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Based on observation, interview, record review and policy review, the hospital's Governing Body failed to ensure that care was provided in a safe setting and adequate nursing supervision was provided when the Chief Executive Officer (CEO) failed to effectively manage the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.23 Condition of Participation (CoP): Nursing Services, 42 CFR 482.13 CoP: Patient's Rights and 42 CFR 482.43 CoP: Discharge Planning. These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.12 Condition of Participation: Governing Body.

Please refer to tag A-0057, A-0115, and A-0385.



49489

Based on interview and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.23 Condition of Participation (CoP): Nursing Services, 42 CFR 482.13 CoP: Patient's Rights and 42 CFR 482.43 CoP: Discharge Planning. These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's document titled, "Governing Board Bylaws," dated 09/16/24, showed the CEO was responsible for the overall management of the hospital.

Review of the hospital's undated document titled, "Organizational Chart," showed all administrative leaders reported to Staff A, Interim CEO.

During an interview on 09/17/24 at 12:30 AM, Staff A, Interim CEO, stated she was responsible for the hospital and the staff.



49489

Based on observation, interview, record review and policy review, the hospital failed to provide care in a safe setting when the hospital failed to:
- Ensure that the patient, patient's representative, or patient's legal guardian was informed of the patient's rights prior to the patient's discharge. (A-0117)
- Ensure patients were not having sexual contact on one unit (Acute Inpatient Unit) of four units observed. (A-0144)
- Ensure that contraband (items that are illegal, forbidden, or that can be used to harm self or others) was not accessible to patients on three units (Acute Inpatient Unit, 400 Unit and 500 Unit) of four units observed. (A-0144)
- Ensure that wheelchairs had protective coverings over openings to prevent contraband transport into the hospital for one unit (Acute Inpatient Unit) of four units observed. (A-0144)
- Secure and/or remove ligature (anything which could be used for the purpose of hanging or strangulation) and safety risks related to a fire alarm pull protective case on one unit (Acute Inpatient Unit) of four units observed. (A-0144)
- Secure and/or remove ligature risk and safety risks related to a nine-inch round metal floor plate for one unit (Acute Inpatient Unit) of four units observed. (A-0144)
- Secure and/or remove ligature and safety risks related to three unattended shower chairs for one unit (Acute Inpatient Unit) of four units observed. (A-0144)
- Ensure that psychiatric (relating to mental illness) safe chairs were used in one day room and in the telephone area on one unit (Acute Inpatient Unit) of four units observed. (A-0144)
- Ensure bathroom doors did not lock from the inside for unit (500 Unit) of four units observed. (A-0144)
- Ensure that there were psychiatric safe screws used for door hinges, locks and latches for two units (Acute Inpatient Unit and 500 Unit) of four units observed. (A-0144)
- Secure and/or remove ligature risk and safety risks related to wooden doors and sheetrock walls for one unit (Acute Inpatient Unit) of four units observed. (A-0144)
- Secure and/or remove ligature risk and safety risks related patient beds for one unit (Acute Inpatient Unit) of four units observed. (A-0144)
- Ensure that staff were trained in de-escalation (reduction of the intensity of a conflict or potentially violent situation) techniques prior to being assigned patient care. (A-0144)
- Ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were ordered by a physician or other licensed practitioner (LP) responsible for the care of the patient for five patients (#50, #57, #64, #70 and #72) of nine restraint patients reviewed. (A-0168)
- Ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) for five discharged patients (#50, #57, #64, #70 and #72) of nine restraint patients reviewed. (A-0175)

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.



49489

Based on interview, record review and policy review, the hospital failed to inform the patient's representative of the patient's rights before patient care was discontinued for one patient (#7) of 17 discharged patients reviewed. These failures had the potential to violate the rights of all patients admitted to the hospital.

Findings included:

Review of the hospital's undated policy "Statement of Patient Rights," showed patients had the right to:
- Be informed of the hospital's plan of care for their treatment.
- Be involved with treatment decisions and care planning process.
- Choose among Medicare providers for services provided.
- Participate in their discharge planning process.

Review of Patient #7's medical record showed the hospital had not communicated with Patient #7's legal guardian about when and where the patient would be discharged to. There was no signature from the patient or the patient's guardian on the discharge aftercare plan.

During an interview on 09/11/24 at 10:30 AM, Staff C, Physician, stated:
- The hospital communicated with Patient #7's father about treatment decisions, his care plan and discharge planning
- After being hospitalized for a few weeks, Patient #7 was ready to be discharged.
- When the hospital attempted to contact Patient #7's father about the patient being discharged, he informed them that he was no longer able to take care of the patient in his home and they would need to find placement for the patient.
- The hospital attempted to find placement for Patient #7 but he was not accepted.
- Patient #7's condition improved by the time he was discharged but he would always require a legal guardian and would benefit from long-term placement.

During a telephone interview on 09/11/24 at 4:00 PM, Staff LL, Registered Nurse (RN), stated:
- She worked as the house supervisor on the day Patient #7 was discharged.
- Her role with the discharge process was to make sure the discharge paperwork was finalized and shared with the staff of the facility the patient was being discharged to.
- Whenever a patient had a guardian and the hospital communicated with the guardian about the patient being discharged, it would be documented in a discharge or progress note.
- A few days after being admitted, a patient's anticipated discharge date was added to the discharge calendar. During the daily treatment team meetings, a patient's progress toward achieving the anticipated discharge date, was reviewed.




49489

Based on observation, interview, record review and policy review, the hospital failed to provide care in a safe setting when the hospital failed to:
- Ensure patients were not having sexual contact on one unit (Acute Inpatient Unit) of four units observed.
- Ensure that contraband (items that are illegal, forbidden, or that can be used to harm self or others) was not accessible to patients on three units (Acute Inpatient Unit, 400 Unit and 500 Unit) of four units observed.
- Ensure that wheelchairs had protective coverings over openings to prevent contraband transport into the hospital for one unit (Acute Inpatient Unit) of four units observed.
- Secure and/or remove ligature (anything which could be used for the purpose of hanging or strangulation) and safety risks related to a fire alarm pull protective case, call light cover, and exit light on one unit (Acute Inpatient Unit) of four units observed.
- Secure and/or remove ligature risk and safety risks related to a nine-inch round metal floor plate for one unit (Acute Inpatient Unit) of four units observed.
- Secure and/or remove ligature and safety risks related to three unattended shower chairs for one unit (Acute Inpatient Unit) of four units observed.
- Ensure that psychiatric (relating to mental illness) safe chairs were used in one day room and in the telephone area on one unit (Acute Inpatient Unit) of four units observed.
- Ensure bathroom doors did not lock from the inside for one unit (500 Unit) of four units observed.
- Ensure that there were psychiatric safe screws used for door hinges, locks and latches for two units (Acute Inpatient Unit and 500 Unit) of four units observed.
- Secure and/or remove ligature risk and safety risks related to wooden doors and sheetrock walls for one unit (Acute Inpatient Unit) of four units observed.
- Secure and/or remove ligature risk and safety risks related patient beds and for one unit (Acute Inpatient Unit) of four units observed.
- Ensure that all staff were educated related to de-escalation (reduction of the intensity of a conflict or potentially violent situation) techniques prior to being assigned patient care.

