HospitalInspections.org

Based on observation, interview, record review and policy review the hospital failed to:
- Recognize the worsening of a patient's condition and transfer to a more intensive level of care for one patient (#7) of 22 medical records reviewed.
- Escalate concerns through the chain of command for one patient (#7) of 22 medical records reviewed.
- Obtain the patient's written consent for one patient (#7) of 22 medical records reviewed.
- Obtain a specialist's opinion on a patient's condition or treatment for one patient (#7) of 22 medical records reviewed.

The cumulative effect of these failures resulted in non-compliance with 42 CFR 485.635 Condition of Participation (CoP): Provision of Services.

Please refer to C-1006 for further details.

Based on interview, record review and policy review, the hospital failed to:
- Recognize the worsening of a patient's condition and transfer to a more intensive level of care for one patient (#7) of 22 medical records reviewed.
- Escalate concerns through the chain of command for one patient (#7) of 22 medical records reviewed.
- Obtain the patient's written consent for one patient (#7) of 22 medical records reviewed.
- Obtain a specialist's opinion on a patient's condition or treatment for one patient (#7) of 22 medical records reviewed.

Findings included:

Review of the hospital's policy titled, "Scope of Service," reviewed 06/2022, showed, the Medical Surgical Nurse at Sainte Genevieve County Memorial Hospital (SGCMH) is a professional nurse committed to ensuring that the acutely ill medical and/or surgical patient receives optimal care. Should the medical surgical patient experience a worsening of his/her condition, the patient shall be transferred to a more intensive level of care, designed to provide the level of service necessary to address the patient's condition.

Review of the hospital's policy titled, "Chain of Command," revised 11/21/22, showed SGCMH is committed to deliver an optimum level of quality patient care and it is the expectation that staff place the wellbeing of the patient above all else. SGCMH supports staff raising issues concerning quality patient care, behaviors and work processes. The chain of command process should be initiated when a nurse's assessment of the patient varies significantly from the physician's assessment, in clinical situations where the nurse believes the physician has not responded in a manner to fully address the issues raised and may present an immediate risk to the patient, and any action that may jeopardize safe patient care. The notification process will follow the organizational chart beginning with Peer to Peer, then Supervisor or Charge Nurse, Department Director, Leadership Staff to the CEO. Issues related to physician management of care shall first be discussed with the physician at the department level and then, as needed, referred to the House Supervisor, Nurse Manager/Directors and appropriate Senior Leader for referral to the appropriate medical staff member. Unresolved issues are to be taken to the next line of authority if the first line of authority does not sufficiently resolve issues. If it is felt at any point the person contacted does not respond in an appropriate timeframe, the next level of authority is to be notified, up to the CEO or Chief of Staff. If an issue is related to patient care; objective, concise information should be included in the medical record. An event report is to be completed on any implementation of the Chain of Command Policy in which the first line is not effective.

Review of the hospital's policy titled, "Consent-Informed and Implied," reviewed 09/08/23, showed SGCMH recognizes the right of a competent adult patient to consent to or refuse medical procedures and treatment. The authorization of a procedure consent form shall be signed after a full explanation from the involved provider by the patient. A Registered Nurse (RN) or Advanced Practice Registered Nurse (APRN) shall be responsible for the verification of and witnessing that the patient has signed the consent form in their presence and can attest to the fact that the patient is competent to provide consent.

Review of the hospital's policy titled, "Consultation," reviewed 12/2022, showed the purpose of the policy is to obtain a second opinion and/or seek a specialist's opinion on a patient's condition and/or treatment.

Review of the hospital's "Bylaws," amended 02/26/24, showed an active staff member must work cooperatively with members, nurses, hospital administration and others so as not to affect patient care adversely.

