on 05/19/2022 at 1350 with the Director of Quality and Patient Safety Officer revealed every death where a patient was restrained does not have to be reported. Interview revealed "the reg (regulation) states if reasonable to assume" death was related to the restraint then would need to report. Interview revealed the staff do not always recognize chemical restraints when ordered. Interview confirmed Patient #3's chemical restraint was not captured as such, therefore it was not reported as a death in restraints.

Based on policy and procedure review, medical record review, incident report log review, death log review, staff and physician interviews, the facility's leadership failed to implement and maintain an effective quality assessment and performance improvement program ensuring adverse events were evaluated and services were provided in a safe manner.

The findings included:

1. The hospital staff failed to identify, report, analyze, and track adverse patient care events that resulted in patient deaths in 2 of 2 sampled death records (Patient #3 and #13).

~cross refer to 482.21 (a), (c)(2), (e)(3) -QAPI Standard: Patient Safety, Tag A0286

Based on review of the patient safety and clinical quality performance improvement program plan, hospital death reporting in restraints log review, hospital incident log review, medical records review, and staff interviews, the hospital staff failed to report, analyze, and track patient care incidents in quality assurance and performance improvement for 2 of 2 adverse events reviewed (Patient #3 and Patient #13).

The findings include:

1. Review of the Patient Safety and Clinical Quality Performance Improvement Program Plan last revised 04/2021 revealed "The governing body, senior leadership, physician, and staff at (Facility Name) are committed to deliver safe, effective, quality patient care and services in an environment of minimal risk to the patient ... collects data to assess its performance in providing safe, quality care, treatment, and services to patients. Data collection includes, but may not be limited to the following processes or outcomes: ... Adverse Events/Near Misses; Analyses of clinical processes that include hazardous conditions, process malfunctions, and how the errors occurred; ...Use of restraint/seclusion; ... The results of resuscitation; ...All data will be aggregated and analyzed and submitted to the PSCQ (Patient Safety and Clinical Quality) for their review, consideration and, if indicated, prioritization and corrective actions identified ... Information from the analysis of data collection will be used to identify changes that will improve performance or reduce the risk of sentinel events ...Analysis of data will use a structured process for identifying underlying causes of problems, such as root cause analysis, or Learning from Defects ..."

Review on 05/19/2022 at 1350 of the Death Reporting in Restraints log dated January 01, 2022 to May 19, 2022 revealed there were no names listed on the log. The log confirmed Patient #3's death in restraints was not reported or captured on the log.

Review of the hospital incident log for January 01,2022 through May 19, 2022 revealed there was no incident report for Patient #3 nor Patient #13. Review confirmed Patient #3 and Patient #13's adverse events were not reported or captured on the log.

Interview on 05/18/2022 at 1116 and 05/19/2022 at 1350 with the Director of Quality and Patient Safety Officer revealed Patient #3 and Patient #13 were not captured in the quality assurance and performance improvement (QAPI) data. Interview revealed mortality data was reviewed "only if it falls in the CMS (Centers for Medicare and Medicaid Services) required areas which are stroke, MI (myocardial infarction [heart attack]), COPD (chronic obstructive pulmonary disease), and CHF (congestive heart failure)." Interview revealed if a RL (incident report) was not entered for the incident/near miss/injuries it would not have been captured in the QAPI data.




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2. Review of facility policy "Restraint and Seclusion Policy" last revised 11/2021 revealed "Restraint-related deaths and Reporting Requirements: As required in 482.13(g), Centers for Medicare and Medicaid Services (CMS) is notified of any death associated with the use of seclusion or restraint no later than the close of business on the next business day following the knowledge if the patient's death...The following scenarios require reporting:... Each death that occurs while a patient is in a restraint or seclusion; Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion..."

