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Based on staff interview, review of medical records (MR), facility documents, and a video surveillance recording, it was determined the facility failed to provide care in a safe setting for all patients, as evidenced by: failing to ensure that all staff follow the documentation process for Q15 (every 15) minute observation and monitoring in accordance with facility policy (A-0144), failing to ensure all medical consultations are completed, and documented on all patients (A-0114), and failure to ensure all staff begin Cardiopulmonary Resuscitation (CPR) without delay, possibly contributing to negative patient outcomes (A-0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.

On October 2, 2025, at 12:50 PM, an IJ was identified for the facility's failure to ensure all staff members will initiate CPR without delay (A-0144). On October 2, 2025, at 3:05 PM, the IJ template was presented to the Chief Executive Officer (CEO), and a removal plan was requested. On October 3, 20235, at 10:06 AM, and an acceptable removal plan was received. The facility implemented the following to address the IJ: education regarding "Resuscitation and Emergency Response" was given to staff at the beginning of each shift. Staff members signed individual attestations to acknowledge and affirm the education of three major points: timely response in resuscitation, immediate action, and patient supervision during emergencies. The IJ was removed on October 3, 2025, at 11:25 AM, after the State Survey Agency verified the full implementation of the removal plan. Condition Level non-compliance remains (A-0144).

Verification of the implementation was completed through signed attestation of staff education and staff
interviews.

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on staff interview, review of medical records (MR), a surveillance video recording, and facility documents, it was determined the facility failed to ensure that 1.) staff immediately begin Cardiopulmonary Resuscitation (CPR) for one of one patients reviewed experiencing a medical emergency, 2.) all staff follow the documentation process for Q15 (every 15) minute observation and monitoring in accordance with facility policy for four of five MRs reviewed; and 3.) all medical consultations are completed and documented on all patients as indicated for one of five MRs reviewed.

Findings include:

1. Facility policy titled, "Code Blue Emergency, Life Threatening Situation" dated 03/24, stated, "... Purpose: To provide immediate response in life threatening situations ... Procedures: 1. Any staff finding a patient or staff member in medical distress will call for assistance ... initiate cardiopulmonary resuscitation (CPR) immediately ..."

On 10/01/25 at 10:25 AM, Patient (P)1's MR was reviewed in the presence of Staff (S)2 and revealed:
The "BH (Behavioral Health) Intake Call Details-Text " dated 09/19/25, stated, "BH [behavioral health] Inpatient Recommendation Criteria: Behavior life threatening, destructive or disabling to self or others."
The "Notify/Precautions Observation Level" order, dated 09/20/25 at 12:44 PM, stated, "q15min [every 15 minutes], Constant Order."
The "BH (Behavioral Health) Admission/Observation/Transfer" order, dated 09/20/25 at 6:21 PM, stated, "Bipolar affective, Admit as Inpatient, Involuntary Status, [doctor's name, nurse's name]."
The "BH Psychiatric Evaluation "dated 09/20/25 at 6:47 PM, stated, "... Admit to [facility name] for stabilization ...Start every 15-minute checks. ..."
The "BH- Progress Note-Nurse" dated 09/23/25 at 11:00 PM, stated, "Called to patient room by staff nurse at 9:40pm with report that patient is unresponsive in bed. Patient found lying in bed, with no pulse, no blood pressure, no respirations, and pupillary reflexes were all absent. Code Blue [a hospital code for a medical emergency that requires resuscitation] called and CPR initiated at this time along with attaching the Defibrillator... 911 called and CPR continued shock advised x 1. CPR resumed until paramedics arrived and took over at 9:52pm. Patient pronounced after several rounds of CPR, post mortem care given. Spouse called and message left and son [name of son] made aware. ..."

On 10/01/25 at 12:26 PM, a surveillance video recording dated 09/23/25, was viewed in the presence of S1 and S2. The video was recorded on 09/23/25 and showed the hallway outside of P1's room, 603 on Unit 6. Viewing began at the 8:00 PM time stamp and ended at the 10:22 PM time stamp.
The video revealed:
On 09/23/25 at 9:40 PM, S11 entered the patient's room. At 9:40 PM, a Code Blue (a hospital code for a medical emergency that requires resuscitation) was called. At 9:41:25 PM, S11 left the room and returned at 9:41:59 PM with S13. S11 and S13 both left the room at 9:42 PM. At 9:43 PM, S13 returned to the room with the code cart.
On 10/01/25 at 1:10 PM, S2 confirmed the above findings, and confirmed there was no evidence that staff initiated CPR upon finding the patient unresponsive.