Findings Included:

Review of the hospital's policy titled, "Contraband," dated 04/2020 showed:
- On admission a thorough search will be made of the patient, purses, pockets, luggage, and belongings.
- Staff would send contraband items with the family or secure in designated locations.
- Contraband includes any item deemed unsafe by staff, any item with strings or any item with sharp edges.
- Additional contraband items listed were, belts, shoelaces, handkerchiefs, scarves, and clothing with ties, boots (includes steel toe), cans (aluminum, metal - such as aerosol cans), cameras, cell phones, chains, cigarette lighters, computers, cosmetic containers, mirrors, mouthwash/gel toothpaste containing alcohol, aerosols, drawstrings, earphones, electronic devices (all), glass or ceramic objects, picture frames, glass containers, guns, hats, headbands, knives, mace/pepper spray, matches, medications (including any type of medication or illegal substances), metal grooming equipment (including combs), mirrors (including make-up compacts with mirrors), nail polish or polish remover, needles, paperclips, pins (includes straight and safety pins), plastic bags of any size, purses, razors, scissors, sewing needles, hooks or scissors of any kind.

Review of a hospital self-report incident dated 08/22/24, showed two patients (Patient #76 and Patient #77) on the Acute Inpatient Unit were found in Patient #77's bathroom. Patient #76 exited the room upon discovery and Patient #77 jumped down from sitting on the sink and adjusted her pants. A staff member noticed that Patient #77 was in a room not assigned to him on their digital observation device and found them together. The patients were interviewed and disclosed that they were having consensual sexual intercourse. Video footage reviewed showed that the patients entered the room and were alone together for one to two minutes before the staff member entered and separated them. Patient #76 disclosed that he was positive for human immunodeficiency virus (HIV, virus that attacks the cells that help the body fight infection). Both patients were placed on precautions for sexually acting out, and Patient #76 was transferred to another unit. Patient #77 consented to baseline HIV testing, preventative medications and spoke voluntarily with law enforcement. The corrective actions for this incident included staff re-education about sexually acting out precautions, monitoring for closed doors of patient rooms. However, hospital leadership were unable to produce documentation of this re-education when requested.

During an interview on 09/10/24 at 10:20 AM, on the Acute Inpatient Unit, Patient #8 related an incident that occurred the previous evening. She stated a male patient got too close to Patient #59 making her uncomfortable. Another male patient intervened and stepped in between the two, upsetting the first male patient. This caused the staff to reprimand the patient who intervened. Staff commented that the first male patient was behaving inappropriately since he was off his medications. Patient #8 stated the staff attempted to separate the patients, but there were not enough staff members to ensure that they stayed apart. The other patients on the unit felt compelled to intervene, because the hospital staff were either unable or unwilling to prevent inappropriate interactions. Patient #8 and the other patients who witnessed the event wrote a letter describing the events, signed it, and presented it to "someone from HR." She confirmed the male patient never touched Patient #59 and she was discharged later that day, on 09/10/24.

The interview supports the hospital's continued difficulty with properly monitoring patient interactions.

During an interview on 09/10/24 at 10:30 AM, Staff L, Behavioral Health Associate (BHA), stated if a patient was harassing someone, she would separate them and keep the harasser somewhere where the staff could maintain direct line of sight. When asked if it was possible to keep them separated consistently, she shrugged and said it depended on what else was going on in the unit and how well they were staffed.

Observation on 09/09/24 at 2:48 PM, on the Acute Inpatient Unit, showed:
- In room 111, a pair of tennis shoes with shoestrings. In the bathroom, there were three unopened rolls of toilet paper, an 18-inch stack of paper towels, and one bottle of mouthwash.
- In room 112, there was a hairbrush on the nightstand.
- In room 113, a pair of flip flop sandals with a metal letter "G" on each one and cloth straps. In the bathroom, there were three rolls of unopened toilet paper and a twelve-inch stack of paper towels.
- In room 114, there was one pair of flip flop sandals with leather straps and two metal buckles on each shoe.
- In room 115, the bathroom contained three unopened rolls of toilet paper and an 18-inch stack of paper towels.

Observation on 09/09/24 at 3:20 PM, on the Acute Inpatient Unit, showed the bathroom of room 109, contained extra rolls of toilet paper and an excessive amount of paper towels. In room 108, personal clothes and shoes with shoelaces.

Observation on 09/09/24 at 3:25 PM, on the Acute Inpatient Unit, showed room 105's bathroom contained two bottles of conditioner, one bottle of body wash, one toothbrush, one hairbrush, an 18-inch stack of paper towels, and one bottle of lotion. In room 104, there was one bottle of skin cleanser and the bathroom contained four rolls of unopened toilet paper and two 18-inch stacks of paper towels.

An observation on 09/10/24 at 9:25 AM, on the Acute Inpatient Unit, showed the bathroom shared by Patient #10 and his roommate contained a toothbrush, toothpaste, and excess paper towels and toilet paper.

During an interview on 09/10/24 at 9:38 AM Staff O, BHA, stated communication from leadership and among the staff at the hospital was inconsistent. There was a lot of confusion about contraband and the rules in general. She was concerned there were no security guards and some of the patients who were admitted were too aggressive to be managed.

During an interview on 09/10/24 at 10:30 AM, Staff L, BHA, stated better communication regarding rules and contraband was needed. The previous night a supervisor had allowed multiple patients to have hoodies, which she then had to collect at the start of her shift upsetting those patients unnecessarily.

During interviews on 09/09/24 at 3:03 PM and 3:40 PM, and on 09/17/24 at 10:30 AM, Staff, E, Chief Nursing Officer (CNO), stated it was expected for environmental rounds to be completed every shift by everyone. Each shift the BHAs look for contraband and safety concerns. Environmental rounds were to be documented. Hairbrushes, flip flop sandals with leather straps and metal clasps, tennis shoes with shoestrings, hygiene products, excess toilet paper, and excess paper towels were considered contraband, and those items should not be left in patient rooms. Hygiene items were not to be left in patient rooms. They were to be given to the patients to use and then returned to the patient bin when finished.