Closed medical record review of Patient #3 revealed a 70 year old male admitted to the facility on 01/17/2022 for diagnoses including acute respiratory failure with hypoxia and COVID-19. Review of Patient #3's physician orders on 01/22/2022 at 1723 revealed "Restraints Violent Chemical" and acknowledged by RN #6 at 1737. Review of Patient #3's medication administration record revealed Geodon (antipsychotic medication) 20 mg given IM (intramuscularly) in left upper arm at 1733. Record review revealed Patient #3 was found unresponsive on 01/23/2022 at 0300 and pronounced deceased at 0334 (10 hours 1 minute after administration of a chemical restraint).

Interview on 05/19/2022 at 1350 with the Director of Quality and Patient Safety Officer revealed every death where a patient was restrained does not have to be reported. Interview revealed "the reg (regulation) states if reasonable to assume" death was related to the restraint then would need to report. Interview revealed the staff do not always recognize chemical restraints when ordered. Interview confirmed Patient #3's chemical restraint was not captured as such, therefore it was not reported as a death in restraints.



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3. Review of History and Physical dated 03/22/2022 at 1249 revealed Patient #13 was a 60-year-old male admitted on 03/22/2022 for shortness of breath for the last 3 months and increased lower body swelling. Past medical history for Patient #13 revealed he had insulin-dependent diabetes, primary hypertension, COPD (Chronic Obstructive Pulmonary Disease), gout, daily alcohol use disorder, and CAD (Coronary Artery Disease) with 1 stent. Review of the physician orders dated 03/22/2022 at 1249 for Patient #13 revealed "Bed Type: Telemetry--Includes CCM" (Continuous cardiac monitoring). Review of RN #10's hourly rounding note dated 03/23/2022 at 0302 revealed "Alert, Oriented. Are you having pain? No." Review of MT (monitor technician) #11 note dated 03/24/2022 (which date) at 0309 (7 minutes after RN #10's hourly rounding) revealed "pt (patient) off monitor/leads off. Name of Nurse Notified: (RN #10)." Review revealed Patient #13 was found unresponsive by a clinical technician (phlebotomist) without telemetry leads in place at 0320, 11 minutes after RN #10 received phone call of leads being off. Review of discharge summary dated 03/24/2022 at 0741 written by MD #8 revealed Patient #13 was "noted to not have monitor in place. Upon evaluation by nursing staff patient was found unresponsive and pulseless. CODE BLUE (emergency team arrived) was initiated to include CPR (Cardiopulmonary resuscitation--act of performing chest compressions and ventilation) the code without successful return of circulation. About 32 minutes and after unsuccessful repeat defibrillation, patient's time of death was called...." Review revealed Patient #13's time of death was 0351.

Review of the Code Blue sheet dated 03/24/2022 revealed Code Blue was initiated at 0321, 13 minutes after MT #11 notified RN #10 (primary RN) that Patient #13's telemetry leads were off.

Interview on 05/19/2022 at 0837 with MT #11 revealed no one has interviewed MT #11 about this incident until now.

Interview on 05/19/2022 at 1420 with Supervisor #14 revealed the nursing management team was not aware of this incident until now. Interview revealed no incident report was completed for this incident of the telemetry leads being off of Patient #13.

Based on policy and procedure review, medical record review, security log review, code blue sheet review, incident report review, staff and physician interviews, the facility's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to post-fall patients, telemetry patients, and behavioral health patients.

The findings include:

1. The facility's nursing staff failed to supervise and evaluate patient care by failing to monitor, identify, and report a patients change in condition in 1 of 1 post-fall patients reviewed (Patient #3).

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

2. The facility's nursing staff failed to supervise and evaluate patient care by failing to respond immediately to replace disconnected leads after notification in 1 of 2 telemetry monitored patients (Patient #13).

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

3. The facility's nursing staff failed to monitor a behavioral health patient at high risk for suicide in 1 of 1 behavioral health patient record reviewed (Patient #22).

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

Based on review of facility policy, medical record review, code blue sheet review, incident report review, interviews with physicians and staff, the facility's nursing staff failed to supervise and evaluate patient care by failing to monitor, identify, and report a patients change in condition in 1 of 1 post-fall patients reviewed (Patient #3); respond immediately to replace disconnected leads after notification in 1 of 2 telemetry monitored patients (Patient #13); monitor a behavioral health patient at high risk for suicide in 1 of 1 behavioral health patient record reviewed (Patient #22).