Review of Patient #7's medical record showed:
- On 02/16/24 around 2:00 AM, Patient #7 presented to the ED with a complaint of headache.
- At 4:34 AM, he was awake, alert, appropriate and restless. He was oriented to person, place, and time and his speech was clear and appropriate. His pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and ten means the worst pain possible) was a seven out of ten. He was continent of urine. He moved all extremities well and walked with a steady gait.
- At 5:22 AM, he was given Narcan (a medication used to counter the effects of narcotic overdose) for ongoing lethargy (weak, sluggish) and pinpoint pupils. He jumped out of bed and became suddenly very alert. His sodium (a type of electrolyte in the blood, normal is 135-145) was 128, with suspected dehydration. There were no current concerns for encephalopathy (inflammation of the brain, caused by infection or an allergic reaction). His head computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) on 02/11/24 and 02/16/24 were negative and was not repeated for this visit. He had no rash or skin breakdown and his genitourinary (relating to the urinary and genital organs) assessment was negative. A withdrawal severity assessment (questionnaire that measures the severity of an individual's withdrawal symptoms) showed Patient #7 was lethargic, responded slowly to verbal stimuli, his hand grasps were equally strong and he had rambling speech.
- During his hospitalization he received several withdrawal severity and psychosocial (relating to the interrelation between social factors and individual thought and behavior) assessments which repeatedly showed him to be lethargic, either slow to respond to stimuli or responsive only to painful stimuli, unclear speech and uncooperative to nursing cares or medical advisement. He was often drowsy and responded inappropriate; but oriented to person, place and time. He was restless and "fidgety," woke often during the night hours, refused to wear clothing and repeatedly showered.
- Pain assessments consistently showed he reported head and neck pain, throbbing in nature, and rated with The Wong-Baker (Faces) pain scale. Pain was rated regularly between five and eight on a scale of ten. He received acetaminophen, ibuprofen and ketorolac for pain.
- On 02/16/24 at 7:05 PM, Patient #7 came out of his room, wandered into another patient's room and started watching television. He was redirected to his own room and the nurse practitioner (NP) was notified.
- At 8:26 PM, he was given lorazepam (a medication that has a calming effect, used to treat anxiety or sleep difficulty).
- On 02/17/24 at 4:09 PM, Staff EE, Physician, documented Patient #7 was wandering around in different rooms overnight, he was naked, often in the shower and was impulsive and anxious. Upon arrival in the ED, his Urine Drug Screen (UDS) was positive for methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant), amphetamine (an addictive mood-altering drug), and possibly other substances including heroin (an illegal, very addictive drug). His headache was treated with acetaminophen and ketorolac. His irritability and anxiety were treated with hydroxyzine (medication used to treat anxiety, nausea, vomiting, allergies, skin rash, and itching).
- At 7:27 PM, he was given trazodone (a medication used to treat depression) and acetaminophen. His temperature was 99.8 degrees Fahrenheit. He was also given hydroxyzine.
- At 10:00 PM, Patient #7's sister-in-law called Staff NN, RN, into Patient #7's room. Staff NN found Patient #7 on the bathroom floor with the sister-in-law holding him up in a sitting position. The shower chair was laying on its side. Patient #7 was ashen in color, lethargic, pupils were dilated, he was making a groaning sound, his current BP was 79/54 with a heart rate of 91. The sister-in-law stated that Patient #7 was taking a shower when she heard a loud noise. Staff NN; Staff JJ, NP; the House Supervisor, and another nurse assisted Patient #7 from the bathroom floor to a wheelchair and then to bed. Staff NN began a Normal Saline (solution made of salt and water) bolus (large volume) per Staff JJ's orders. Repeat assessment showed BP 129/79 and heart rate of 91. Patient #7 was able to verbalize neck and head pain and followed commands appropriately.
- At 11:21 PM, he was given IM Olanzapine (medication used to treat mental disorders).
- At 11:32 PM, Staff JJ, NP, documented that Patient #7 was actively withdrawing from an illicit drug of unknown source. He was impulsive, had ripped out multiple intravenous catheters (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream), refused to wear telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen), and was reluctant to cooperate with nursing cares and/or medical recommendations. Repeated nudity exposures were redirected and he was adamant to bathe at least eight times per shift. He had what appeared to be postictal (pertaining to the period follow a seizure) symptoms initially; but once he started to arouse after the fluid bolus, he had no residual effects. Staff JJ believed this was a syncopal (fainting) episode in the setting of acute withdrawal. Patient #7 was reluctant to converse with family and nursing staff and seemed to have more psychiatric (psych, relating to mental illness) related behaviors when he became more alert. He was groaning, asking for pain medication, and continued to repeat that he needed his head/neck rubbed. His sodium was initially 128, it was now 132. Staff JJ contacted the attending physician and explained the events leading up to the syncopal episode along with his current symptoms. Recommendations included a one-time dose of Olanzapine. If mood fluctuations continued