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Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure contraband (items that are illegal, forbidden, or that can be used to harm self or others) was not accessible to patients on the behavioral health unit (BHU); (A-144)
- Ensure psychiatric safe screws were used in all patient areas of BHU; (A-144)
- Ensure cabinets containing contraband items were secured and locked; and (A-144)
- Follow their own policies and procedures that outlined staff roles for informing, retrieving, assisting with formulation, and documenting Advance Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) information for seven (#6, #7, #8, #9, #10, #11 and #19) discharged psychiatric (relating to mental illness) patients of eight psychiatric records reviewed. (A-0132)

These failures had the potential to affect the quality of care and safety of all patients.

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

Please refer to A-0132 and A-0144 for details.

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 one discharged patient (#11) of one record reviewed.

These failures had the potential to affect the quality of care and safety of all patients.

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

Please refer to A-0808 for details.

Based on interview, record review and policy review, the hospital failed to follow their own policies and procedures that outlined staff roles for informing, retrieving, assisting with formulation, and documenting Advance Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) information for seven (#6, #7, #8, #9, #10, #11 and #19) discharged psychiatric (relating to mental illness) patients of eight psychiatric records reviewed.

These failures had the potential to affect all patients who presented to the hospital seeking care.

Review of the hospital's policy titled, "AD/Living Wills," review 03/20/24, showed:
- Individuals have the right to make decisions concerning their care, including the right to formulate ADs as permitted under state statutory and case law.
- Mercy Hospital Stoddard provides assistance to patients who do not have an AD but wish to formulate one.
- The nurse will determine if the patient does or does not have advance directives and document this at the time of admission.

Although requested, the hospital did not provide an interview with the Psychiatric Unit Nurse Manager, she was on leave.

Findings included:

Review of Patient #6's medical record showed the psychiatric AD was not discussed.

Review of Patient #7's medical record showed the psychiatric AD was not discussed.

Review of Patient #8's medical record showed the psychiatric AD was not discussed.

Review of Patient #9's medical record showed the psychiatric AD was not discussed.

Review of Patient #10's medical record showed the psychiatric AD "was done in a different department." There was no documentation from any other department in regards to the AD.

Review of Patient #11's medical record showed the psychiatric AD was not discussed.

During an interview on 07/16/25 at 9:10 AM, Staff A, Director of Nursing, stated that she expected staff to follow all policies and procedures. She expected staff to question if a patient had an AD and offer to assist with writing one as needed. She was surprised the AD was not addressed in the Psychiatric Unit.

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 contraband (items that are illegal, forbidden, or that can be used to harm self or others) was not accessible to patients on the behavioral health unit (BHU).
- Ensure psychiatric safe screws were used in all patient areas of the BHU.
- Ensure cabinets containing contraband items were secured and locked.

Findings Included:
Review of the hospital's policy titled, "BHU Safety," dated 11/08/24, 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 included: objects made with glass or containing glass parts, weapons, aerosol cans of any type, medications of any type, electrical devices, cigarettes and/or tobacco products, plastic bags, clothing with strings, pens and pencils.

Review of the hospital's document titled, "Safety Event Manager #WSK195792," dated 04/30/25, showed Patient #25 brought the nurse a cigarette that was in his possession while on the BHU and it was not discovered during the admission search of his belongings.

Observation on 07/14/25 at 12:05, showed Room #202 had full sized shampoo and conditioner bottles with a large pile of clothing on the counter.

During an interview on 07/14/25 at 12:05 PM, Staff F, Charge Registered Nurse (RN), stated that patients could have whatever clothing they wanted, if there were no strings or elastic. She added, the patients were allowed their own personal care items to be kept in their rooms. The rooms were not locked, and the patients had access whenever they want to go in the rooms.

Observation on 07/14/25 at 12:10 PM, showed the group therapy room had unlocked cabinets that contained contraband items such as: 12 plastic bags, 26 full sized pencils, five full sized pens, one can of aerosol room freshener and two three-foot-long electronic cables.

During an interview on 07/14/25 at 12:45 PM, Staff G, Recreational Therapist, stated that cabinets were usually locked in the group room. She did not keep count of the items in the cabinets.

Observation on 07/14/25 at 12:10 PM, showed the white board in the Group Therapy room was secured with five non-psychiatric safe screws.

