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Based on observation, record review, interview, and document review the Governing Board failed to provided oversight of the medical staff for the quality of care provided to patients, the medical staff failed to physically approach, examine and assess a patient (Patient 4) after witnessing Patient 4 fall in the commons area. Failure of the governing board to provide oversight of the medical staff for the quality of care provided places all patients at risk for inadequate medical care resulting in harm.


Findings Include:


A review of the hospital policy for Physician Notification Escalation, dated 10/2020, indicated, "The Hospital's Governing Board has the responsibility for assuring hospital services are provided according to acceptable conditions of participation and standards ...

A review of the hospital policy titled "Fall Prevention Protocol," dated 03/2022, indicated, "All hospitalized patients will be assessed to minimize their risk of falls by ensuring a safe physical environment, appropriate identification of patients at risk for falls and utilizing best practices." Further, the policy showed, ...Post Fall Follow up: Assess patient and document circumstances of the fall and the patient assessment in the patient health record. - Notify the physician of the fall and document in patient health record.


Patient 4

Review of Patient 4's current medical record showed Patient 4 was admitted on 05/19/22 for suicidal ideation (SI), depression and bipolar disorder.

Observation in the commons area on 05/27/22 at 11:45 AM, a commotion was heard, and a patient identified as Patient 4 was seen falling to the floor. Patient 4 had been ambulating with a front wheeled walker. The walker was tipped over when Patient 4 fell. The nurse was immediately by his side and assessed him. Patient 4 stood up from the floor and sat in a chair. At the time of his first assessment after the fall his blood pressure (BP) was 97/54 (BP normal range 90-120/50-80). Patient 4's second assessment showed his BP was 134/83 at 11:55 AM.

Review of a Medical Progress Note dated 05/27/22, showed Staff F, Doctor of Osteopathy (DO) documented, "Observation: Post fall evaluation. Pt fell in the common room while ambulating (sic) with his walker. I actually witnessed the whole event from the nursing bubble. Pt was ambulating in front of the television at a pretty good pace, walker began a forward tilt, instead of letting the walker fall, pt continued to hold on the walker and fell to ground. Staff was at pt's side in a matter of seconds Pt was assisted off the floor to a chair. Pt states that he felt dizzy prior to fall. No dizzy at this time. No reported pain."

The "Physical Exam" showed: General Appearance: alert, no acute distress; Eyes: PERRLA (Pupils Equal Round Reactive to Light and Accommodation); ENT (ears, nose, throat): Moist Mucosal Membranes, Hearing Normal; Neck: Full ROM (range of motion); CVS (cardiovascular system) Regular rate and Rhythm, Systolic Murmur; Respiratory: Bilaterally clear to auscultation, Normal work of breathing; Abdomen: Soft, non-tender; Back: Non-tender to touch, Normal ROM; Neuro: Cranial nerves II-XII intact, tremors Present; Skin: Warm Dry, no skin tears noted; Musculoskeletal: Good Strength, No deformities noted, no pain on palpation.

Further review of the progress not showed, "Assessment and Plan: S/P fall - non-injury. Pt is currently under therapy care. Recommended that pt be evaluated for use of 4-wheel walker verses a 2-wheel walker if insurance will allow. Continue fall protocol. Staff reports pt will be put on 1:1 nursing. Meds were reviewed. Pt not on any blood pressure meds. Pt has been having low BP, but not low enough to start midodrine." The note was electronically signed by Staff F, DO on 05/27/22 at 12:17 PM.

During an interview on 05/27/22 at 12:10 PM, Patient 4, while seated in a chair in the commons area, stated that he was walking, felt like he blacked out and went down, saying he didn't know for sure what happened.

During an interview on 05/31/22 at 2:16 PM, Staff F, Doctor of Osteopathy (DO), reported he performed a medical assessment on Patient 4 after Patient 4 fell in the milieu at lunch time on 05/27/22.

Review of video stills of the commons area showed the time was 11:09 AM, the actual time of the fall was witnessed on 05/27/22 at 11:45 AM. The time on the video stills was inaccurate.

Further review of the facility milieu still video footage showed Staff F, DO, was seated at the desk looking out a window into the milieu from the nursing station. Staff F DO was witnessed seated at the desk the entire time that Patient 4 was being medically assessed by Staff G, Registered Nurse (RN) and Staff L, Mental Health Tech (MHT).

The video stills footage indicated Staff F, DO, was never witnessed on the floor assessing Patient 4.

Staff F, DO, was witnessed by the surveyor seated at the nursing station and then exiting the unit at approximately 12:30 PM.

During an interview on 05/31/2022 at 2:43 PM, Staff L, MHT, reported that Staff F, DO, did not assess Patient 4 after the fall. Staff L, MHT, indicated Staff F, DO, sat at the nursing station and observed Patient 4's care from there.

During an interview on 05/31/2022 at 3:05 PM, Staff G, Registered Nurse (RN), reported it was unknown if Staff F, DO, entered the milieu and assessed Patient 4 after the fall. Staff G, RN, indicated there was no recall of Staff F, DO, coming into the milieu to medically assess Patient 4.

During an interview on 06/01/2022 at 2:45 PM, Staff B, Director of Nursing (DON), was asked to describe the process which should take place during and after a fall. Staff B, DON, reported that the hospital staff should follow the fall hospital policies. The physician, if not present, would be notified of the fall.

Based on policy and procedure review, document review, record review, and interview the Hospital failed to ensure a written notice of a grievance resolution that included the name of the hospital's contact person, the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process, and when the investigation was completed for one of 11 patients (Patient 3) reviewed during the revisit survey. This deficient practice has the potential to cause unresolved concerns, harm or other adverse outcomes.

Findings Include:

Review of the Hospital's, "Patient Handbook," undated, showed, "Grievance Process . . . "[The above-named Hospital] asks concerns to be expressed to [Hospital] . . . you have the right to receive a written notice of the grievance determination that contains the name of the hospital contact person, the steps taken on your behalf to investigate the grievance, the results of the grievance and the grievance completion date."

Review of the Hospital's policy "Patient Complaint and Grievance Process," last revised 12/2020, showed "a patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues ... . . .all grievances receive immediate priority and must be investigated with efforts made toward resolution within five (5) days . . .if the corrective action is still being evaluated within the seven (7) day timeframe, the hospital shall send a response to the patient or the individual filling the grievance stating that the hospital continues to work to resolve the complaint and the hospital will follow-up with another response within seven (7) days . . . The patient or the patient's representative will be provided with written notice of: The name of the hospital contact person; the steps taken to investigate and resolve the grievance; the phone number and address to the relevant state authority; the results of the grievance process; [and] the date of completion.

Patient 3

Review of Patient 3's discharged medical record showed Patient 3 was admitted on 04/26/22 after displaying physical and verbal aggression, agitation, irritability, anxiety, and depression.

Review of "Consents for Treatment," showed that family F2 signed for Patient 3, on 04/26/22 at 11:25 AM. Further review showed that F2 wrote under "Medication and Treatment: "Please notify [F2] @ [at] [phone number] of any and all medication changes."