throughout the night or Patient #7 became combative, Seroquel (an anti-psychotic medication used to treat certain mental/mood conditions) was to be added. The family was updated and agreeable to the medication changes. Patient #7's mother was concerned that he had syphilis (an infection caused by bacteria and spreads from person to person through direct contact with sores of the mouth, genitals or rectum). He had high fevers and headaches at home for the past week with extreme weakness. He was homosexual and had many partners, did not practice safe sex, had been sexually active for 15 years and never had testing for sexually transmitted infections (STI, an infection transmitted through sexual contact, caused by bacteria, viruses, or parasites). There were no current lesions or rashes noted to the groin, hands, feet, or mouth. He had low grade temperatures off and on over the past 12 hours. His current temperature was 99.8 °F. Staff JJ suspected the fever and restlessness were related to withdrawal of an unknown substance; but planned to test for STIs.
- On 02/18/24 at 9:00 AM, Patient #7 was lethargic and oriented to person, place and time. He was arousable to name and deep pain. His speech pattern was unclear. He was apprehensive and resistive to care.
- At 11:12 AM, Staff MM, RN, attempted to give Patient #7 Risperidone (a medication used to manage certain mental/mood disorders). Patient #7 did not open his eyes. A sternal rub (painful stimulus with knuckles or closed fist to the center chest of a patient who is not alert and oriented) was performed and he opened his eyes for a second. He groaned and shook his head that he would take the medication; but when Staff MM put the medication cup up to his mouth, he sealed his lips and would not take the medication. She attempted a couple more times, but he was resistant to taking the medication. Staff EE, Physician, was notified.
- At 11:58 AM, Staff EE, Physician, documented that Patient #7 continued to detox from an unknown substance, refused bloodwork and medications, had a history of multiple sexual partners per family and never had a STI work up. He had one known partner that had neurosyphilis (an infection that affects the coverings of the brain, the brain itself, or the spinal cord). Labs ordered included Rapid Plasma Regain (RPR, screening test for syphilis), chlamydia (a sexually transmitted infection caused by a bacteria), gonorrhea (an infection caused by a bacterium), and Human Immunodeficiency Virus (HIV, virus that attacks the cells that help the body fight infection). He continued to exhibit impulsive behaviors, such as constantly being naked and taking frequent showers. He was started on Risperidone.
-At 1:00 PM, a withdrawal severity assessment showed he was stuporous (unresponsiveness from which a person can be aroused only by vigorous, physical stimulation) and responded only to painful stimuli. His hand grips were equal and strong, his speech was clear.
- At 5:00 PM, a withdrawal severity assessment showed Patient #7 was obtunded (a dulled or reduced level of alertness or consciousness), he was drowsy and responded to touch stimuli. His hand grips were equal and strong, his speech was clear.
- At 7:51 PM, his head and neck pain was rated at four out of ten. He was given acetaminophen and Risperidone.
- At 9:00 PM, Patient #7 was drowsy, arousable to name, appropriate, followed commands, and oriented to person, place and time. His speech was clear and appropriate. He reported pain at six out of ten. He was apprehensive and resistive to care.
- At 11:36 PM, he was given ibuprofen. His pain score was nine out of ten in his head, and he described the pain as achy.
- On 02/19/24 at 8:12 AM, he was given Risperidone and acetaminophen. His pain score was seven out of ten in his head, and he described the pain as achy.
- At 9:00 AM, Patient #7 was drowsy, aroused to name, and was only oriented to person and place. His speech was clear. He reported achy pain at four out of ten. He was withdrawn, impulsive and moved around without thought to medical equipment such as his IV. Staff LL, Hospitalist, was notified that the patient was confused to date, year, time, and month.
- At 10:15 AM, Staff KK, RN, documented that Staff LL, Hospitalist, was updated that Patient #7 was sleeping, woke up to stimuli, was disoriented to time, complained of a headache. He had poor oral intake. Staff LL reported that a psychiatric consult was made.
- At 12:05 PM, Staff LL, Hospitalist, documented that Patient #7 was examined with his mother at bedside. Patient #7 knew he was in the hospital but did not know the year or month. He was drowsy and kept repeating that he had a headache. No infectious etiology was discovered thus far; HIV was nonreactive, gonorrhea and chlamydia were negative. However, the Hepatitis (inflammation of the liver) panel, RPR, and Treponema (syphilis testing) were still pending. Patient #7 did not have any neck rigidity, no leukocytosis (an increased number of white blood cells in the blood, especially during an infection) and no documented fevers; although family reported fevers at home.
- At 12:57 PM, Staff L, Social Worker, spoke with Staff OO, Emergency Services Specialist. Staff OO had interviewed Patient #7's mother in psychiatric consult as Patient #7 was asleep and unarousable. Staff OO did not feel that this was a psychiatric issue and felt the patient was detoxing.
- At 1:06 PM and 3:53 PM, Patient #7 described his head pain as pressure and achy and rated it at seven out of ten. He was given ibuprofen and acetaminophen respectively.
- At 4:59 PM, a withdrawal severity assessment showed Patient #7 was fully conscious, he was awake aware and oriented. His hand grips were equal and strong, his speech was clear.