Observation on 09/09/24 at 3:25 PM, on the Acute Inpatient Unit, showed a patient wheelchair that was missing the rubber protective piece on the front wheels in room 109.

Observation on 09/09/24 at 2:48 PM, on the Acute Inpatient Unit, showed:
- In room 105, the ceiling call light cover was not attached on one side.
- In room 112, the ceiling light cover was missing.
- In the hallway, across from room 115, the plastic ceiling exit sign had a ¾ inch gap between the sign and the ceiling. On the wall, the fire alarm pull plastic protective cover was not latched down.

Observation on 09/09/24 at 3:20 PM, on the Acute Inpatient Unit, in room 108, showed an unlocked thermostat cover.

Observation on 09/09/24 at 3:20 PM, on the Acute Inpatient Unit, in the hallway outside of room 109, showed a five-inch round metal plate, with sharp edges, secured to the floor with one loose non-psychiatric safe screw.

Observation with concurrent interview on 09/09/24 at 3:10 PM, showed in the patient dayroom of the Acute Inpatient Unit, 13 non-psychiatric safe chairs, a fire extinguisher cabinet with one non-psychiatric safe screw, and a metal wall heater that had a round plastic, removable knob. Staff E, CNO, stated patients could come and go out of the dayroom whenever they wanted. Staff were not assigned to the dayroom, and it was not continuously supervised.

Observation with concurrent interview on 09/09/24 at 3:10 PM, showed in the patient telephone area, two non-psychiatric safe chairs.

Observation on 09/09/24 at 3:25 PM, on the Acute Inpatient Unit, showed:
- The patient shower room had one non-psychiatric safe shower chair.
- In room 105, one non-psychiatric safe shower chair.
- In room 111, one non-psychiatric safe shower chair.

Observation on 09/10/24 at 8:58 AM, on the 500 Unit, showed:
- In the bathroom for rooms 500 and 501, the doors locked from the inside and required a key to enter.
- In the bathroom for rooms 503 and 504, the doors locked from the inside and required a key to enter.
- In the bathroom for rooms 509 and 510, the doors locked from the inside and required a key to enter.

Observation on 09/09/24 at 2:48 PM, on the Acute Inpatient Unit, showed:
- In the hallway, across from room 112, the fire extinguisher protective case had two non-psychiatric safe screws.
- In the hallway, across from room 115, the fire alarm pull's plastic protective cover had four non-psychiatric safe screws.
- In room 113, a loose door latch with two non-psychiatric safe screws.

Observation 09/09/24 at 3:20 PM, on the Acute Inpatient Unit, showed room 109, had one loose psychiatric safe screw. In room 107, four non-psychiatric safe screws and two loose non-psychiatric safe screws secured the door plate. The bathroom had a metal plate under the sink that had 2 screws that were non-psychiatric safe and the metal backing behind the toilet had five missing psychiatric safe screws.

Observation on 09/09/24 at 3:25 PM, on the Acute Inpatient Unit, showed in the hallway across from room 109, the fire extinguisher protective case had two non-psychiatric safe screws.
Observation on 09/10/24 at 8:58 AM, on the 500 Unit, showed the patient water station lock had two non-psychiatric safe screws. The patient medication roll-up door had seven non-psychiatric safe screws.

Observation on 09/10/24 at 9:50 AM, on the 400 Unit, showed:
- In room 406, the doorstop was secured with non-psychiatric safe screws.
- In the hallway adjacent to room #406 there was a five-inch section of chipped away drywall leaving one exposed and raised plastic vinyl bead (a piece of plastic that cover the corner of a wall where two pieces of drywall meet).
- In room 407, there was chipped away pieces of drywall near the entrance of the room.
- In room 408, there were two non-psychiatric safe screws securing the door's strike plate and the wooden door had pieces of chipped wood on the inside of the door.
- In Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) room Two, the wooden heater cabinet was missing two psychiatric safe screws and an elevated sharp corner on the top right-hand side of the metal window frame of the door facing the inside of the room. Inside of the room, 10 inches of scotch tape was found stuck to the camera housing. The anteroom had a ½ inch piece of chipped drywall. The bathroom was missing a screw in the door jamb.

Observation on 09/10/24 at 9:50 AM, on the 400 Unit, showed in room 403 and 404, two beds that appeared to be wet from the base of the bed, where it touched the floor, to halfway up the wooden bed frame. The floors had evidence of water damage and seepage. The shower in room 403 had a steady stream of water flowing down the wall, from the base of the shower fixture, that flowed out of the wall.

During an interview on 09/10/24 at 10:27 AM, Staff X, Environmental Services (EVS), stated she had reported to the nurses on duty on 06/26/24 that the shower had been leaking and water was going into two patient rooms. She showed a picture she had taken with her phone of the rooms on 06/26/24. The picture showed a darkened, wet areas on the beds and crumbling drywall, on the wall near the baseboards.

During an observation and concurrent interview on 09/10/24 at 1:50 PM, on the 400 Unit, room 403 had one patient in the room, sleeping. Room 404 was locked, no patients occupying the room. Staff E, CNO, stated the hospital was closing rooms 403 and 404, due to leaking water from the bathroom. She stated Patient #38 was sleeping inside room 403 and would be moved to another room when he woke up.

During an interview on 09/10/24 at 1:40 PM, Staff V, Division President, stated she expected all patient rooms, areas, and equipment to be psychiatric safe.

During an interview on 09/17/24 at 10:30 AM, Staff, E, CNO, stated all furniture and patient equipment should be psychiatric safe. All screws should be psychiatric safe. All coverings on call lights, fire alarm pulls, and lights should be secure.

Observation and concurrent interview on 09/12/24 at 3:00 PM, on the Acute Inpatient Unit, showed Patient #59 banging on a locked door and being let into the main area of the acute unit, unaccompanied by any staff. She came from a long narrow room containing tables and chairs, where all potential exits were locked. She was escalated, talking loudly, moving quickly, waving her arms, complaining about the staff and her care. Staff RR, Director of Risk, stated the patient had been with other patients in a group therapy meeting room off the corridor. She was disruptive in the group and a staff member with the group had communicated to the staff in the acute unit via walkie-talkie that she was going to be walking back over. The patient appeared to be unaccompanied when she came back, but staff stated they had direct line of sight as she went from the group room back to the main unit.

During an interview on 09/10/24 at 9:50AM, Staff M, BHA stated it was her first day at the Acute Inpatient Unit. She was an agency staff member and had not been given any training in de-escalation.








49489




50496

Based on interview, record review and policy review, the hospital failed to ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were ordered by a physician or other licensed practitioner (LP) responsible for the care of the patient for five patients (#50, #57, #64, #70 and #72) of nine restraint patients reviewed.