The findings included:

1. Review of facility policy "Falls Prevention Policy, 14.5" last revised 07/2020 revealed "... Definitions: Swarm: A 10-15 minute safety huddle that takes place at the nurses station as closely as possible to the time of the fall...Post Fall Management: Assess for any injury,(abrasion, contusion, laceration, fracture, head injury); Obtain vital signs and record; Assess for change in range of motion; Notify MD(Medical Doctor) and enter a note in the EMR (electronic medical record) under "Critical Lab/Provider/MRT (Medical Response Team) notification stating the MD was notified of the fall; Notify Charge Nurse, Director, Administrative Supervisor, and family as appropriate. Conduct a "SWARM"at the nursing station as soon as possible after the fall, once the patient has been assessed and safety has been insured...Fall is reported to Quality/Risk Management by entering occurrence in the Safety Incident/ Occurrence Reporting System (RL Solutions) for each fall and near fall...The Director is responsible for ensuring a Learning from Defects or RCA(root cause analysis) is conducted on all falls with injury..."

Review of facility policy "Restraint and Seclusion Policy" last revised 11/2021 revealed "... Monitoring & Documentation: A. When a chemical restraint is used there is an increased risk for patient monitoring and assessment to ensure safety and no harm was caused to the patient. Documentation should include this assessment as well as the patient's response and any adjustments made. Assessments should be documented every 15 minutes times four. Vital signs are monitored every 30 minutes times two, then every 1 hour times three...C. Only hospital personnel who have received training and demonstrated competency will document information related to the use of chemical restraints..."

Closed medical record review of Patient #3 revealed a 70 year old male admitted to the facility on 01/17/2022 for diagnoses including acute respiratory failure with hypoxia and COVID-19. Review of physician orders on 01/17/2022 at 1426 vital signs to be performed every 4 hours and continuous pulse oximetry. Review of "Provider Progress Note" on 01/22/2022 at 1354 revealed "He was found on the floor by nursing staff on 01/21 with laceration to his occipital (back of head). Stat CT (cat scan) did not show any acute intracranial bleed. This morning he has been more confused, agitated, disoriented. Could not provide a history..." Review of the medical record revealed no fall documentation by nursing staff. Review of physician orders on 01/21/2022 at 1542 revealed neuro (neurologic check- evaluateds brain and nervous system functioning) checks to be performed every 4 hours. Review of neuro checks revealed they were completed on 01/21/2022 at 1540, 1940, 2340 and on 01/22/2022 at 0830 (8 hours 50 minutes later), 1210 and last performed at 1610. Review of Patient #3's physician orders on 01/22/2022 at 1723 revealed "Restraints Violent Chemical" and acknowledged by RN #6 at 1737. Review of Patient #3's medication administration record revealed Geodon (antipsychotic medication) 20 mg given IM (intramuscularly) in left upper arm at 1733. Review of Nursing Note at 1744 revealed "Pt (patient) increasingly confused from last night, RN had this pt Tuesday and Wednesday pt was alert/oriented. Pt condition has drastically changed. Per report from night shift pt fell 01/21/2022 and hit his head. Pt had to get CT, Pt was very restless trying to get out of bed. RN called MD about change of condition. MD put in orders for Haldol, Ativan and Morphine pt still continues to get out of bed. MD put in new orders for Geodon IM." Record review revealed vital signs on 01/22/2022 at 0830 were BP (blood pressure) 168/79, Pulse 76 and pulse oximetry 90% on 4/L min(liters per minute); at 1610 (7 hours 40 minutes later) BP 168/79 (no documented pulse) , pulse oximetry 90 % on 4L/min; at 1718 BP 150/122, Pulse 102 and pulse oximetry 93% and at 2000 BP 202/80, Pulse 115 and pulse oximetry 92%. Record review revealed no further documentation of monitoring vital signs or neuro assessments. Record review revealed Patient #3 was found unresponsive (7 hours after last documented vital signs and 10 hours 50 minutes after last documented neuro check) on 01/23/2022 at 0300 and pronounced deceased at 0334.