Review of Patient 3's "Social Services Progress Note," dated 05/02/22 at 5:29 PM, Staff C, Judicial Doctor (JD), Social Service Designee (SSD) documented, "[Patient 3] did have a visitor over the weekend (F2); there are some family concerns, but nothing reported."


Review of an email dated 05/03/22 at 8:21 showed that F2 wrote to Staff C, JD, SSD, "In short, when I called the facility this morning to talk to [Patient 3]'s nurse and ask a few questions, I was told by the nurse that one of his medications (Lexapro) [mediation used to treat anxiety with depression, general anxiety disorders or major depressive disorders] was increased and another one (Depakote) [medication used to treat seizure disorders, certain psychiatric conditions, and to prevent migraine headaches] was discontinued yesterday. I was not notified by the facility that they were making these changes. I specifically wrote on the intake forms that I was to be notified of all medication changes."

Review of Staff C, JD, SSD's notes dated 05/06/22 at 8:15 AM showed, "F2 contacted [Staff C] on May 6th at 8:15am (sic), [F2] stated, 'too much medication, why up the dosage on Lexapro? He never made eye contact with me. He did not know who I was. He was teary-eyed. He looked like a zombie on log. Not himself. He has torn fingernails, looked like he had not been showered. His personal care looked terrible. His hair was greasy.' [F2] wanted [Patient 3] off the increase in Lexapro and back to 5mg (sic) [milligrams] and the DON [Director of Nursing] said 'okay.' The wife [F2] states already had informed [Staff D, Psychiatrist] to decrease it. The DON stated, 'he had showered today and will follow up on the wedding ring, a band of silver, as well as nail care.' F2 stated that she will visit again on Sunday at 2pm (sic)."

During an interview on 06/02/22 at 6:47 PM F2, Patient 3's DPOA stated that she did not receive a resolution letter addressing her grievances from the hospital .

During an interview on 06/02/22 at 3:47 PM Staff C, JD, SSD, stated that he did not complete a grievance letter to F2. Staff C stated that his notes were from a conversation that he had with F2 over the phone.

During an interview on 06/03/22 at 12:04 PM Staff A, CEO, stated that Staff C, JD, SSD, was responsible to respond to all grievances. Staff A stated that grievances are reported through the Medical Executive Committee (MEC), Governing Board, and QAPI (Quality Assurance and Performance Improvement). Staff A stated that Staff C would send out the resolution letters.

Based on document review, record review and interview the hospital failed to ensure that the patient or legal representative were involved in the development and implementation of the care plan for three (Patients 3); and failed to collaboratively develop and implement an appropriate discharge plan for one (Patient 1) of 11 patients reviewed. This deficient practice has the potential to cause harm or other adverse outcomes.

Findings Include:

Review of the Hospital's "Patient Handbook," undated showed, "Patient Rights and Responsibilities . . . all patients shall have the right to . . . receive information about any proposed treatment or procedures in which he/she may need to participate in the development of the plan of care, to give informed consent or to refuse the course of treatment and to participate in planning for care after discharge." ... ...Discharge Planning, ..."Discharge planning starts during the patient's first assessment with his or her social worker. The final discharge date is determined by the patient's attending physician. Licensed Social Workers work with the patient and family members to determine the most successful plan for discharge. "SAH [St. Anthony Hospital] offers family conferences in person or over the phone with the patient's social worker. This time is used to address any questions or concerns loved ones may have. To prepare patients for discharge, SAH wants patients to understand their medications, have scheduled appointments for follow-up care and have instructions on what to do in case of an emergency.

Review of a hospital policy titled, "Multidisciplinary Treatment Plan" last revised 10/2020, showed, ...4. Patient care decisions are collaborative and interdisciplinary to develop the care, treatment, and services of the patient. The treatment team compositions includes the patient or legal representative for the patient, Psychiatry, Social Services, Nursing and Activities ...

Patient 1

Review of Patient 1's discharged medical record showed she was a voluntary admission on 05/05/22 at 3:00 PM with a Diagnosis: Bipolar disorder, current episode mixed, severe without psychotic features and Lithium (medication use to treat bipolar disorder) toxicity.

Review of Patient 1's "Master Treatment Plan," dated 05/05/22, showed the discharge plan was to return home. The Long-Term Goal (Ultimate Goal of Hospitalization - In Patient's/Legal Representative's Words showed: "[Family (F1)] long term goal is for her sister's hospitalization is, "to have my sister be self-sufficient so that I am not her care provider and pushing her to do things that she can do for herself. I want to have the depression decreased and her not to be so reliant upon me." Patient 1's long term goal for her hospitalization is, "to be able to live on my own and do things for myself like I used to."

The "Master Treatment Plan" lacked documentation of Patient 1's or F1's signature.

Review of a Social Service Progress note dated 05/10/22 at 3:38 PM, showed, Patient 1 was very disruptive to the facility and to the staff over the weekend and on 05/10/22. When SSD arrived this morning, SSD was informed that Patient 1 had been verbally aggressive with staff, asking for SSD since yesterday, threatening to staff, and refusing to do personal care needs and allowed self to remain in bed and have bowel movements and urination. ...Patient 1 also stated that she will do whatever she wants until she goes home. SSD tried to reason with Patient 1 and although she was polite, she was adamant about leaving and "the torment will continue until I am able to leave!" SSD, again, tried to reason with Patient 1 and she was not having it. SSD called DPOA [Durable Power of Attorney] and informed DPOA of the situation and that a discharge would be in place for Thursday." (05/12/22).

Review of an email dated 05/10/22 at 1:17 PM, sent by Staff C, JD, SSD to F1, DPOA showed, ..."Fourth, discharge is set for 05/12/22 at 10am."

Review of an email dated 05/10/22 at 2:28 PM, sent by Staff C, JD, SSD to F1, DPOA showed, "I know you are still in your meetings, but the DON will get her back on the Lithium and I have been informed that she will discharge back to her residence on tomorrow, 05/11/22. Our transportation will transport her home and Home Health has been notified for assistance. You should receive a call from them, as well. Just wanted to give you an update, since the last email."

During an interview on 06/01/22 at 2:40 PM, F1, DPOA, stated that Patient 1 had been in and out of hospitals and had been mentally unstable and couldn't take care of herself since April. She stated that she had talked to Staff C the day Patient 1 was admitted and gave an overview of Patient 1's mental and physical status. F1 stated that she wanted Patient 1 to go to a long-term care or rehab facility to build her strength and get her back on her feet. F1 stated that she had talked to Staff C and made them very aware that she would not be back until Thursday 05/12/22 and ask them not to discharge Patient 1 until F1 got back. F1 stated that on 05/11/22 at 9:50 AM, she started getting phone calls from Patient 1's apartment complex, who reported that Patient 1 had been brought back to her apartment. She stated that it was reported to her that Patient 1 was sitting in a wheelchair (WC), disheveled, had a [bowel movement] in the WC, had open wounds on one arm, a bandage on the other arm that looked like it had not been changed in quite some time and a bandage on her leg. F1 stated that the apartment complex said Patient 1 was delusional and making no sense. F1 stated that she told them to call 911. F 1 stated that she then called Staff C about Patient 1 being sent home and was told an email was sent the evening before informing her of the discharge on 05/11/22. F1 stated that she did not receive a phone call that they were sending Patient 1 home on 05/11/22, and that she had not seen the email that was sent until after she started receiving phone calls from the apartment complex. F1 stated that Patient 1 is still in a hospital receiving treatment for her unstable mental status and the wound on her leg.