Findings included:

Review of the hospital's policy titled, "Restraint," dated 04/2020, showed:
- Restraint may only be ordered by the attending physician or covering practitioner.
- A physical restraint includes manual measures to limit or restrict body movement. Holding a patient who is not cooperative while receiving a medication through injection is considered a physical restraint.
- A chemical restraint is defined as a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
- A trained registered nurse (RN) may initiate the restraint in the absence of a practitioner. The attending physician/covering practitioner will be contacted during the initiation of seclusion or immediately after.
- The order shall indicate the reason and maximum duration of the restraint.

Review of the hospital's policy titled, "Seclusion," dated 04/2020, showed:
- Seclusion may only be ordered by a psychiatrist (physician who specializes in mental health disorders) and only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled out.
- Seclusion is defined as the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.
- A trained RN may initiate seclusion in the absence of a practitioner. The attending physician/covering practitioner will be contacted during the initiation of seclusion or immediately after.
- The order shall indicate the reason and maximum duration of the seclusion.

Review of the hospital's document titled, "Rules and Regulations of the Medical Staff," dated 09/2024, showed orders for restraint or seclusion are to be given by a Practitioner, the use of which is limited to Emergency Situations. If a practitioner is not immediately available, a specifically trained RN may initiate restraint or seclusion based on appropriate assessment of the patient. A Practitioner will be notified as soon as possible thereafter to obtain an order.

Review of the hospital's document titled, "Incident Report Form," dated 05/17/24, showed Patient #50 was placed into seclusion from 3:00 PM until 7:00 PM.

Review of Patient #50's medical record showed the following:
- She was a 43-year-old female admitted on 05/14/24.
- She had a past medical history of schizophrenia (serious mental disorder that affects a person's ability to think, feel and behave clearly).
- On 05/14/24, there was no physician's order for Patient #50 to be placed in seclusion.

Review of the hospital's document titled, "Incident Report Form," dated 08/08/24, showed five staff and four police officers used a manual hold to administer a sedative (a drug taken for its calming or sleep-inducing effect) injection to Patient #57.

Review of Patient #57's medical record showed:
- He was a 53-year-old male admitted on 08/08/24 for suicidal ideation (SI, thoughts of causing one's own death).
- He had a past medical history of depression (extreme sadness that does not go away).
- On 08/08/24, there was no physician's order for the manual hold or sedative injection.

Review of Patient #64's medical record showed:
- He was a 47-year-old male admitted to the acute unit at North Kansas City.
- On 07/17/24, he was placed in seclusion at 7:30 AM according to the Seclusion and Restraint Log.
- On 07/17/24, there was no physician order for seclusion.

Review of Patient #70's medical record showed:
- He was a 37-year-old male admitted to the acute unit at Liberty.
- On 07/19/24, a physical restraint was used on him at 4:25 PM according to the Seclusion and Restraint Log.
- On 07/19/24, there was no physician order for the restraint.

Review of Patient #72's medical record showed:
- She was a 19-year-old female who was admitted to the North Kansas City Valor Unit.
- On 02/22/24, she was exhibiting unspecified self-harm behaviors (behavior that is harmful or potentially harmful to oneself) and was placed in a physical restraint at 12:40 PM and at 7:20 PM according to the Seclusion and Restraint Log.
- On 02/22/24, there were no physician orders for physical restraints.

During an interview on 09/17/24 at 2:40 PM, Staff E, Chief Nursing Officer (CNO), stated she expected staff to be familiar with the hospital's restraint policy. Staff were to get a physician's order for restraint and seclusion.



49489

Based on interview, record review, and policy review, the hospital failed to ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) for five discharged patients (#50, #57, #64, #70 and #72) of nine restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Restraint," dated 04/2020, showed:
- A physical restraint includes manual measures to limit or restrict body movement. Holding a patient who is not cooperative with receiving a medication through injection is considered a physical restraint.
- A chemical restraint is defined as a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
- The nurse will document behaviors which led to the need for the use of restraint.
- The patient shall be monitored and reassessed through continuous in-person observation.
- A practitioner or trained registered nurse (RN) shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. The evaluation must be completed even if the physical restraint has been discontinued prior to the in-person evaluation.
- The patient shall be debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for restraint.
- The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent reoccurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion.

Review of the hospital's policy titled, "Seclusion," dated 04/2020, showed:
- Seclusion may only be ordered by a psychiatrist (a physician who specializes in mental health disorders) and only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled out.
- Seclusion is defined as the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.
- A trained RN may initiate seclusion in the absence of a practitioner. The attending physician/covering practitioner will be contacted during the initiation of seclusion or immediately after.
- The order shall indicate the reason and maximum duration of the seclusion.
- The nurse will document behaviors which led to the need for the use of seclusion.
- The patient shall be monitored and reassessed through continuous in-person observation.
- A practitioner or trained RN shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. The evaluation must be completed even if the seclusion has been discontinued prior to the in-person evaluation.
- The patient shall be debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for seclusion.
- The treatment plan shall be reviewed and revised following the first episode of seclusion to include measures to prevent reoccurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is secluded on more than one occasion.

Review of the undated educational document titled "Seclusion/Restraint Assessment Skills Checklist," showed staff were required to complete restraint and seclusion education during orientation and annually with their performance evaluation. Their evaluation included a demonstration of the ability to document restraints and seclusion accurately and in a timely manner and assure that the treatment plan was updated with each seclusion or restraint episode.

Review of the hospital's document titled, "Incident Report Form," dated 05/17/24, showed Patient #50 was given a chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) and placed into seclusion from 3:00 PM until 7:00 PM.

Review of Patient #50's medical record showed:
- She was a 43-year-old female admitted on 05/14/24.
- She had a past medical history of schizophrenia (serious mental disorder that affects a person's ability to think, feel and behave clearly).
- On 05/14/24, there was no nursing documentation related to restraints.

Review of the hospital's document titled, "Incident Report Form," dated 08/08/24, showed five staff and four police officers used a manual hold to administer a sedative (a drug taken for its calming or sleep-inducing effect) injection to Patient #57.

Review of Patient #57's medical record showed:
- He was a 53-year-old male admitted on 08/08/24 for suicidal ideation (SI, thoughts of causing one's own death).
- He had a past medical history of depression (extreme sadness that does not go away).
- On 08/08/24, there was no nursing documentation related to restraints.

Review of Patient #64's medical record showed:
- He was a 47-year-old male admitted the acute unit at North Kansas City.
- On 07/17/24, he was placed in seclusion at 7:30 AM according to the Seclusion and Restraint Log.
- On 07/17/24, there was no physician order for the seclusion, no one hour face-to-face assessment, and no nursing documentation of the event.