- At 8:27 PM, Patient #7 was given Risperidone and acetaminophen. His pain score was seven out of ten in his head.
- At 9:00 PM, Patient #7 was awake, alert, and oriented to person, place and time. His speech was unclear and delayed. He reported his pain at eight out of 10 and described it as throbbing. He was angry, depressed, withdrawn, anxious, impulsive, dependent and resistant to care. A withdrawal severity assessment showed Patient #7 was fully conscious, aware and oriented. His hand grips were equal and strong, his speech was clear, and he was restless and "fidgety."
- Patient #7's drug screen was negative. He tested negative for chlamydia; gonorrhea; Treponema; HIV; Hepatitis A, B and C; and syphilis.
- On 02/20/24 at 5:00 AM, a withdrawal severity assessment showed Patient #7 was fully conscious, he was awake, aware, and oriented. His hand grips were equal and strong, his speech was clear. He was restless and "fidgety."
- At 7:20 AM, Patient #7 was awake, alert, and oriented to person and place. His speech was delayed. Staff R, RN, noted that Patient #7 had episodes of not wanting to talk and answer questions. She asked him to blink for yes, and he was able to follow that command. He refused to wear telemetry, was naked in bed and refused clothing. He was withdrawn, anxious, apprehensive, impulsive, and resistant to care.
- At 9:00 AM and 12:45 PM, a withdrawal severity assessment showed Patient #7 was fully conscious, he was awake, aware and oriented. Staff R, RN, felt a tremor that was not visible and his speech was clear. He was awake half the night or more, and he was restless and "fidgety."
- At 10:45 AM, Patient #7 rated his pain at a five out of ten and described the pain as achy. He requested pain medication. He was sitting up in bed, drinking soda, and refused to wear clothing. He exhibited humming and rocking type repetitive behavior, was restless in bed and was not answering questions. He looked at the nurse and then stared off "into space." She asked Patient #7 to blink to say yes to communicate and he followed that command.
- At approximately 11:40 AM, Staff R, RN, went into Patient #7's room and his mother expressed concerns over the patient's odd behavior that morning, with the patient appearing dazed, restless, exhibiting finger spasms and not verbal; as he was talking more yesterday.
- At 11:58 AM, Staff L, Social Worker, met with Patient #7's mother. Patient #7 was very restless during the conversation, biting his nails and rolling back and forth in bed, staring at the ceiling. Patient #7 did not want to speak and exhibited strange behaviors that were reportedly new from yesterday. Staff L spoke with Staff LL, Hospitalist, who requested Patient #7's chart be sent to inpatient psychiatric units. Staff OO, Emergency Services Specialist, had reported that she assessed Patient #7 and he had medical issues and did not recommend psychiatric treatment.
- At 12:45 PM, Patient #7's mother remained concerned over the patient's odd movements. He moved all extremities independently with occasional repetitive movement. He was noted to be inconsistently following commands on that day's initial assessment and no new deficits noted. He was able to turn, twist, sit up and lie flat without assistance. He had delayed verbal response but this was unchanged from his initial assessment. No slurred speech was noted. His pupils were three millimeters, round and reactive. The physician was notified.
- At 12:51 PM, Staff LL, Hospitalist, documented that Patient #7 was examined with his mother at bedside. Overnight, Patient #7 pulled out his IV, was constantly picking at his fingers, chewing on his fingers and making lip movements. He was admitted as an inpatient from the ED after presenting with acute psychosis (a serious mental illness characterized by defective or lost contact with reality), likely an underlying psychiatric disorder associated with multiple substance abuse (misuse of alcohol and/or other drugs) and high-risk sexual behavior. There was concern for underlying history of mania (a period of time when a person cannot sleep for days, feels elevated and grandiose, and is easily distracted) based on information provided by family. No infectious etiology was discovered. All laboratory tests (Hepatitis panel, RPR, Treponema, HIV, gonorrhea and chlamydia) were negative. Patient #7 did not have any neck rigidity, no leukocytosis and no documented fevers; although family reported fevers at home. He was started on Risperidone and showed some signs of improvement. A syncopal episode secondary to low blood pressure and hypovolemia (condition where the liquid portion of the blood is too low) was suspected. Patient #7 needed psychiatric placement and case management was involved.
- At 1:20 PM, Patient #7's mother stated that the odd behaviors with his fingers had continued. No new behaviors were noted between Staff R's initial assessment that morning. Patient #7 was able to make eye contact with her and then moved his eyes away from her. The physician and house supervisor were notified.
- At 2:19 PM, Staff R, RN, documented that during Patient #7's 9:00 AM and 12:45 PM withdrawal assessment, he was noted to have bilateral weakness in his hand grips.
- At 4:13 PM, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived to transport Patient #7 to Hospital B for inpatient psychiatric care. The patient was documented as incontinent of urine before transfer to the transport stretcher.
- Patient #7's medical record included a transfer authorization form signed by his mother, not by Patient #7. There was no order to consult infectious disease. There was no order to test for the Herpes Simplex Virus (HSV, an STI) one or two.