The hospital failed to collaboratively work with Patient 1's legal representative or include and consider F1's concerns with Patient 1's discharge plan.

Patient 3

Review of Patient 3's discharged medical record showed Patient 3 was admitted on 04/26/22 after displaying physical and verbal aggression, agitation, irritability, anxiety, and depression.

Review of Patient 3's "Consent to Receive Psychopharmacological Medications," dated 04/26/22, signed by Family (F) 2, Patient 3's wife and DPOA, showed that F2 wrote "Please notify [F2's name] @ (sic) (at) [phone number] of any and all medication changes."

Review of an email dated 05/03/22 at 8:21 showed that F2 wrote to Staff C, JD, SSD, "I visited with [Staff D, Psychiatrist] for a short time this afternoon regarding my [Patient 3]'s progress. [Staff D] told me that it is your responsibility to let the family member/members know of the meeting outcomes. Since I have not heard from you as yet, I am sending this email. In short, when I called the facility this morning to talk to [Patient 3]'s nurse and ask a few questions, I was told by the nurse that one of his medications (Lexapro) was increased and another one (Depakote) [mediation used to treat anxiety with depression, general anxiety disorders or major depressive disorders] was discontinued yesterday."

Further review of the email showed, "I was not notified by the facility that they were making these changes. I specifically wrote on the intake forms that I was to be notified of all medication changes."


During an interview on 06/02/22 at 6:47 PM, F2 stated that she informed the hospital that she wanted to be involved with all medication changes when Patient 3 was admitted. F2 stated that the nurses didn't know anything about his care, would ask, and would get back to her. F2 stated that nobody ever followed up with her. F2 stated that when Patient 3 was discharged she was not provided with discharge instructions, didn't know what the medication changes were, and did not have follow ups to any of her concerns during Patient 3's hospitalization.

Based on policy review, document review, record review, and interview, the hospital failed to ensure they provided clear and consistent written policies and procedures regarding patient's visitation rights affecting one (Patient 3) of 11 patients reviewed. This deficient practice has the potential to affect all patients and may lead to harm or other adverse outcomes.


Findings Include:


Review of the Hospital's policy presented as the current policy during the COVID-19 pandemic, "Visitors," last revised 10/2020, showed "To facilitate continued interactions between patients and their significant others, visiting hours are scheduled twice a day to provide maximum opportunity to visit patients . . . nursing staff will notify patients and family members of scheduled visiting hours: between 5:00 p.m (sic) to 7:00 p.m. (sic) weekdays, weekends, and holidays. If exceptions are made to the scheduled visiting hours, the Charge Nurse will approve the change."

Review of a letter dated 02/17/22 to the families and partners of patients showed, "visitation is limited to 20 minutes per patient per week. Visitation is by appointment only between 3 p.m. (sic) and 5 p.m. (sic)." The letter failed to inform the patients that alternative visiting hours could be approved and arranged through the Charge Nurse.

Review of "Patient's Rights and Responsibilities," dated 12/2018, as signed by the patient or representative at admission showed, "All patients shall have the right to (which include, but are not limited to the following) . . . Have a family member, friend, or other individual be present for emotional support throughout the course of stay . . . all patients shall also have the right . . . to see visitors each day at reasonable times."

Review of the Hospital's "Patient Handbook," undated, showed, "In person Visitation Hours, Due to the COVID-19 pandemic, there is no in-person visitation at this time. Phone visitation hours: every day 3:00 PM to 5:00 PM."


Patient 3

Review of Patient 3's discharged medical record showed Patient 3 was admitted on 04/26/22 after displaying physical and verbal aggression, agitation, irritability, anxiety, and depression.

Review of Patient 3's signed "Consents for Admission and Treatment" lacked evidence that the patient or legal representative was presented with the alternative policy on scheduled visitations during COVID-19, the letter to family, or that they signed the "Acknowledgement of Receipt" of the "Patient Handbook" where the limited visitation information is provided.

The medical record lacked evidence Patient 3's Durable Power of Attorney (DPOA) and wife signed or received any of the visitation adaptations due to COVID or a signed acknowledgement form from the patient handbook.

During an interview on 06/02/22 at 6:47 PM, Patient 3's DPOA and wife, stated that she was only able to visit twice and that she was informed that she was only allowed three times while Patient 3 was there and that was their policy. F2 stated that visitation was stipulated and that they kept telling her that she was informed of the limited visitation in the contract she signed at admission. F2 stated that she did not get a letter, a policy or anything from the hospital.

During an interview on 06/01/22 at 2:50 PM Staff M, mental health technician (MHT) stated that patients can have visits or make phone calls each day from 3:00 PM to 5:00 PM.

Based on record review, policy review, and interview the hospital failed to ensure that when verbal orders are used, they must be used infrequently for 11 of 11 patient's (Patients 1-11) physician orders reviewed. This deficient practice poses an increased risk of miscommunication that could contribute to medication or other errors, resulting in a patient adverse event.


Findings Include:


Review of "Medical Staff Rules and Regulations," last approved 11/2020, showed "Written/Verbal/Telephone Treatment Orders: orders for treatment shall be in writing, dated, timed, authenticated and legible. Verbal orders are discouraged except in emergency situations. A verbal or telephone order shall be considered to be in writing if dictated to an R.N. and signed by the R.N. and countersigned by the physician giving the order . . . all verbal and telephone orders shall be signed by the qualified person to whom the order is dictated . . .


Patient 1

Review of Patient 1's discharged medical record showed she was a voluntary admission on 05/05/22 at 3:00 PM with a Diagnosis: Bipolar disorder, current episode mixed, severe without psychotic features and Lithium (medication use to treat bipolar disorder) toxicity.

Review of Patient 1's physician orders showed that 68% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 2

Review of Patient 2's current medical record showed Patient 2 was admitted on 05/13/22 due to increased physical aggression at his long-term care facility that included tying a call light cord around his roommate's neck and putting a pillow over his face and punching staff in the stomach and face.

Review of Patient 2's physician orders showed that 84% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 3

Review of Patient 3's discharged medical record showed Patient 3 was admitted on 04/26/22 after displaying physical and verbal aggression, agitation, irritability, anxiety, and depression.

Review of Patient 3's physician orders showed that 95% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 4

Review of Patient 4's current medical record showed Patient 4 was admitted on 05/19/22 for suicidal ideation (SI), depression and bipolar disorder.