Review of Patient #70's medical record showed:
- He was a 37-year-old male admitted to the acute unit at Liberty.
- On 07/19/24, a physical restraint was used on him at 4:25 PM according to the Seclusion and Restraint Log.
- On 07/19/24, there was no physician order for the restraint, no nursing documentation, and no one hour face-to-face assessment documented.

Review of Patient #72's medical record showed:
- She was a nineteen-year-old female who was admitted to the North Kansas City Valor Unit.
- On 02/22/24, she was exhibiting unspecified self-harm behaviors (behavior that is harmful or potentially harmful to oneself) and was placed in a physical restraint at 12:40 PM and at 7:20 PM according to the Seclusion and Restraint Log.
- On 02/22/24, there were no orders for the physical restraints, and no one hour face-to-face assessments documented.

During an interview on 09/17/24 at 2:40 PM, Staff E, Chief Nursing Officer (CNO), stated she expected staff to be familiar with the hospital's restraint policy. Staff were to follow the policy on the frequency of assessments, monitoring, and documenting on restraints.





49489

Based on observation, interview, record review and policy review, the hospital failed to ensure staff followed medication administration guidance for 20 current patients (#1, #20, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #39, #40, #41, #43, #44, #45, #46 and #47), and one discharged patient (#65) of 24 patients reviewed, and ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) for five discharged patients (#50, #57, #64, #70 and #72) of nine restraint patients reviewed in restraint and seclusion.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Nursing Services.

Please refer to tags A-0395 and A-0405.



49489

Based on interview, record review, and policy review, the hospital failed to ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) for five discharged patients (#50, #57, #64, #70 and #72) of nine restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Restraint," dated 04/2020, showed:
- A physical restraint includes manual measures to limit or restrict body movement. Holding a patient who is not cooperative with receiving a medication through injection is considered a physical restraint.
- A chemical restraint is defined as a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
- The nurse will document behaviors which led to the need for the use of restraint.
- The patient shall be monitored and reassessed through continuous in-person observation.
- A practitioner or trained registered nurse (RN) shall conduct an in-person evaluation of the patient within one hour of initiation of a restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. The evaluation must be completed even if the physical restraint has been discontinued prior to the in-person evaluation.
- The patient shall be debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for restraint.
- The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent reoccurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion.

Review of the hospital's policy titled, "Seclusion," dated 04/2020, showed:
- Seclusion may only be ordered by a psychiatrist (a physician who specializes in mental health disorders) and only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled out.
- Seclusion is defined as the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.
- A trained RN may initiate seclusion in the absence of a practitioner. The attending physician/covering practitioner will be contacted during the initiation of seclusion or immediately after.
- The order shall indicate the reason and maximum duration of the seclusion.
- The nurse will document behaviors which led to the need for the use of seclusion.
- The patient shall be monitored and reassessed through continuous in-person observation.
- A practitioner or trained RN shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. The evaluation must be completed even if the seclusion has been discontinued prior to the in-person evaluation.
- The patient shall be debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for seclusion.
- The treatment plan shall be reviewed and revised following the first episode of seclusion to include measures to prevent reoccurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is secluded on more than one occasion.

Review of the hospital's undated educational document titled "Seclusion/Restraint Assessment Skills Checklist," showed staff were required to complete restraint and seclusion education during orientation and annually with their performance evaluation. Their evaluation included a demonstration of the ability to document restraints and seclusion accurately, in a timely manner and assure that the treatment plan was updated with each seclusion or restraint episode.

Review of the hospital's document titled, "Incident Report Form," dated 05/17/24, showed Patient #50 was given a chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) and placed into seclusion from 3:00 PM until 7:00 PM.

Review of Patient #50's medical record showed:
- She was a 43-year-old female admitted on 05/14/24.
- She had a past medical history of schizophrenia (serious mental disorder that affects a person's ability to think, feel and behave clearly).
- On 05/17/24, there was no nursing documentation related to restraints.

Review of the hospital's document titled, "Incident Report Form," dated 08/08/24, showed five staff and four police officers used a manual hold to administer a sedative (a drug taken for its calming or sleep-inducing effect) injection to Patient #57.

Review of Patient #57's medical record showed:
- He was a 53-year-old male admitted on 08/08/24 for suicidal ideation (SI, thoughts of causing one's own death).
- He had a past medical history of depression (extreme sadness that does not go away).
- On 08/08/24, there was no nursing documentation related to restraints.

Review of Patient #64's medical record showed:
- He was a 47-year-old male admitted to the acute unit.
- On 07/17/24 at 7:30 AM, he was placed in seclusion.
- On 07/17/24, there was no physician order for the seclusion, no one hour face-to-face assessment and no nursing documentation of the event.

Review of Patient #70's medical record showed:
- He was a 37-year-old male admitted to the acute unit.
- On 07/19/24 at 4:25 PM, a physical restraint was used on him.
- On 07/19/24, there was no physician order for the restraint, no nursing documentation and no one hour face-to-face assessment documented.

Review of Patient #72's medical record showed:
- She was a nineteen-year-old female admitted to the Valor Unit.
- On 02/22/24, she was exhibiting unspecified self-harm behaviors (behavior that is harmful or potentially harmful to oneself) and was placed in a physical restraint at 12:40 PM and at 7:20 PM.
- On 02/22/24, there were no orders for the physical restraints, and no one hour face-to-face assessments documented.

During an interview on 09/17/24 at 2:40 PM, Staff E, Chief Nursing Officer (CNO), stated she expected staff to be familiar with the hospital's restraint policy. Staff were to follow policy on the frequency of assessments, monitoring, and documenting on restraints.





49489

Based on observation, interview, record review and policy review, the hospital failed to ensure staff followed medication administration guidance for 20 current patients (#1, #20, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #39, #40, #41, #43, #44, #45, #46 and #47), and one discharged patient (#65) of 24 patients reviewed. This had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Medication Administration and Documentation," dated 8/2020, showed:
- All medications must be immediately documented on the Medication Administration Record (MAR) after administration.
- Documentation includes the dose, time, route, site, their staff initials and signature at the bottom of the MAR. The signature must be legible and include their initials, surname and title.
- Medications can be administered by licensed personnel, which include Licensed Practical Nurses (LPN), Registered Nurses (RN), Physicians and Nurse Practitioners (NP).
- During medication administration staff are to check the patient's MAR to ensure that the order is accurate by verifying the right patient, medication, dosage, route, frequency, and stop date. Review any cautionary statements, keep the unit dose packages intact until just prior to administration, and properly prepare medications according to practitioner's instructions or the medication label.
- Staff are to review the five rights prior to administering medication by verifying the right: patient (with two identifiers), medication, dosage, route, and time. Patient identifiers include the patient's picture, wristband, or asking for the patient's name and date birth date, then verifying them with the MAR.
- Medications should not be administered if there are any questions, inconsistencies, or unclear items identified by the five rights. Any questions or inconsistencies should be clarified by the physician, another nurse, a pharmacist and/or reference material.
- Two nurses must check the dosage order and prepared amount of insulin (medication that regulates the amount of sugar in the blood) prior to administration.