Interview on 05/18/2022 at 1135 with RN #6 revealed she recalled and cared for Patient #3 on the day shift (7am-7pm) on 01/22/2022. Interview revealed she forgot to document monitoring and assessments of Patient #3. Interview revealed she was aware of the 15 minute assessment requirement with chemical restraints after administration. Interview revealed she did not report the elevated blood pressure to the physician because sometimes administered medications can "bring down" the blood pressure.

Interview on 05/18/2022 at 1410 with MD #26 revealed he recalled Patient #3. Interview revealed he was notified of the patient's fall and ordered the CT Scan and Neuro checks. Interview revealed he also was notified of him getting out of bed and ordered the chemical restraints. Interview revealed no one made him aware of the the vital sign changes. Interview revealed the nurses do typically notify him if there is a change in condition.

Interview on 05/18/2022 with RN #27 revealed he was the preceptor and charge nurse for RN #28. Interview revealed RN #28 was in her last 2 days of orientation and was the primary nurse for Patient #3 on the night of 01/22/2022. Interview revealed he recalled the night of 01/22/22. Interview revealed he was walking by Patient #3's room, RN #28 was in the room setting up a respiratory treatment when he recalled Patient #3 "looking gray." Interview revealed he approached the patient and he was unresponsive, left the room to call for the medical response team. Interview revealed the medical response team arrived and CPR was started. Interview revealed he did not call for help from the room because the nurses station was not far away from Patient #3's room.

RN #28 (the night shift nurse on 0/22/2022) was not available for interview and has separated from the facility.


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2. Review of the policy titled "Policy and Procedure for Central (Remote) Monitoring in the Medical/Surgical Areas" with revision date of 10/2020, revealed "PURPOSE: To provide cardiac monitoring services to adult patients under the care of the primary care provider in the Medical/Surgical and Telemetry areas of the hospital outside of the Intensive Care Unit to define the roles and responsibilities pertaining to remote cardiac monitoring....12. The MT (monitor technician) will notify the charge nurse or primary care nurse of any needed battery or electrode changes utilizing the regular phone system. MT calls for battery changes or lead placement should be responded to immediately."

Review of History and Physical dated 03/22/2022 at 1249 revealed Patient #13 was a 60-year-old male admitted on 03/22/2022 for shortness of breath for the last 3 months and increased lower body swelling. Past medical history for Patient #13 revealed he had insulin-dependent diabetes, primary hypertension, COPD (Chronic Obstructive Pulmonary Disease), gout, daily alcohol use disorder, and CAD (Coronary Artery Disease) with 1 stent. Review of the physician orders dated 03/22/2022 at 1249 for Patient #13 revealed "Bed Type: Telemetry--Includes CCM" (Continuous cardiac monitoring). Review of RN #10's hourly rounding note dated 03/23/2022 at 0302 revealed "Alert, Oriented. Are you having pain? No." Review of MT (monitor technician) #11 note dated 03/24/2022 at 0309 (7 minutes after RN #10's hourly rounding) revealed "pt (patient) off monitor/leads off. Name of Nurse Notified: (RN #10)." Review revealed Patient #13 was found unresponsive by clinical technician (phlebotomist) without telemetry leads in place at 0320, 11 minutes after RN #10 received phone call of leads being off. Review of discharge summary dated 03/24/2022 at 0741 written by MD #8 revealed Patient #13 was "noted to not have monitor in place. Upon evaluation by nursing staff patient was found unresponsive and pulseless. CODE BLUE (emergency team arrived) was initiated to include CPR (Cardiopulmonary resuscitation--act of performing chest compressions and ventilation) the code without successful return of circulation. About 32 minutes and after unsuccessful repeat defibrillation, patient's time of death was called...." Review revealed Patient #13's time of death was 0351.