Review of Patient 4's physician orders showed that 84% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 5

Review of the Patient 5's current medical record showed Patient 5 was admitted on 05/16/22 at 11:14 AM for complaints of delusions, anxiety, depression, wandering, and behavioral disturbances. Patient was currently on hospice.

Review of Patient 5's physician orders showed that 89% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 6

Review of Patient 6's current medical record showed Patient 6 was admitted on 05/15/22 after displaying symptoms of delusions, paranoia, verbal and physical aggression.

Review of Patient 6's physician orders showed that 81% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 7

Review of Patient 7's current medical record showed Patient 7 was admitted on 05/20/22 for increased confusion and agitation, delusional behaviors, wandering and inability to care for self while living alone. Patient had a past medical history of dementia.

Review of Patient 7's physician orders showed that 96% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 8

Review of Patient 8's discharged medical record showed Patient 8 was admitted 05/04/22 at 4:10 PM and discharged 05/09/22 at 10:30 AM. Admitting diagnosis was generalized anxiety disorder.

Review of Patient 8's physician orders showed that 97% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 9

Review of Patient 9's discharged medical record showed Patient 9 was admitted on 03/21/22 after displaying agitation, hallucinations and physical aggression towards staff at a long-term care facility. Patient 9 was discharged on 04/13/22.

Review of Patient 9's physician orders showed that 72% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 10

Review of Patient 10's discharged medical record showed Patient 10 was admitted on 03/31/22 after displaying aggression and then eloped from her long-term care facility. While admitted at acute care she hit and kicked staff and required soft restraints prior to her admission.

Review of Patient 10's physician orders showed that 90% of all physician orders were entered by nursing staff as telephone/verbal orders.


Patient 11

Review of Patient 11's discharged medical record showed Patient 11 was admitted on 04/04/22 for stabilization and medication management with complaints of anxiety, harm to others, exit seeking, paranoia, and refusal of medications at a long-term care facility. Patient 11 was discharged on 04/18/22.

Review of Patient 11's physician orders showed that 50% of all physician orders were entered by nursing staff as telephone/verbal orders.


During an interview on 06/02/22 at 3:10 PM, Staff A, CEO, stated that Staff E and the physicians have access to the electronic health record outside the hospital and can enter their own orders.

During an interview on 06/02/22 at 3:20 PM, Staff B, DON stated that nurses enter orders directly into EMR and do not hand write verbal/telephone orders on paper. When asked why the majority of physician orders are entered as verbal/telephone orders by the nurses instead of physicians entering direct orders, she did not provide an answer.

During an interview on 06/03/22 at 8:35 AM, Staff E, APRN, stated that he see patients Tuesday through Thursday by video and comes to the facility once a month. When asked about verbal/telephone orders, Staff E stated that he enters his own orders in the [electronic health record].

Based on document review, record review, and interview, the Hospital failed to ensure all orders, including verbal orders, were dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient within 48-hours per hospital Medical Staff Rules and Regulations. This affected 11 (Patient 1-11) of 11 patients reviewed for the revisit survey. The failure to sign orders places all patients at risk for subpar care, medication and treatment errors, and other adverse outcomes.

Findings Included:

A review of a hospital policy for, Medical Staff Rules and Regulations, dated 11/2020, indicated, 1. Written/Verbal Telephone Treatment Orders: Orders for treatment shall be in writing, dated, timed, authenticated and legible. Verbal orders are discouraged except in emergency situations. A verbal or telephone order shall be considered to be in writing if dictated to a registered nurse (RN) and signed by the RN and countersigned by the physician giving the order. The recipient's name, the name of the practitioner, and the date and time of the order shall be noted. The physician who gave the verbal order or another practitioner (who is credentialed and grated privileges to write orders) who is also responsible for the care of the patient shall authenticate, time and date any order, including but not limited to medication orders, as soon as possible, such as during the next patient visit, and in no case longer than forty-eight (48) hours from dictating the verbal order.

Patient 1

Review of Patient 1's discharged medical record showed she was a voluntary admission on 05/05/22 at 3:00 PM with a Diagnosis: Bipolar disorder, current episode mixed, severe without psychotic features. She also had Lithium toxicity. Patient 1 discharged home on 05/11/22.

Review of Patient 1's clinical order history showed 13 of 22 physician orders failed to have a Physician or Advanced Practice Registered Nurse (APRN) signature to authenticate and validate the orders within a 48-hours and one signed order was not signed by the APRN or Physician within 48 hours.

Patient 1's medical record showed a Physical Therapy (PT) evaluation and "Physical Therapy Plan of Care" completed on 05/07/22 was not signed by the physician. Patient 1's record failed to show any evidence of PT being completed following the evaluation. A PT clarification order dated 05/07/22 not signed by the physician.


Patient 2

Review of Patient 2's current medical record showed Patient 2 was admitted on 05/13/22 due to increased physical aggression that included tying a call light cord around his roommate's neck and putting a pillow over his face. He was also punching his staff in the stomach and face at his long-term care facility.

Review of Patient 2's clinical order history showed 23 of 37 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours and five signed orders were not signed by the APRN or Physician within 48 hours.

Patient 2's medical record showed a PT evaluation and "Physical Therapy Plan of Care" completed on 05/14/22 was not signed by the physician. The PT clarification order dated 05/14/22 was not signed by the Physician. Review of Patient 2's "Physical Therapy Daily Treatment Note," dated 05/14/22, 05/24/22, and 05/26/22, showed that Patient 2 received treatment without evidence the "PT Plan of Care," was signed by the physician.


Patient 3

Review of Patient 3's discharged medical record showed Patient 3 was admitted on 04/26/22 after displaying physical and verbal aggression, agitation, irritability, anxiety, and depression. Patient 3 was discharged on 05/10/22.

Review of Patient 3's clinical order history showed 19 of 30 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours.

Patient 3's medical record showed a PT evaluation and "Physical Therapy Plan of Care" completed on 04/27/22 was not signed by the physician. Patient 3's clinical record failed to show any evidence of PT being completed following the evaluation. A PT clarification order dated 04/27/22 was not signed by the Physician.


Patient 4

Review of Patient 4's current medical record showed Patient 4 was admitted on 05/19/22 for suicidal ideation (SI), depression and bipolar disorder.

Review of Patient 4's clinical order history showed 12 of 29 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours.

Patient 4's medical record showed a PT evaluation and "Physical Therapy Plan of Care" completed on 05/20/22 was not signed by the physician. Patient 4's "Physical Therapy Daily Treatment Note," dated 05/25/22 showed that Patient 4 received treatment without evidence the "PT Plan of Care," was signed by the physician. A PT clarification order dated 05/20/22 was not signed by the Physician.


Patient 5

Review of the Patient 5's current medical record showed Patient 5 was admitted 05/16/22 for complaints of delusions, anxiety, depression, wandering, and behavioral disturbances. Patient is currently on hospice.