Review of the hospital's document titled, "Medication Errors," dated 07/01/24 to current, showed:
- On 07/06/24, a patient was given the wrong dose of suboxone (a medication that decreases the severity of withdrawal symptoms and reduce a patient's long-term dependence on opioids) 2/0.5 mg. They were given a double dose, twice. The error could have been prevented if the medication had been scanned.
- On 07/09/24, a patient was given two of his roommates' medications. The error could have been prevented if the medication had been scanned.
- On 09/03/24, a patient missed three days of medications due to expired orders.

Observation with concurrent interview on 09/09/24 at 3:07 PM, on the Acute Unit, showed Patient #1, was wearing a patient identification wristband. Staff G, RN, administered two medications in a cup to the patient without scanning his patient identification wristband. The RN did not verify his name or date of birth. Staff G stated she would usually scan the patient's identification wristband and ask the patient's date of birth. She did not scan his wristband because he got agitated when scanning his band and wasn't cooperative.

Observation with concurrent interview on 09/11/24 at 2:10 PM, on the 400 Unit, showed Patient #20 was not wearing an identification wristband. Patient #20 stated he had been at the hospital since 09/06/24 and never had a wristband.

Observation on 09/10/24 at 10:32 AM, on the 500 Unit, showed Staff P, RN, administer clonazepam (medication used to treat anxiety) to Patient #27. He did not scan her patient identification wristband, ask her name or date of birth.
Observation on 09/10/24 at 10:02 AM, on the 500 Unit, showed Staff P, RN, administer nicotine gum (used to help people stop smoking cigarettes) and check Patient #28's BG. Staff P did not scan the patient's identification wristband or ask her name or her date of birth.
Observation on 09/10/24 at 10:25 AM, on the 500 Unit, showed Staff P, RN, administer two insulin injections to Patient #28. He did not scan the patient's identification wristband or ask her name or her date of birth.
During an interview on 09/10/24 at 1:40 PM, Staff V, Division President, stated medication passes should follow the policy and Staff P did not follow policy when he gave medications to Patient #27 and Patient #28.
During an interview on 09/10/24 at 2:35 PM, Staff P, RN, stated that he did not scan Patient #27's identification wristband because she did not have the band and Patient #28's wristband because he had verified her name earlier. He could either scan the patient chart or the patient identification wristband. He had too many patients to care for and felt that it was appropriate not to scan the patient's identification wristband during medication pass.
Observation with concurrent interview on 09/10/24 at 9:20 AM, on the Acute Unit, showed Patient #29's identification wristband was not checked for her name or date of birth prior to checking her BG. Staff Q, LPN, stated she normally would have checked the patient's wristband prior to doing a BG check.

Observation with concurrent interview on 09/10/24 at 8:55 AM, on the Acute Unit, showed Patient #30's, home medication was left out and unsecured, in a plastic bag on the counter in the medication room. Staff P, RN, stated all home medications were to go into a safe and returned to the patient at discharge.

During an interview on 09/10/24 at 1:55 PM, Staff AA, Pharmacist, stated controlled medications from home were to be handed off to pharmacy when the patient arrived and locked in the patient belongings medication locker. The controlled medication should not have been left on the counter, unattended and unsecured. She expected the home medication's to be secured in the belonging's locker. The pharmacist verified that there was one hydrocodone (opioid pain medication) tablet in the patient's labeled home medication bottle. There was one pill inventoried on 09/09/24 and the information was written on the outside of the plastic bag.

Observation with concurrent interview on 09/10/24 at 9:20 AM, on the Acute Unit, showed Patient #32, was not wearing a patient identification wristband. Staff Q, LPN, administered one medication to the patient without verifying his name and date of birth. The LPN stated she was not able to scan the medication barcode as she had not been taught how to scan or use the scanner and it was her first day at the hospital.

Observation with concurrent interview on 09/11/24 at 2:40 PM, on the 400 Unit, showed Patient #33 was wearing a patient identification wristband that did not contain a scannable barcode. Patient #33 stated her wristband could not be scanned.

Observation on 09/11/24 at 2:30 PM, on the 400 unit at Liberty, showed Patient's #34, #35 and #37 were not wearing patient identification wristbands.

Observation with concurrent interview on 09/11/24 at 2:35 PM, on the 400 Unit, showed Patient #36 was wearing a patient identification wristband that did not contain a scannable barcode. Patient #36 stated her wristband had not been scanned during medication passes since she had been in the hospital.

Observation on 09/11/24 at 2:40 PM, on the Acute Unit, showed Patient #39, was not wearing a patient identification wristband.

Observation on 09/11/24 at 2:45 PM, on the Acute Unit, showed Patient #40, was not wearing a patient identification wristband.

Review of the hospital's untitled document showed between 08/24/24 and 09/10/24, Patient #41's identification wristband was not scanned 28 out of 55 times oxycodone (synthetic pain medication with a high risk for misuse) was administered.

Observation on 09/11/24 at 12:00 PM, on the Acute Unit, showed that Patients #43, #44, #46, and #47 were not wearing an identification wristband.

Observation with concurrent interview on 09/11/24 at 12:10 PM, on the Acute Unit, showed Patient #45 was not wearing an identification wristband and was receiving medication at the nurse's station. Staff HH, RN, stated when a patient was not wearing an identification wristband or when their identification wristband could not be scanned for medication administration, the patient's identity was to be verified by their photograph in the MAR and stated name and date of birth.