Review of the Code Blue sheet dated 03/24/2022 revealed Code Blue was initiated at 0321, 13 minutes after MT #11 notified RN #10 (primary RN) that Patient #13's telemetry leads were off.

Interview on 05/19/2022 at 0850 with RN #10, the primary nurse for Patient #13 and charge nurse for the shift, remembers Patient #13. Interview revealed RN #10 was sitting at the desk documenting when MT #11 phoned RN #10 of Patient #13's leads being disconnected. Interview revealed RN #10 remained at the desk and did not immediately enter the room. Interview revealed Clinical technician #13 entered the room a few minutes later to collect the routine morning labs. Interview revealed CNA (Certified Nursing assistant) #17 was asked to come into the room by the Clinical Technician #13. Interview revealed CNA #17 screamed out to RN #10 who was at the desk. RN #10 then entered the room. Interview revealed CPR was started and a code blue was activated using the code blue button in Patient #13's room.

Interview on 05/18/2022 at 1935 with Clinical technician #13 revealed she found the Patient #13 unresponsive when entering to collect blood sample. Interview revealed Patient #13 was not connected to the telemetry box. Interview revealed Clinical technician #13 called to the CNA #17. Interview revealed CNA #17 called to the desk for RN #10. Interview revealed RN #10 entered the room and began CPR after pressing the code blue button in the room.

Interview on 05/19/2022 at 0837 with MT #11 revealed the leads were off Patient #13 and she notified RN #10 via phone at 0309. Interview revealed the nurse should have replaced the leads or troubleshoot immediately. Interview revealed there was no documentation that the leads were replaced on Patient #13. Interview revealed if the primary nurse did not respond immediately, the charge nurse was called to troubleshoot the telemetry box. Interview revealed the house supervisor should also be notified if there was no response.

Interview on 05/19/2022 at 0915 with MT #15, employed 5 years, revealed if the primary nurse did not resolve the telemetry issue immediately, another phone call was made to the charge nurse and the house supervisor within 5 minutes. Interview revealed MT #15 had previously entered patients` rooms to resolve some telemetry box concerns.

Interview on 05/19/2022 at 1420 with Supervisor #14 revealed if the primary nurse was busy and unable to resolve the telemetry box issue, another staff member should have been called. Interview revealed immediate response was not seen in Patient #13. Interview revealed policy was not followed.



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3. Review on 05/17/2022 of the hospital policy titled "Suicide Risk and Assessment Precautions" effective October 2021 revealed "...Policy: To provide for the appropriate level of screening and assessment for all patients at risk for suicidal tendencies, to provide safe patient care...Procedures: When a patient is determined to be at risk for suicide through screening...the patient's safety is maintained using the following interventions...High Risk...immediately implement suicide prevention strategies including...1:1 observation within arm's reach..."

Review on 05/17/2022 of a closed medical record revealed Patient #22 was a 41-year-old male that was brought to the emergency department (ED) on 04/18/2022 at 1356 via EMS (emergency medical service) with a stated complaint of "Pt presents by EMS stating he wants to take a bunch of pills to end his life..." Medical record review revealed Patient #22 had a history of manic depression and multiple suicide attempts. Medical record review revealed at 1425 Registered Nurse (RN) #17 triaged Patient #22 and documented he was a "High Risk" for suicide based on the "Columbia Suicide Severity Rating Scale" (suicide ideation rating scale). Review of an "Emergency Department Note" signed by RN #17 on 04/18/2022 at 1435 revealed "...charge nurse aware of pt, will be placed in room when available..." Medical record review revealed Patient #22 returned to the lobby of the ED to wait for an available room and exam. Medical record review failed to reveal evidence Patient #22 was monitored by staff while in the lobby.