Review of Patient 5's clinical order history showed 8 of 19 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours.

Patient 5's medical record showed a PT evaluation and "Physical Therapy Plan of Care" completed on 05/17/22 was not signed by the physician. A PT clarification order dated 05/17/22 was not signed by the Physician. Patient 5's "Physical Therapy Daily Treatment Notes," dated 05/23/22 and 05/25/22 showed that Patient 5 received treatment without evidence the "PT Plan of Care," was signed by the physician.


Patient 6

Review of Patient 6's current medical record showed Patient 10 was admitted on 05/15/22 after displaying symptoms of delusions, paranoia, and verbal and physical aggression.

Review of Patient 6's clinical order history showed 12 of 18 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours. Further review showed a handwritten order dated 05/17/22 to discontinue aspirin. The order was signed by an unidentifiable RN, and near the RN signature were unidentified initials, there was no indication as to who the initials belonged to and there was not date or time documented by the initials.

Patient 6's medical record showed a PT evaluation and "Physical Therapy Plan of Care" completed on 05/19/22 was not signed by the physician. A PT clarification order dated 05/19/22 was not signed by the Physician. Patient 6's "Physical Therapy Daily Treatment Note," dated 05/23/22 showed that Patient 6 received treatment without evidence the physician signed the "PT Plan of Care."


Patient 7

Review of Patient 7's current medical record showed Patient 7 was admitted 05/20/22 for increased confusion and agitation, delusional behaviors, wandering and inability to care for self while living alone. Patient had a past medical history of dementia.

Review of Patient 7's clinical order history showed two of 27 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours.

Patient 7's medical record showed a PT evaluation and "Physical Therapy Plan of Care" completed on 05/24/22 was not signed by the physician. A PT clarification order dated 05/24/22 was not signed by the Physician. Patient 7's "Physical Therapy Daily Treatment Note," dated 05/24/22 and 05/26/22 showed that Patient 7 received treatment without evidence the physician signed the "PT Plan of Care."


Patient 8

Review of Patient 8's discharged medical record showed Patient 8 was admitted 05/04/22 at 4:10 PM and discharged 05/09/22 at 10:30 AM. Admitting diagnosis was generalized anxiety disorder.

Review of Patient 8's clinical order history showed that 10 of 27 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours.


Patient 9

Review of Patient 9's discharged medical record showed Patient 9 was admitted on 03/21/22 after displaying agitation, hallucinations and physical aggression towards staff at a long-term care facility. Patient 9 was discharged on 04/13/22.

Review of Patient 9's clinical order history showed that 18 of 22 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours.

Patient 9's medical record showed a PT evaluation and "Physical Therapy Plan of Care" completed on 03/22/22 was not signed by the physician. A PT clarification order dated 03/22/22 was not signed by the Physician.


Patient 10

Review of Patient 10's discharged medical record showed Patient 10 was admitted on 03/31/22 after displaying aggression and then eloped from her long-term care facility. While admitted at acute care she hit and kicked staff and required soft restraints prior to transfer to the above-named hospital. Patient 10 was discharged on 04/13/22.

Review of Patient 10's clinical order history showed that 11 of 25 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours.

Review of Patient 10's "Physical Therapy Plan of Care," dated 04/23/22, went unsigned by the physician. A PT clarification order dated 04/03/22 and an order dated 04/12/22 to discontinue PT effective 04/11/22, were not signed by the Physician. Patient 10's clinical record failed to show any evidence of PT being completed.


Patient 11

Review of Patient 11 discharged medical record showed Patient 11 was admitted on 04/04/22 for stabilization and medication management with complaints of anxiety, harm to others, exit seeking, paranoia, and refusal of medications at a long-term care facility. Patient 11 was discharged on 04/18/22.

Review of Patient 11's clinical order history showed that 7 of 14 physician orders failed to have a Physician or APRN signature to authenticate and validate the orders within a 48-hours.

Review of Patient 11's "Physical Therapy Plan of Care," dated 04/08/22, went unsigned by the physician. An undated PT clarification order was not signed by the Physician. Patient 11's clinical record failed to show any evidence of PT being completed following the PT evaluation.


During an interview on 06/01/2022 at 2:45 PM, Staff B, Director of Nursing, DON, Registered Nurse (RN), was unable to disclose why the hospital physicians had failed to sign orders. Staff B reported that services were continuing to be provided although the physicians' orders were not properly signed and submitted.

During an interview on 06/01/22 at 3:58 PM, Staff A, Chief Executive Officer (CEO) stated that verbal orders are entered into the (Electronic Medical Record) (EMR) by the nurse and then the physician is to sign off on the order. She stated that the physician has 48 hours per policy to sign the orders.

Based on record review, document review, policy review and interview, the hospital failed to ensure the discharge planning process identified a patient likely to suffer adverse health consequences upon discharge and failed to provide a discharge evaluation for one (Patient 1) of six discharged patient records reviewed. This deficient practices places patients at risk for inappropriate discharge, loss of continuity of care which could potentially cause harm to the patients and result in rehospitalization.

Findings Include:

Review of a hospital policy titled, "Discharge of Patients" last revised 03/2020, showed, "Purpose: This document outlines the process for discharge to ensure a well-planned discharge process, a smooth transition to the next level of care (i.e., partial hospitalization, board and care setting) and to ensure continuity of the treatment modalities selected for the patient ...

Review of a hospital policy titled, "Discharge Planning" last revised 03/2020, showed, ..."Discharge planning begins at the time of admission, Based on input from the patient, family/significant other, physician and members of the multidisciplinary team, a discharge plan is developed." ..."Procedure: Discharge Planning will be a focus of the initial data collection, psychosocial assessment process and goals in the treatment plan. Information will be obtained from the patient and/or family member, physician, medical records and other information available. Information may include: The patient's home environment, The patient's ability to function independently before current hospitalization, What type of situation the patient will be discharged to, Patient's optimal level of functioning outside of the hospital, Patient's current support system, Follow-up care needed, i.e., therapist, specific program identified during hospitalization ...

...Discharge Planning, ..."Discharge planning starts during the patient's first assessment with his or her social worker. The final discharge date is determined by the patient's attending physician. Licensed Social Workers work with the patient and family members to determine the most successful plan for discharge.

"SAH [St. Anthony Hospital] offers family conferences in person or over the phone with the patient's social worker. This time is used to address any questions or concerns loved ones may have. To prepare patients for discharge, SAH wants patients to understand their medications, have scheduled appointments for follow-up care and have instructions on what to do in case of an emergency.

Review of "Patient's Rights and Responsibilities," dated 12/2018, as signed by the patient or representative at admission showed, "All patients shall have the right to (which include, but are not limited to the following) . . . be informed by his/her physician or a delegate of his/her physician of the continuing healthcare requirements following his/her discharge from the hospital."


Patient 1

Review of Patient 1's medical record showed she was a voluntary admission on 05/05/22 at 3:00 PM with a Diagnosis: Bipolar disorder, current episode mixed, severe without psychotic features. She also had Lithium (mood stabilizer) toxicity. Patient 1's record showed she had a durable power of attorney (DPOA).