Review of Patient #65's medical record showed:
- On 08/10/23, he was a 45-year-old male, with Type 1 diabetes (a condition where the body produces little to no insulin [hormone] resulting in the person requiring artificial insulin injections or medication) was admitted for suicidal ideation (SI, thoughts of causing one's own death). His psychiatric (relating to mental illness) diagnosis was major depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed).
- He was not able to have his insulin pump (delivery device for insulin [medication that regulates the amount of sugar in the blood]) at the hospital.
- The MAR indicated for a blood glucose (BG, sugar that circulates in the blood and when too high or too low can be detrimental to a person's health. Normal range for a known diabetic is 80 to 180) range of 351- 400 mg/dL, 10 units of regular insulin was to be given. The BG was to be repeated in one hour and the provider was to be called.
- Insulin was identified as a high alert medication and was to be checked by two RNs.
- On 08/11/2023 at 7:23 AM, his BG was elevated at 314 mg/dL.
- At 7:37 AM, he was given 5 units of insulin per the physician's order.
- At 11:08 AM, his BG was 446 mg/dL.
- At 11:45 AM, 10 units of humalog (a rapid-acting blood-glucose-lowering medication) insulin was ordered to be given.
- At 11:47 AM, 10 units of regular insulin was given.
- At 3:15 PM, regular insulin was ordered to be given for a BG of 490 mg/dL.
- At an undocumented time, his BG was 490 mg/dL, and 10 units of regular insulin was given. The medication was signed by one RN.
- At an unknown time, his BG was recorded as "HI" and an "X" was placed through units of insulin and the nurse's initials.

During an interview on 09/16/24 at 2:13 PM, Staff E, CNO, stated Pt #65's MAR indicated that insulin administration, there were no times, only dates written for his insulin administration. Insulin was a double-checked medication and two nurses should have signed on the MAR. The double signature indicated that the correct dose was verified against the physician's order prior to administration by two nurses.

Review of Patient #65's Hospital B medical record showed on 08/11/23 at 6:06 PM, he was transferred via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) for BG levels of 499 mg/dL and 566 mg/dL. Upon arrival at Hospital B's Emergency Department (ED), his BG was 464 mg/dL.

During an interview on 09/10/24 at 1:55 PM, Staff AA, Pharmacist, stated she expected all staff to scan the patient identification wristbands and medications before administering medication to the patient. Medication errors would have been caught and prevented had the staff used the medication scanner prior to administering medications to the patients. She manually inputted errors on a spreadsheet from incident reports that were reported to her by Risk Management and believed that medication errors were underreported.

During an interview on 09/17/24 at 10:30 AM, Staff E, Chief Nursing Officer (CNO), stated each patient should have a photograph in the MAR. Prior to a medication pass staff were to verify with the patient their name and date of birth. All patients should have been wearing patient identification wristbands.

During an interview on 09/11/24 at 1:10 PM, Staff II, LPN, stated staff were expected to scan the barcode on the patient's identification wristband, prior to medication administration. However, most patients on the unit did not have a wristband and whenever they did, the wristbands could not be scanned from inside the patient's room.

During an interview on 09/10/24 at 1:20 PM, Staff DD, RN, stated that all patients were to have a patient identification wristband. There should not be a reason that a patient did not have a patient identification wristband. If the patient did not have a patient identification wristband, then it was the nurse's responsibility to ensure a replacement band was made, which any nurse could do. There had been instances where a patient's identification wristband was unable to be scanned and the patient's identification sticker was placed on a sticky note and placed in the medication administration drawer for that patient. If the patient's identification wristband was unable to be scanned, then that barcode on the sticky note would be scanned as a backup. Before a nurse administered medication to a patient, the patient's identification wristband must be scanned. During medication administration, the medications were "popped" from the package. The patient's medications should never be "pre-popped," placed into a cup all together and given to the patient all at once as that practice would hinder the nurse from knowing when the patient refused a medication. She expected each medication to be scanned first, then popped from the package and given to the patient.

During an interview on 09/11/24 at 2:40 PM, Staff DD, RN, stated staff were to scan the barcode on the patient's identification wristband prior to medication administration. However, most patients on the unit did not have a wristband. If a patient did not have an identification wristband staff were to look at their photograph in the MAR. That process did not work if staff had to take medications to the patient because they could not take their portable workstation to patient rooms and most patients did not have a photograph in the MAR. A lot of the time the scanners did not even work to scan the patient identification wristband or the medication.



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49489




50151




50496

Based on interview, record review and policy review, the hospital failed to have an effective discharge planning process that focused on the patient goals and treatment preferences and included the patient and his or her caregivers/support person(s) in the discharge planning for post-discharge care when they failed to:
- Periodically review discharge plans on a representative sample of patients who were readmitted to the hospital within 30-days of the previous admission and to regularly assess their discharge planning process to ensure discharge plans were responsive to the patient's post-discharge needs. (A-0803)
- Ensure the patient's discharge planning evaluation was included in the patient's medical record for use in establishing an appropriate discharge plan and ensure the results of the evaluation was discussed with the patient or the patient's representative. (A-0808)
- Inform the patient or the patient's representative of their freedom to choose among Medicare providers and suppliers of the post-discharge services and when possible, respect the patient's or the patient's representative goals of care and treatment preferences, as well as other preferences they expressed. (A-0816)

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.43 Condition of Participation: Discharge Planning.

Please see A-0803, A-0808 and A-0816




49489

Based on interview, record review and policy review, the hospital failed to periodically review discharge plans on a representative sample of patients who were readmitted to the hospital within 30-days of the previous admission, and to regularly assess their discharge planning process, to ensure discharge plans were responsive to the patient's post-discharge needs. These failed practices had the potential to cause medical errors during transitions of care and negatively impact vulnerable patient populations.

Findings included:

Review of the hospital's policy "Discharge Planning," dated 04/2020, showed:
- Hospital leadership should assess the effectiveness of their discharge planning process and the assessment should be integrated into the hospital's Performance Improvement (PI) program.
-The hospital must have a mechanism in place to ensure its discharge planning process is re-assessed on an on-going basis.
- The review of the discharge planning process included review of discharge plans from closed medical records to determine if the hospital was responsive to the patient's post-discharge needs.
- 30-day readmission rates will be tracked to identify trends in preventable readmissions.

Review of the hospital's policy, "Healthcare Equality," dated 01/01/24, showed:
- Health care disparities will be identified in the hospital's patient population by stratifying quality and safety data, using the socio-demographic characteristics of the hospital's patients.
- Data will be collected and analyzed based on a sample of records each month.
- After the data is studied and analyzed, a written action plan will be developed that addresses at least one of the healthcare disparities identified in its patient population.
- The analysis and plan are reported to the Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) team, the Medical Executive Committee and the Governing Body.
- The hospital will act when the goals in its action plan are not achieved or sustained.
- Key stakeholders which included leaders, licensed practitioners, and staff will be informed of the progression of the plan to reduce identified healthcare disparities, at least annually.

During an interview on 09/11/24 at 2:45 PM, Staff D, Acadia Quality, stated:
- The hospital had not been having QAPI meetings for the past year.
- The hospital had a QAPI meeting on 08/08/24, but discharge planning was not included.
- The hospital had scheduled monthly QAPI meetings moving forward.