Review of an "Emergency Department Note" signed by Certified Nursing Assistant (CNA) #19 on 04/18/2022 at 1617 (2 hours, 21 minutes after Patient #22's arrival to the ED) revealed "Received a call from...with Mobile Crisis letting staff know the patient called him and said he got his pills back and was going to take them all. Staff alerted the RN in triage and Charge Nurse." Review of an "Emergency Department Note" signed by the charge nurse (RN #18) on 04/18/2022 at 1625 (2 hours, 29 minutes after arrival to ED) revealed "Patient locked himself in lobby bathroom with his home meds which were given to him by EMS which was unknown to this RN. Security notified immediately and to bathroom to unlock door..." Medical record review revealed on 04/19/2022 at 2202, Patient #22 was discharged to jail/detention facility.

Interview on 05/18/2022 at 1322 with RN #17 revealed she triaged Patient #22 when he presented to the ED. Interview revealed RN #17 notified the charge nurse (RN #18) that Patient #22 was at high risk for suicide based on the screening. Interview revealed there were no beds available and Patient #22 was sent from the triage room back to the lobby of the emergency department. Interview revealed RN #17 could not keep Patient #22 in the triage area because she had to triage other patients.

Interview on 05/18/2022 at 1137 with RN #18 revealed she was the charge nurse on 04/18/2022 in the emergency department. Interview revealed there were no beds available when Patient #22 came into the ED. Interview revealed there was no staff member assigned to monitor Patient #22 while he waited in the lobby of the ED.

Interview on 05/18/2022 at 1500 with the interim Emergency Department Director revealed patients that are identified as high risk for suicide should be monitored by staff for their safety. Interview revealed the staff should have put the patient in a room or a hallway bed in view of staff at all times. Interview revealed the triage nurse and charge nurse did not follow the hospital's policy.

Based on facility policy review, medical record review, and staff interview, the facility staff failed to reassess the appropriateness of a patient's discharge plan after significant changes in housing were discovered for 1 of 2 guardianship patients reviewed (Patient #5).

The findings included:

Review of the facility policy, "Discharge Planning," effective 05/2020, revealed, "... Policy ... B. Discharge planning is a responsibility for all hospital staff within each department... C. As part of the case manager's process to reassess patients, if the following circumstances occur, a case management consult will need to be completed to update the discharge plan... 4. A change in social or financial status becomes apparent..."