2. Facility policy titled, "Patient Observation" revised on 03/24, stated, "Policy: To ensure safety, as well as, to provide a process for observing and documenting patient location and behavior. Procedures: ... IV. Q [every] 4 Hour Patient Observation Rounding Verification A. A unit RN [Registered Nurse] or Nursing Supervisor will review and sign the patient observation rounds every 4 hours (minimum of 6 times evenly distributed over a 24-hour period) ... 3. Once the last 4 hours of patient observation rounds have been reviewed, the RN/Supervisor will perform and document a patient observation round for each patient. A. The RN/Supervisor will perform the following steps: ... Navigate to the RN/Supervisor verification tab and select "Q4 Verification completed". 4. Click the box labeled "Sign" to electronically sign the patient observation round."

On 10/01/25, P2, P3, P4 and P5's medical records were reviewed, and revealed the following:

P2 was admitted to the facility on 09/09/25 at 9:25 AM, with an admitting reason of bipolar.
P2 was on Q15 minute observation.
On 09/10/25 to 9/22/25 from 5:00 AM to 11:00 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
P2 was discharged on 09/24/25 at 5:17 PM.

A review of P3's medical record was conducted and revealed the following:
P3 was admitted to the facility on 07/15/25 at 3:01 PM, with an admitting reason of depression.
P3 was on Q15 minute observation.
On 07/16/25 from 4:56 AM to 1:59 PM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
On 07/16/25 from 8:20 PM to 07/17/25 at 2:11 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
On 07/17/25 from 4:32 AM to 11:11 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
P3 signed out AMA (Against Medical Advice) on 07/17/25 at 12:49 PM.

A review of P4's medical record was conducted and revealed the following:
P4 was admitted to the facility on 09/03/25 at 2:11 PM, with an admitting reason of depression.
P4 was on Q15 minute observation.
On 09/03/25 to 10/01/25 from 5:00 AM to 11:00 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
P4 was discharged on 10/01/25 at 12:35 PM.

A review of P5's medical record was conducted and revealed the following:
P5 was admitted to the facility on 08/02/2025 at 2:50 PM with an admitting reason of "psych."
P5 was on Q15 minute observation.
On 08/03/25 from 5:00 AM to 11:00 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
On 08/05/25 to 08/10/2025 from 5:00 AM to 11:00 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
On 08/11/25 from 5:11 AM to 4:13 PM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
On 08/12/25 from 3:33 AM to 11:17 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
On 08/13/25 to 08/17/25, from 5:00 AM to 11:00 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
On 08/19/25 from 5:00 AM to 11:00 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.
On 08/21/25 from 5:00 AM to 11:00 AM, the medical record lacks evidence that an RN documented verification of the Q15-minute safety checks every four hours.

On 10/02/25 at 11:58 AM, S2 confirmed the above findings. When asked how often the nurse should be documenting the Q15-minute safety check verification, S2 explained that the verification should be documented three times a shift. Surveyor reviewed the policy titled, "Patient Observation" with S2. The policy stated, "... A unit RN or Nursing Supervisor will review and sign the patient observation rounds every four hours (minimum of six times evenly distributed over a 24-hour period)." S2 stated, "... yes, it should be every four hours, that is a long gap."

3.) Facility policy titled, "Sub- Specialty Consultations," revised on 10/24, stated, "... Policy: Sub- specialty consultations by providers, approved by the Medical Staff, will be requested by the Licensed Independent Practitioner when medically indicated to clarify issues related to diagnosis and/or behavior ... Procedure: ... 1. Licensed Independent Practitioner will order in the patient chart requesting the consultation and stating the reason for consultation ... 2. The consultant will be responsible for documenting on the consultation form noting significant findings, diagnostic impressions, and recommendations (treatment rendered). ..."

On 10/01/25, a review of P1's medical record revealed the following:
P1 was admitted to the facility on 09/20/25 at 6:47 PM with life threatening behavior, destructive or disabling to self or others.
The "History and Physical (H&P)" dated 09/20/25, completed by S10, indicated medical history of Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Hypertension, Seizure Disorder, and Thyroid Disorder. The H&P noted the need for medical consultations, the indications being cardiac disease and diabetes.
P1's MR lacked evidence of an order for medical consultation.
P1's MR also lacked documentation of a completed medical consult.

On 10/02/25 at 2:04 PM, upon interview with S8, he/she confirmed that his/her consult documentation was not in P1's chart. S8 indicated that he/she was "waiting for additional laboratory results." S8 also stated that he/she knew P1 had been aggressive with staff, and assessment/evaluation was not performed at the time S8 went to P1's room.
S8 explained that he/she had "started a note" and it wasn't saved to P1's MR.

On 10/02/25, at 12:05 PM, a review of the incomplete provider's note, dated 09/22/25 by S8, lacked evidence of a physical assessment, or any documentation that P1 was seen by S8.




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