Review of the "Master Treatment Plan" dated 05/05/22 showed the discharge plan was to return home.

The Long-Term Goal (Ultimate Goal of Hospitalization - In Patient's/Legal Representative's Words showed: [Family, F1] long term goal is for her sister's hospitalization is, "to have my sister be self-sufficient so that I am not her care provider and pushing her to do things that she can do for herself. I want to have the depression decreased and her not to be so reliant upon me." [Patient 1's] long term goal for her hospitalization is, "to be able to live on my own and do things for myself like I used to."

Review of a "Nursing Narrative" note dated 05/06/22 at 4:00 AM, showed Hematoma to the left calf. Measures approx. 10 cm x 10 cm. Red and warm to touch. Pt complains of pain. Hematoma has a blister that is leaking serosanguinous (thin, watery, bloody) fluid.

Review of a "Nursing Narrative" notes dated 05/07/22 6:05 AM; 05/07/22 6:00 AM - 6:00 PM; and 05/07/22 6:00 PM to 6:00 AM showed no documentation concerning the hematoma, wound care or any other skin issues.


Review of a Social Service Progress note dated 05/10/22 at 3:38 PM, showed, Patient 1 was very disruptive to the facility and to the staff over the weekend and on 05/10/22. ...Patient 1 also stated that she will do whatever she wants until she goes home. ...she was adamant about leaving and "the torment will continue until I am able to leave!" ...SSD (Social Service Designee) called DPOA (Durable Power of Attorney) and informed DPOA of the situation and that a discharge would be in place for Thursday" (05/12/22).

During an interview on 06/01/22 at 1:55 PM, Staff C, Judicial Doctor (JD), SSD Patient 1 was adamant about wanting to go home and that she was screaming and acting out because she wanted to go home. Staff C stated that the Director of Nursing (DON) and Chief Executive Officer (CEO) were spoken to about the discharge. Staff C stated Patient 1's sister was called and notified of the discharge and asked if they could wait until she got back. Staff C stated that Patient 1's sister was out of state and would be back on the 05/11/22.

Review of an email dated 05/10/22 at 1:17 PM, sent to F1, DPOA from Staff C, JD, SSD showed, ..."Fourth, discharge is set for 05/12/22 at 10am."

Review of an email dated 05/10/22 at 2:28 PM, sent to F1, DPOA from Staff C, JD, SSD showed, "I know you are still in your meetings, but the DON will get her back on the Lithium and I have been informed that she will discharge back to her residence on tomorrow, 05/11/22. Our transportation will transport her home and Home Health has been notified for assistance. You should receive a call from them, as well. Just wanted to give you an update, since the last email."

During an interview on 06/01/22 at 2:40 PM, F1, DPOA, stated that she had talked to Staff C the day Patient 1 was admitted and gave an overview of Patient 1 mental and physical status. F1 wanted Patient 1 to go to a long-term care or rehab facility to build her strength and get her back on her feet. F1 stated that she had talked to Staff C and made them very aware that she would not be back until Thursday 05/12/22 and ask them not to discharge Patient 1 until she got back Thursday (05/12/22). On 05/11/22 at 9:50 AM, F1 stated that she started getting phone calls from Patient 1's landlord, who reported that transport had brought Patient 1 back to her apartment and that Patient 1 was sitting in a wheelchair (WC), disheveled, had a bowel movement in the WC, had open wounds on one arm and a bandage on the other arm that looked like it had not been changed in quite some time. She also had a bandage on her leg. F1 stated that the landlord said Patient 1 was delusional (having false or unrealistic beliefs) and making no sense. F1 stated that she told the landlord to call 911. She stated that she did not receive a phone call from St Anthony telling her they were sending Patient 1 home. She stated that she called St Anthony after speaking to the landlord and spoke with Staff C who said an email was sent the evening before discharge. F1 stated that Patient 1 was admitted to a psychiatric unit and remains there today. She stated that the wound on her leg was infected and she had been receiving IV antibiotics, is seen by the wound team daily and the wound will need surgical debridement (removal of tissue).

Review of Patient 1's Facility A, medical record dated 05/11/22, showed Patient 1 was seen in the emergency department and was admitted with diagnosis of BAD (Bipolar Affective Disorder) severe; ...RO [rule out] delirium (acute mental disturbance) from medical conditions (cellulitis [skin infection]/DVTs[deep vein thrombosis (blood clot)]); ...DVT LLE, and Cellulitis.

Review of Patient 1's medical record lacked documented evidence that a discharge planning evaluation was used in establishing an appropriate discharge plan for Patient 1 and failed to have a Licensed Social Workers (per facility policy) work with Patient 1, or her legal representative in person or over the phone, to determine the most successful plan for the discharge of Patient 1. Patient 1's medical record lacked documented evidence a discharge planning evaluation was used in establishing an appropriate discharge plan to include wound care following discharge.

During an interview on 06/02/22 at 11:10 AM, Staff K, Registered Nurse (RN) stated that she was working on the day Patient 1 discharged and that Patient 1's leg wound looked like it was a chronic issue, not acute or needing antibiotics. She also stated that when Patient 1 left, it was on the "verge of AMA" (against medical advice).

During a subsequent interview on 06/02/22 at 2:00 PM, Staff K, RN, stated that Patient 1 was not appropriate to go home and that the transport person from St Anthony signed the discharge instructions.

Based on record review, policy, review and interview the hospital failed to ensure all necessary medical information and instruction was provided at the time of discharge for two (Patient 1 & 3) of six discharged patients reviewed. This deficient practice has the potential to place patients at risk for loss of continuity of care and harm.

Findings Include:

Review of a hospital policy titled, "Discharge Planning" last revised 03/2020, showed, ..."Procedure: Discharge Planning will be a focus of the initial data collection, psychosocial assessment process and goals in the treatment plan. Information will be obtained from the patient and/or family member, physician, medical records and other information available. Information may include: The patient's home environment, The patient's ability to function independently before current hospitalization, What type of situation the patient will be discharged to, Patient's optimal level of functioning outside of the hospital, Patient's current support system, Follow-up care needed, i.e., therapist, specific program identified during hospitalization ...

...Discharge Planning, ..."Licensed Social Workers work with the patient and family members to determine the most successful plan for discharge.

"SAH [St. Anthony Hospital] offers family conferences in person or over the phone with the patient's social worker. This time is used to address any questions or concerns loved ones may have. To prepare patients for discharge, SAH wants patients to understand their medications, have scheduled appointments for follow-up care and have instructions on what to do in case of an emergency.

Review of the Hospital's "Patient Handbook," undated showed, "Patient Rights and Responsibilities . . . all patients shall have the right to . . . receive information about any proposed treatment or procedures in which he/she may need to participate in the development of the plan of care, to give informed consent or to refuse the course of treatment and to participate in planning for care after discharge."