Review of Patient #7's EMS record showed the following:
- On 02/20/24, EMS was dispatched to Hospital B.
- Patient #7 was completely disoriented, alert to verbal stimuli, and was only making incomprehensible sounds. He was agitated and flailing around on the stretcher.
- His left arm was tense, and his hand appeared to be contracted at times, causing concern for possible dystonia (a movement disorder where muscles contract involuntarily, causing repetitive or twisting movements). He was given diphenhydramine (medication used to treat itching, insomnia, and allergic reactions).
- He was lifted and placed on the transport stretcher with a draw sheet due to his altered mental status. He was transferred to Hospital C.

Review of Patient #7's medical record from Hospital C showed the following:
- Patient #7 was transferred to Hospital B on 02/20/24 and was unresponsive. Hospital B staff called EMS, who gave Patient #7 diphenhydramine for possible dystonia.
- He was transferred to Hospital C's ED. He did not follow commands or respond to any verbal or painful stimuli but was moving his extremities symmetrically.
- A CT showed swelling in the brain. A lumbar puncture (LP, procedure of taking fluid from the spine in the lower back through a hollow needle) was performed, which showed elevated pressure. His oral temperature was 100.4 degrees Fahrenheit. Final diagnosis was HSV meningitis (inflammation of the tissues surrounding the brain and spinal cord).
- He was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for).