49489

Based on interview, record review and policy review the hospital failed to perform discharge planning evaluations to determine an appropriate discharge plan and review the findings of the evaluation with the patient/patient's representative for four discharged patients (#7, #25, #27 and #28) of 17 records reviewed. These failures had the potential to negatively affect all patients at the time of their discharge from the hospital.

Findings included:

Review of the hospital's policy "Discharge Planning," dated 04/2020, showed:
- The discharge plan was developed on admission.
- Throughout the discharge planning process, the patient and representative/family were prepared for the transition to the next level of care.
- The discharge plan should delineate how the progress made in the current level of care would continue after discharge, identify problems that would continue to the next level of care and determined the responsible party for prescribed follow-up.
- As part of the discharge planning process, direct and timely information was provided to other programs, agencies, or individuals involved with continuing care.
- The patient's readiness to be discharged, will be demonstrated by the patient's progress and achievement of their treatment goals.
- The patient long-term treatment goals may not be completely accomplished when discharged from the hospital's level of care.

Review of the hospital's policy, "Rules and Regulations for Medical Staff," dated 09/2024, showed:
- An initial discharge plan was developed from the provider's psychiatric (relating to mental illness) and mental status examinations.
- The attending physician was expected to specify discharge criteria and discharge planning was to be started as soon as possible, after admission.
- The attending physician was expected to collaborate with facility and aftercare providers, to ensure effective and comprehensive aftercare continued after discharge.

Review of the hospital's document, "Discharge Planner Job Description," dated 01/01/20, showed the discharge planners:
- Developed a continuing after care plan that ensured the patient and their families had ongoing support in recovery and/or other behavioral, mental or health care follow-up when discharged.
- Arranged and scheduled, discharge follow-up appointments for the patient. Appointments that included group and/or individual therapy, appointments with their psychologist (a professional who studies mental states, perceptual, cognitive, emotional, and social processes and behavior), psychiatrist (physician that specializes in mental health disorders), or medical doctor.
- Coordinated community resources to facilitate discharge and the continuum of care.
- Ensured that discharge planning documented in the medical record is clear, concise and timely.

Review of Patient #7's medical record showed:
- On 10/11/23 at 10:52 AM, the assigned discharge planner signed the discharge aftercare plan, which confirmed discharge aftercare instructions were provided and reviewed with the patient and/or patient's representative.
- The discharge aftercare plan was not signed by the patient or their representative.
- There was no documentation that showed the hospital had communicated with the patient's guardian about the discharge aftercare plan.
- The discharge aftercare plan indicated no follow-up appointments were made prior to the patient being discharged.
- On 10/11/23 at 11:15 AM, nursing placed a verbal order to discharge the patient. Medications to be continued after discharge were included in the discharge orders. No additional discharge orders were provided.

Review of Patient #25's medical record, dated 09/05/24, showed no documentation of a discharge plan.

Review of Patient #27's medical record, dated 09/06/24, showed no documentation of a discharge plan.

Review of Patient #28's medical record, dated 09/06/24, showed no documentation of a discharge plan.

During an interview on 09/10/24 at 11:05 AM, Staff U, Discharge Planner, stated discharge planning was not started at admission, it was usually done the day before the patient was discharged. She had difficulty keeping up due to the large number of admissions and discharges.

During an interview on 09/10/24 at 1:40 PM, Staff V, Division President, stated discharge planning should start at admission. The Discharge planner, along with a team, would work together on the patient's discharge plan.

During an interview on 09/11/24 at 10:30 AM, Staff JJ, Nurse Practitioner (NP), stated a safe discharge placement should be determined and verified prior to the day before the patient discharged.

During an interview on 09/11/24 at 10:56 AM, Staff C, Chief Medical Officer (CMO), stated discharge planning started on admission, was discussed every day and adjusted as necessary.

During an interview on 09/11/24 at 2:05 PM, Staff KK, Interim Director of Clinical Services, stated discharge planning should start at admission. The discharge plan was to be updated as the patient's condition changed, reviewed right before the patient discharged and signed by the clinical services team. The discharge plan should be reviewed with the patient's legal guardian and the communication documented in the patient's medical record.






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49489

Based on interview, record review and policy review, the hospital failed to provide the patient or the patient's representative the freedom to choose among participating Medicare providers and suppliers for post-discharge services for one discharged patient (#7) of 17 discharged patients reviewed. These failures had the potential to affect all patients continued progression with treatment goals post-discharge.

Findings included:

Review of the hospital's policy "Discharge Planning," dated 04/2020, showed:
- All patients should be allowed to select providers for follow-up that will be included in the patient's discharge plan.
- Arrangements and aftercare services desired, by the patient and/or the patient's representative, should be assessed as part of the discharge planning process.
- The discharge planning process identified who should be responsible for ensuring the prescribed discharge follow-up is accomplished.

Review of Patient #7's medical record showed:
- On 10/11/23 at 10:52 AM, the assigned discharge planner, signed the discharge aftercare plan, which confirmed discharge aftercare instructions were provided and reviewed with the patient and/or patient's representative.
- The medical record did not contain a list, of Medicare providers and suppliers that offered post-discharge services, for Patient #7 that had been presented or communicated to the patient's representative.
- The discharge aftercare plan was not signed by the patient or representative.
- There was no documentation that showed the hospital communicated with the patient's guardian about the discharge aftercare plan or choices for post-discharge services.
- The discharge aftercare plan indicated no follow-up appointments were made prior to the patient being discharged.

During an interview on 09/10/24 at 1:40 PM, Staff V, Division President, stated discharge planning should begin on admission. The Discharge planner, along with a team, the patient and the patient's family, should work together on the patient's discharge plan.

During an interview on 09/11/24 at 2:05 PM, Staff KK, Interim Director of Clinical Services, stated the discharge plan was to be updated as the patient's condition changed throughout the hospitalization and be discussed with the patient and the patient's family. When post-discharge needs were identified, a list of providers and suppliers of those services should be provided to the patient and/or the patient's representative. Discharge plans and the resources required at discharge were very individualized and based on many factors. Patient #7 required long-term mental health placement when all his post-discharge goals were achieved at the skilled nursing (nursing care and services provided to patients who require medical, nursing, or rehabilitative services but not the level of care or treatment available in a hospital) level of care. The hospital worked with the patient's father to get him placed when he was discharged from the acute care setting. They made several referrals to facilities to find post-discharge placement for Patient #7, but he was denied admission. The patient was discharged to a facility that accepted him and were able to provide long-term care services to ensure he had continued progression toward his treatment goals. After the patient achieved all his goals that can be provided at the skilled nursing facility, the Department of Mental Health (DMH) and the patient and/or the patient's representative would work together to find long-term mental health placement.






49489