Closed medical record of Patient #5 revealed a 30-year-old female who was directly admitted to the facility's Behavioral Health Unit on 01/26/2022 at 2240 with a chief complaint of "... I just feel like killing myself..." Review of the Psychiatric Evaluation/History and Physical dated 01/26/2022 at 2240 by Psychiatrist #3 revealed,"...has a DSS (Department of Social Services) as a guardian... Patient has a history of depression, PTSD (post traumatic stress disorder), mild IDD (intellectual or developmental disability), ADHD (attention deficit hyperactivity disorder), anxiety, SI (suicidal ideation), HIV (human immunodeficiency virus), self harm by cutting... Patient has been living in the current group home since Sept (September) 2021... Disposition - back to group home when psychiatrically stable..." Review of Provider Progress Note dated 01/28/2022 at 1200 revealed, "...Per report group home has refused to accept the patient back... Social worker working on the patient discharge plan... Weaknesses: Housing Issues..." Review of Social Work Notes dated 01/28/2022 at 1801 by SW(social worker) #1 revealed, " Collateral: Social worker completed a phone visit with patient's legal guardian... reports that the patient has eloped from the current group home at least 10 times... was found in the woods... the patient locked herself in a room, broke the glass and began cutting herself with the broken glass. (named DSS guardian) indicates the patient made attempts to wipe blood on the other staff and residents in the group home. (named DSS guardian) reports that this is considered a threatening behavior due to patient being HIV positive. (named DSS guardian) indicates both she and the staff at the the group home hold weekly meetings to address the patient's behavior. She reports they've used all types of interventions including behavior modification... (named DSS guardian) is recommending patient be considered for a higher level of care and is recommending (named mental health facility)..." Review of Social Work Notes dated 01/31/2022 at 0820 by SW #1 revealed, "... (named DSS guardian) insists that due to the less restrictive setting in the group home, the pt would not be a good fit for placement in another group home setting. (named DSS guardian) reiterated that pt would leave the group home during the night, which puts her at risk of being back in a group home setting. (named DSS guardian) agreed to send a list of facilities that would possibly consider pt for placement with the hopes of working in partnership with SW to get pt successfully placed in a location that can best manage pt's needs/behavior." Review of Social Work Notes dated 01/31/2022 at 1355 by SW #1 revealed, "SW reached out to pt's guardian (named DSS guardian) to advise of d/c(discharge) plans for pt, with the expectation of pt returning back to her preadmission place of residence. (named DSS guardian) requested to have 24 hours to come up with an emergency plan to put into place in hopes of finding temporary placement for patient..." Review of Social Work Notes dated 02/01/2022 at 1109 by SW #1 revealed, "SW contacted dispatch and spoke with (named employee) who states he will let dispatch know to transport pt back to preadmission residence tomorrow." Review of Provider Progress Note dated 02/01/2022 at 1251 revealed, "...Per report group home has refused to accept the patient back... Social worker working on the patient discharge plan... Weaknesses: Housing Issues..." Review of Social Work Notes dated 02/01/2022 at 1829 by SW #1 revealed, "...(named DSS guardian) was further advised that because pt's behavior has stabilized since first being admitted to the unit, the plan would be for her to return back to her preadmission residence as she presents no danger or harm to herself while here on the unit." Review of the Discharge Summary dated 02/02/2022 at 1907 by Psychiatrist #3 revealed, "...per guardian, patient had made attempts to wipe blood on the other staff and residents in the group home and this is considered as threatening behavior due to the patient being HIV positive... Patient was discharged back to pre hospitalization group home where she came from..." Review of the Discharge Patient Signature Page revealed the signature line for the Patient or Guardian was not signed. Medical record review revealed Patient #5 was discharged to the address of the group home where she resided prior to facility admission on 02/22/2022 at 1230 via sheriff department. Medical record review failed to reveal documentation of facility attempts to obtain alternative housing options for Patient #5 post hospitalization. Medical record review failed to reveal the reassessment of the discharge plan after notification that the pre-hospitalization group home had discharged Patient #5.

Interview on 05/18/2022 at 1425 with UR (Utilization Review) Specialist #5 revealed she was present while Patient #5 was at the facility. Interview revealed that the SW had reported in treatment team talking to the guardian and group home and the group home agreed to take Patient #5 back. Interview revealed the treatment team moved forward with the discharge plan based on information from the SW.

Interview on 05/18/2022 at 1435 with BHU Director #2 (Behavioral Health Director) revealed she was on orientation when Patient #5 was at the facility. Interview revealed she was responsible for providing oversight for SW #1. Interview revealed that the facility staff were expected to work with the guardian for placement. Interview revealed, "If there's not a safe discharge plan, we're not discharging them."

Interview on 05/18/2022 at 1347 with Psychiatrist #3 revealed he cared for and discharged Patient #5. Interview revealed that he was aware that the group home had refused to take Patient #5 back after admission. Interview revealed Psychiatrist #3 did not talk directly to the group home, but did discuss care with the guardian and SW. Interview revealed that the SW informed the team that an arrangement had been made for Patient #5's discharge plan. Interview revealed the treatment team moved forward with the discharge plan based on information from the SW. Interview revealed that Patient #5 would not have been discharged if the Psychiatrist was aware that the discharge plan was not safe; "the goal is to ensure the discharge plan is safe."

Interview on 05/19/2022 at 0930 with DCM (Director of Case Management) #4 revealed that she had oversight of case management/discharge planning. Interview revealed that when a group home discharged a patient, the patient could not go back, especially if they were a threat to other patients or staff. Interview revealed when the facility had been notified that a patient had been discharged from their group home, the case management staff located alternative housing options based on identified needs. Interview revealed the patient should not have been sent back to the group home they had been discharged from.

NC00188985, NC00188152, NC00188584, NC00188526, NC00186222, NC00185832, NC00186015.