During a telephone interview on 03/07/24 at 9:45 AM, Staff KK, RN, stated that Patient #7 had a headache. The physician ordered a BHE for Patient #7. Patient #7 was confused at times, sometimes appropriate and very intermittent with eating. He did not like the bed alarm and walked to the bathroom. She received in report that he wanted to take hot showers, but during her shift, he did not take any. When asked if his behavior was typical for a detox patient, Staff KK responded that his behavior was typical. She did not recall Patient #7 complaining nor showing signs of being feverish.

During a telephone interview on 03/07/24 at 10:40 AM, Staff MM, RN, stated that she received in report that Patient #7 was lethargic and sleepy. He had come in from the ED and had a positive UDS. The physician said that he was probably detoxing. His first day was uneventful and he slept most of the day. They were mostly waiting for him "to wake up enough" to go to rehab. It was not uncommon for detox patients to sleep a lot. His second day was like the first. He was "in and out of the shower all day" and wanted hot water for his headache. Staff RR, Administrator for the New Vision Drug Rehabilitation Program, came in to talk with him. He refused some medications but wanted his pain medications. He walked into another patient's room and was redirected to his room. On 02/18/24, she ended up having to "sternal rub" him because he would not wake up. He finally woke up and refused his medications. He was supposed to discharge on 02/19/24 to a rehab facility. He was "lethargic and out of it." His mother reported that he felt hot and Staff MM took his temperature. They used temporal thermometers most of the time, but if temperatures were high, they were retaken with an oral thermometer "because they were more accurate." He did complain of a headache but did not report any other pain.

During a telephone interview on 03/07/24 at 12:00 PM, Staff NN, RN, stated that Patient #7 came in through the ED with headache and neck pain, and he was admitted for headache, dehydration, and low sodium. He walked out of his room and into another patient's room; he was confused but redirectable. He drifted in and out of sleep and he was drowsy but arousable. He was up and down to the shower and wanted really hot showers. His skin did feel warm to the touch, and she did get an oral temperature on him, but it was within normal limits. He did not want to wear the telemetry and was constantly pulling it off. He did not complain to her of pain in his neck. He had "odd behaviors, not typical for detox," such as he was awake after being given Hydroxyzine, where most patients usually fall asleep. Normally patients complained of pain, but were able to achieve some pain relief, but Patient #7 still rated his pain a seven or eight out of ten. "Something was off." He was drowsy but never could sit still. He had "odd" interactions with his family. He "never had clothes on," and would always ask for a dairy product (milk, ice cream, etc.). He pulled out his IVs and got in the shower.

During a telephone interview on 03/07/24 at 10:00 AM, Staff R, RN, stated that Patient #7 had odd behaviors. She received in report that he did not want to wear a gown and had repetitive behaviors. He stared at her and then would stare off into space. He intermittently talked and followed some commands. He complained of a headache, but did not complain of pain elsewhere, and he did take pain meds. When asked if she thought his behavior was typical for a detox patient, Staff R stated that every patient was different, but she "did not feel he was withdrawing." She was told that his behavior was not changed since his admission, and he was at his baseline. His mother had concerns and felt strongly that Patient #7 "was off." Staff R stated that there was no change in his assessment from her initial assessment, but she reported the mother's concerns to Staff LL, Hospitalist, and Staff M, Medical-Surgical Director. She did request a head CT from Staff LL because "maybe something changed from the initial CT," and Staff LL told her that there was no need to repeat a head CT.