Observation on 07/14/25 at 12:08 PM, showed an Environmental Services (EVS) cart with cleaning supplies in the hallway of the milieu, left unattended and accessible to patients.

During an interview on 07/16/25 at 9:10 AM, Staff A, Director of Nursing (DON), stated that she expected staff to follow all policies and procedures. She expected the BHU environment to be psychiatric safe. She expected the cabinets were locked and there were to be no plastics bags. Large volume personal hygiene items were to be locked in the nurses' station and dispensed as needed in small amounts. She expected no full-size pencils, only golf pencils, and she expected all pens and pencils were counted and accounted for.


48359

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 one discharged patient (#11) of one record reviewed. These failures had the potential to negatively affect all patients at the time of their discharge from the hospital.

Findings included:

Review of Patient #11's face sheet showed her address as 610 South Chamber Drive, Fredericktown, Missouri, which is the same for Madison County Council for the Developmentally Disabled (MCCDD) business office.

Review of the hospital's policy titled, "Discharge Planning," dated 09/01/23, showed:
- The purpose is to outline the process and procedures for discharging patients with appropriate follow-up to the appropriate next level of care.
- Discharge planning involves identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination and beginning the process of meeting the patient's identified post discharge needs.
- The results of the discharge planning evaluation should be documented in the patient's medical record and updated as needed.
- The documentation should include communication with the patient/patient representative and/or the patient's rejection/refusal of the results of the discharge planning evaluation and plan.

Review of Patient #11's medical record dated 06/10/25, showed:
- On 06/10/25, she was a 22-year-old admitted to the hospital for suicidal ideation (SI, thoughts of causing one's own death) and aggressive behavioral outbursts risking harm to herself or others.
- Her past medical history included bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), oppositional defiant disorder (ODD, a disorder marked by defiant and disobedient behavior to authority figures), and intellectual disability.
- On 06/12/25, Staff I, Mental Health Manager, contacted MCCDD and discussed discharge plans. The Program Manager asked for the patient to not be discharged on a weekend, because staff was difficult to find on the weekend.
- On 06/16/25 at 11:40 AM, Staff H, Social Service worker (SW), documented the receiving facility and patient's guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) were notified of discharge plans. Staff at the facility requested the patient not be discharged without staff to accompany the patient due to the patient's history of behavioral outbursts. They would refuse discharge until a staff member could be secured to accompany the patient, either by them or the hospital, and they would call back later that day with a transportation plan.
- On 06/16/25 at 2:55 PM, Staff F, RN, left a voicemail with the guardian concerning the immediate discharge. The patient was put on a transport bus to return her back to her individualized support living home (ISL, a residential service that enables people with disabilities to live in their own homes, with support tailored to their individual needs) with the discharge paperwork. She did not have staff to accompany her. She was sent to the address of the MCCDD business office.

During an interview on 07/15/25 at 11:25 AM, Staff H, SW, stated that typically they attempted to notify a guardian or leave a message a couple of times and then proceeded with the planned discharge. If there were an emergency discharge from the receiving facility in the chart, they would hold the patient until placement was secured. The patient should have been discharged to the address on her face sheet and even though she does typically set up transport, it was the patient's nurse who set up transport for Patient #11. Staff H would have communicated to the nurse that the ISL expressed concern about wanting staff present prior to and during transport. It was at the physician's and nurse's discretion to determine whether or not it was appropriate to continue with the discharge without an escort.

During an interview on 07/15/25 at 1:20 PM, Staff I, Mental Health Manager, stated that if she set up the transportation, she would have verified the address the patient was sent to. It was not typical for ISL residents to travel by themselves due to their disabilities, and she would have waited on the ISL to contact her with a transportation plan before discharging her.

During an interview on 07/15/25 at 12:15 PM, Staff F, Registered Nurse (RN), stated that she did not have concerns for the patient transporting back to the facility by herself, as she did not exhibit any of the behaviors documented in her chart prior to her admission. She arranged the transport, called report to a nurse at the receiving facility, faxed over the pharmacy paperwork and gave the discharge paperwork to the patient for the ISL staff. She did not verify the address because it was in a SW note in the chart. She did remember someone from the MCCDD's ISL calling for the SW on duty, but did not know if contact was made. She stated that she frequently proceeded with discharges whether or not she spoke with the guardian if she was able to leave a message. She had no knowledge or experience working with an ISL.