Patient 1

Review of Patient 1's medical record showed she was a voluntary admission on 05/05/22 at 3:00 PM with a Diagnosis: Bipolar disorder, current episode mixed, severe without psychotic features. She also had Lithium (mood stabilizer) toxicity.

Review of a "Nursing Narrative" note dated 05/05/22 6:00 PM, showed Staff I, Licensed Practical Nurse (LPN) documented, Patient one complained of pain 8/10 of the left leg. Large blistered hematoma noted on the left leg.

Review of a "Nursing Narrative" note dated 05/06/22 4:00 AM Hematoma to the left calf. Measures approx. 10 cm x 10 cm. Red and warm to touch. Pt complains of pain. Hematoma has a blister that is leaking serosanguinous (thin, watery, bloody) fluid. Hematoma is covered with ABD and wrapped with Kerlix and Ace-wrap.

Review of a "Nursing Narrative" notes dated 05/07/22 6:05 AM; 05/07/22 6:00 AM - 6:00 PM; and 05/07/22 6:00 PM to 6:00 AM showed not documentation concerning the hematoma or any other skin issues.

Review of a "Nurse Narrative Note" dated 05/08/22 from 6:00 AM to 6:00 PM, showed 6:00 AM - ...Patient rates pain to LLE [leg lower extremity (leg)] 10/10, LLE with 3+ edema, red, warm to touch. LLE wrapped with ace wrap, scant shadowing noted. 1:00 PM - ...dressing to LLE changed, ABD applied to wound and covered with co-ban. Dressing to LUE [left upper extremity (arm)] changed, wound cleansed with wound cleanser, covered with non-adherent dressing, ABD and co-ban. Dressing to right hand changed, wound cleansed, covered with non-adherent dressing and co-ban.

There was no documented evidence to show wound care was provided on 05/07/22, 05/09/22, 05/10/22 or on 05/11/22 prior to discharge.

Review of Patient 1's discharge instructions dated 05/11/22 lacked documented instructions for wounds or continued wound care following discharge.

During an interview on 06/02/22 at 2:00 PM, Staff K, RN, stated that Patient 1 was not appropriate to go home. She stated that she was working the day of discharge and the transport person signed the discharge instructions.

The medical record lacked documented evidence of communication with Patient 1's DPOA related to specific discharge instruction and according to Staff K, RN's interview the discharge instructions were signed by the transportation driver.


Patient 3

Review of Patient 3's discharged medical record showed Patient 3 was admitted on 04/26/22 after displaying physical and verbal aggression, agitation, irritability, anxiety, and depression.

Review of Patient 3's discharge instructions, dated 05/02/22, showed that it was not signed by the patient or F2 (family member) who is also Patient 3's durable power of attorney (DPOA). Further review showed that the discharge instructions did not include follow up instructions or educational materials.

During an interview on 06/02/22 at 6:47 PM F2, Patient 3's DPOA, F2 stated that when Patient 3 was discharged nobody spoke to her, nobody went over medications, discharge instructions, education and that no paperwork was given to her.

Based on record review and policy review the hospital failed to ensure staff kept current the Master treatment plan status to show progress towards goals for five (Patients 2, 3, 5, 6 & 7) of 5 patient care plans review, failed to update the care plan with new identified problems for two (Patient 2 & 7) of 5 patient care plans reviewed and failed to include a target date for goals for one (Patient 7) of 5 patient care plans reviewed. This deficient practice has the potential to place patients at risk for a delay in meeting goals and progress toward discharge.


Findings Include:


Review of a hospital policy titled, "Multidisciplinary Treatment Plan" last revised 10/2020, showed, ...5 Every patient's care plan shall identify short and long-term patient goals and associated objectives and interventions necessary to meet the identified goals. ...8. Progress toward care goals will be updated daily by Nursing staff. Other team members will update progress toward care goals at least twice a week ...


Patient 2

Review of Patient 2's current medical record showed Patient 2 was admitted on 05/13/22 due to increased physical aggression that included tying a call light cord around his roommate's neck and putting a pillow over his face. He was also punching his staff in the stomach and face at his long-term care facility.

Review of the "Master Treatment Plan" dated 05/13/22, showed the following problem list with short term goals and interventions:

High Fall Risk: Short term goal target date 05/28/22. Will allow staff to assist him with transfers, ambulation and ADL's to Prevent falls. Interventions: The psychiatrist and/or Advanced Practice Registered Nurse (APRN) will review medications upon rounding and titrate antipsychotics to reduce the instance of falls daily.

Review of a social work note dated 05/16/22 and completed by Staff C, Judicial Doctor (JD), Social Service Designee (SSD) showed, "Staff reports that [Patient 2] is self-harming, physically aggressive."

Review of a social work note dated 05/23/22 and completed by Staff C, JD, SSD, showed "Staff reports [Patient 2] had an altercation with another resident and non-injury."

Review of Patient 2's "Summary Progress Report & Review of Goals," dated 05/23/22, showed "Current psychiatric symptoms, medical status: [Patient 2] has has (sic) no behaviors reported. He is exhibiting anxious behaviors such as lip smacking and teeth grinding."

Review of Patient 2's "Summary Progress Report & Review of Goals," dated 05/31/22, showed "[Patient 2] has been doing well, and has had no behaviors reported."

Review of Patient 2's "Master Treatment Plan," showed no evidence that physical altercation and self-harming behaviors were added or addressed in the "Master Treatment Plan."

During an interview on 06/01/2022 at 2:45 PM, Staff B, Director of Nursing (DON), Registered Nurse (RN), stated that the Master Treatment Plan is to be updated with progress/status on a weekly basis.

The treatment plan status was not updated with progress or if goals were met on a weekly basis.


Patient 3

Review of Patient 3's discharged medical record showed Patient 3 was admitted on 04/26/22 after displaying physical and verbal aggression, agitation, irritability, anxiety, and depression.

Review of the "Master Treatment Plan" dated 04/26/22, showed the following problem list with short term goals and interventions:

High Fall Risk: Short term goal: Open date 04/27/22, Patient 3 will allow staff to assist him with transfers and ambulation as needed. Interventions: The psychiatrist and/or APRN will review medications upon rounding and titrate antipsychotics to reduce the instance of falls daily.

The treatment plan status was not updated with progress or if goals were met on a weekly basis.


Review of Patient 3's "Social Services Progress Note," dated 04/28/22 at 3:53 PM showed Staff C, JD, SSD, documented "Staff reported that [Patient 3] was doing okay and not having any major behaviors but did become a bit sexual during cares with the staff."


Review of Patient 3's "Master Treatment Plan," showed that it was not updated to reflect the sexual behaviors.


Patient 5

Review of the Patient 5's current medical record showed Patient 5 was admitted on 05/16/22 at 11:14 AM for complaints of delusions, anxiety, depression, wandering, and behavioral disturbances. Patient was currently on hospice.