During a telephone interview on 03/07/24 at 9:20 AM, Staff JJ, NP, stated that they had tried to admit Patient #7 on his second ED visit the previous day (02/15/24), but he had refused. Patient #7 was admitted after his third ED visit for headache and low sodium. He was given Narcan for pinpoint pupils and then he improved. His UDS was positive. On 02/16/24, he was impulsive, was found naked in another room, and was hard to manage. He was "all over the place." Per family, his behaviors were the same. He was obsessed with hot showers. He did have a fall and was found sitting on the floor with his systolic BP in the 70s. They thought he had a vasovagal (temporary fall in blood pressure with pallor, fainting, sweating) event from the steam and dehydration. At that point, they did not know if he was withdrawing. Staff JJ ordered STI testing after Patient #7's mother voiced concerns. He did start to respond once he was on mood stabilizers for two days. He never had neck rigidity, and his highest temperature was 99 degrees Fahrenheit. The physicians were thinking there was a psychiatric component because of his response to the psychiatric medications. Staff JJ did not know if Patient #7 was tested for HSV. She gave report to the physicians. She had heard that the physicians had gotten a hold of the Infectious Disease physician to discuss the case and were to hold off on testing. Staff JJ did not do a lot with STI testing and leaned on the consulting physician for assistance in determining which orders to place.

On 03/07/24 at 11:15 AM, Staff L, Social Worker, stated that Patient #7 came in for a recurrent headache. She was involved to give Patient #7 treatment options. Staff RR, Administrator of the New Visions Program, was contacted to assist with safe disposition planning. Staff L spoke with Patient #7's mother, and Patient #7 was not wanting to communicate. He was sleeping in the bed. The mother voiced her concerns about Patient #7 exhibiting different behaviors recently. He was sexually active with a partner who had an STI, and Patient #7's mother was concerned about him having intercourse with another man. She was also concerned about his UDS showing methamphetamine. An STI panel was run per the physician. Staff EE, Physician, felt there were psychiatric issues and contacted a behavioral health professional to do a behavioral health evaluation (BHE). On 02/19/24, Patient #7 was still there and had behaviors that made it unsafe to discharge Patient #7. Staff LL, Hospitalist assessed Patient #7 and initiated a referral. Patient #7's behaviors were more psychiatric like so the staff wanted to "make sure all the I's were dotted and T's were crossed," Patient #7's mother was notified of the psychiatric evaluation. Staff OO, Emergency Services Specialist, was at Patient #7's bedside to perform the BHE. Patient #7 was drowsy and only answered a few questions. He denied suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideations (HI, thoughts or attempts to cause another's death). Staff OO determined that he was not in crisis at that time and said it was more medical and that "we needed to focus more on that." Staff L notified Staff LL, Hospitalist. On 02/20/24, he started exhibiting odd behaviors (biting his nails, restless, taking his clothes off, and rocking in bed). His mother asked if he was "coming off of something" and that these "were not normal behaviors." Staff L notified Staff LL of the mother's concerns. During staff huddle Staff L was asked again to get Patient #7 into a psychiatric facility because his behaviors were more psychiatric like. Staff L told Patient #7's mother and made referrals to psychiatric facilities. She was still concerned and tearful, and Staff L told her to keep advocating for Patient #7. Staff L had mixed feelings about Patient #7, the behaviors he exhibited, and that behavioral health professional told them that it was not a psychiatric episode. She did notify Staff LL of her concerns, and she was directed to continue with psychiatric placement, since physicians had the ultimate decision. His behaviors (taking clothes off, wandering in the halls into another patient's room, etc.) caused him to be denied by drug rehabilitation facilities/programs. She also heard a report that he had taken eight to nine showers in one evening. On average, there were 12-14 medical detox patients per month. Staff RR usually oversaw their discharge planning.

During a telephone interview on 03/07/24 at 12:55 PM, Staff EE, Physician, stated that Patient #7 was admitted for abnormal lab values. He was asleep and would not interact with Staff EE. At night, they had a tough time and family had to be called in to sit with the patient. He refused his meds and labs. Staff JJ, NP, told her that Patient #7's family shared that he was sexually active and had multiple partners, one of which had syphilis. STI testing was completed, they "did what we had access to." One of Staff EE's colleagues contacted the Infectious Disease physician, who said to hold off on other tests until the tests for syphilis, gonorrhea, chlamydia, and HIV came back. Staff EE was not sure if they had official access to an Infectious Disease provider on the inpatient side. Patient #7 would not talk to staff or follow commands, he did not participate in a physical exam, he was calm and not acting bizarre. An LP would