Review of the "Master Treatment Plan," dated 05/16/22, showed the following problem list with short term goals and interventions:

Restlessness: Short term goal target date 05/29/22: Will engage in therapy twice a week, and one activity daily. Interventions: The psychiatrist will titrate medications and will also round daily to monitor for effectiveness and response.


High Fall Risk: Short term goal target date 05/31/22. Will allow staff to assist with toileting and ADLs. Interventions: The psychiatrist and/or APRN will review medications upon rounding and titrate antipsychotics to reduce the instance of falls daily.

The treatment plan status was not updated with progress or if goals were met on a weekly basis.


Patient 6

Review of Patient 6's current medical record showed Patient 6 was admitted on 05/15/22 after displaying symptoms of delusions, paranoia, and verbal and physical aggression.

Review of the "Master Treatment Plan" dated 04/26/22, showed the following problem list with short term goals and interventions:

High Fall Risk: Short term goal: Open date 05/16/22 with a target date of 05/31/22. Patient 6 will remain independent with ambulation while inpatient. Interventions included: The psychiatrist and/or APRN will review medications upon rounding and titrate antipsychotics to reduce the instance of falls daily.

The treatment plan status was not updated with progress or if goals were met on a weekly basis.


Patient 7

Review of Patient 7's current medical record showed Patient 7 was admitted 05/20/22 for increased confusion and agitation, delusional behaviors, wandering and inability to care for self while living alone. Patient had a past medical history of dementia.

Review of the "Master Treatment Plan," dated 05/20/22, showed the following problem list with short term goals and interventions:

Delusional: Short term goal target date 05/28/22: Will engage in therapy once a week, and one activity daily. Interventions: psychiatrist will titrate medications and will also round daily to monitor for effectiveness and response.

The treatment plan status was not updated with progress or if goals were met on a weekly basis
Moderate Fall Risk: Short term goal target date (none listed): Will allow staff to assist her with ADLs (activities of daily living) as needed to prevent falls. Interventions: Psychiatrist and/or APRN (advanced practice registered nurse) will review medications upon rounding and titrate antipsychotics to reduce the instance of falls.

The treatment plan failed to show a target date for goals and was not updated to reflect patient progress towards goals/objectives on a weekly basis.

The "Master Treatment Plan" failed to include dehydration or malnutrition on the problem list as identified by the provider on the admission assessment. Review of the medical record showed an order for a dietary consult was placed on 05/31/22 (two days before discharge) and consult was completed on 06/01/22 (day before discharge.) The consult failed to provide patient education on increased protein intake or interventions to improve malnutrition.

During an interview on 06/02/22 at 3:20 PM, Staff B, Director of Nursing, DON stated that the Interdisciplinary team (IDT) meets weekly to discuss patients progress and/or concerns. The patient care plans should be updated weekly after the meetings. After reviewing the care plans for Patient's 5 and 7, Staff B confirmed that patient care plans were not updated with patient current status on goals, changes, or problems.

Based on record review, policy review and interview, the hospital failed to ensure the discharge summary accurately recapitulated a patient's hospitalization (Patient 1) of six discharged patients reviewed. Failure to ensure the discharge summary is accurate has the potential to place patient's at risk for future unmet needs and services.

Findings Include:

Review of the document titles, Medical Staff Rules and Regulations last revised 11/2020 showed, ...The Attending Physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current. The record shall include ...progress notes, final diagnosis, condition on discharge, discharge summary or note ...


Patient 1

Review of Patient 1's medical record showed she was a voluntary admission on 05/05/22 at 3:00 PM with a Diagnosis: Bipolar disorder, current episode mixed, severe without psychotic features. She also had Lithium (mood stabilizer) toxicity. Patient 1's record showed she had a durable power of attorney (DPOA).

Review of a nurse's note dated 05/06/22 at 12:00 AM showed, "Pt [Patient] is in bed yelling for staff assist approx. (approximately) q (every)10 minutes. Staff have tried to reorient pt to person, place, and time. Each time staff go in pt complains of or request a different item. Pt becomes tearful and exclaims staff is holding her here and she is leaving the second she can speak to her sister. This nurse explains to pt about procedures at SABH [St Anthony Behavior Hospital] and attempts to provide reassurance that pt may speak with her sister and doctor and confer on the best plan of action at a more appropriate hour."

Review of a Social Service Progress note dated 05/10/22 at 3:38 PM, showed, Patient 1 was very disruptive to the facility and to the staff over the weekend and on 05/10/22. When SSD [Social Service Designee] arrived this morning, SSD was informed that Patient 1 had been verbally aggressive with staff, asking for SSD since yesterday, threatening to staff, and refusing to do personal care needs and allowed self to remain in bed and have bowel movements and urination ... ......Patient 1 also stated that she will do whatever she wants until she goes home. ...she was adamant about leaving and "the torment will continue until I am able to leave!"

During an interview on 06/01/22 at 1:55 PM, Staff C, Judicial Doctor (JD), SSD, stated that Patient 1 was adamant about going home and was screaming and acting out because she wanted to go home.

Review of a physician order dated 05/10/22 at 4:37 PM, showed a verbal order to discharge Patient 1 was written by Staff S Licensed Practical Nurse (LPN) and signed by Staff D on 05/11/22 at 8:23 AM.
Patient 1 discharged to home the morning of 05/11/22.

Review of Patient 1's discharge summary dated 05/12/22 at 9:49 AM, showed "He [sic]
required infrequent doses of anxiolytics (medications for anxiety) and psychotropic medications during hospitalization. Patient was compliant with meds and attended groups. Patient tolerated medications well without any adverse reaction and there was noticeable improvement in mood, anxiety and behavioral symptoms prior to discharge." Psychiatric condition at discharge was stable with no evidence of anxiety, impulsivity, paranoia, or delusions. Physical condition at discharge is stable with no noticeable decline or deconditioning. Patient is calm and cooperative with staff and requires assistance in completion of ADL's. Treatment goals were met as evidenced by the patient's improved clinical course, medication compliance, and improved behaviors. Patient engaged with peers, therapy, and staff appropriately.


During an interview on 06/03/22 at 8:35 AM, Staff E, Advance Practice Registered Nurse, (APRN), when asked about Patient 1's discharge summary, he stated that the discharge summary was written based on clinical exam, patient progress and updates reported by nursing. Staff E stated that Patient 1 had some yelling out but felt that it was not related to psychosis. He stated that she was clinically better but that she would have benefited from staying with them a little longer. He stated that Staff F, Doctor of Osteopathy (DO), would have addressed the wounds.


Review of Patient 1's discharge summary showed it did not accurately recapitulate Patient 1's hospitalization compared to the nurses notes and social services progress note.


Review of Patient 1's Facility A, medical record showed Patient 1 was seen in the emergency department dated 05/11/22, and was admitted with diagnosis of BAD (Bipolar Affective Disorder) severe; ...RO [rule out] delirium (acute mental disturbance) from medical conditions (cellulitis [skin infection]/DVTs[deep vein thrombosis (blood clot)]); ...DVT LLE, and Cellulitis.