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Based on surveyor observations, review of facility incident reports and patient record review, and confirmed in interview, the facility failed to ensure patients received care in a safe setting for six of six (Patient #A, B, C, D, E, H) patients reviewed. Refer to A0144-A

The deficient practices were identified under the following Condition of Participation §482.13 Patient's Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Surveyor reviewed the updated Patient Observation Policy and confirmed re-training records confirmed IJ abated on 04/25/2025 at 1:55 PM.

Based on record review and interview, the governing body failed to ensure the facility written policies and procedures were followed in that Memorandum of Transfer (MOT) was not completed and sent with each patient transferred in two of three (Patient #A, G) patients reviewed for hospital transfer to the emergency room.

Findings included:

Review of the facility policy Transfer of Patient (Policy ID 10623375, effective 11/2024) it stated "The hospital will follow the procedure outlined below when transferring / transporting a patient to another health care facility. Patient transfers will be carried out per physician order in a safe and timely manner, keeping quality patient care a focus, with consideration for patient status. Appropriate patient information will accompany the patient during transfer / transport...Arrange transportation as ordered by physician Type of transportation must be decided based on the patient's condition: Nursing to prepare the patient for transport The reason for, including the risks and benefits of the transport, need to be explained to the patient. This is documented on the nursing assessment. The patient or personal representative shall consent to transfer. Prior to transport, and upon returning, the Nurse will document a patient assessment, condition, on the nursing assessment. The original will remain on the medical record and the copy shall accompany the patient. The following forms are required to be completed when transporting the patient: Transfer Order The following will accompany the patient during transport: A copy of all pertinent medical records pertaining to the reason for transport. Transfer Order Any additional documents requested by the receiving facility."

Patient #A

Review of Patient#A medical record revealed he was a 66 year old male who had a history of Parkinson and bipolar. He was readmitted on 4/2/2025 with cellulitis on contact precautions for MRSA and on an EDO (emergency detention order) as he was a risk to himself and others.

On 4/21/2025, Patient #A had an incident at an unknown time with the tech finding him in his room with a bleeding toe at 5:15 AM. After nurse assessment, patient was transported to an ER (Facility B) for continuity of care.

Review of records from Facility B revealed Patient #A was transferred via ambulance without an escort. Review of the patient records revealed no information was provided to the facility as to his medical history. He was treated for hypothermia and hypotension and was admitted.

In an interview with Staff #2 on 04/24/2025 at 1:23 PM in the meeting room, she stated that if a patient is transferred out, a tech would typically escort the patient when they are on an EDO. In another interview with Staff #2 on 04/25/2025 at 1:45 PM in the meeting room, she acknowledged that with Patient #A above, the staff did not assess vitals prior to transfer; they also did not escort the patient nor were patient records to include the MOT and EDO provided to Facility B per facility policy.

Patient #G

Review of Patient #G medical record revealed she was a 55 year old female who was an involuntary admission for psychiatric stabilization for depression with suicidal ideation with a plan.

On 3/31/2025 at 7:30 AM, Patient #G had an unwitnessed fall on the unit and complained of a hip pain with pain level at 10/10. There were orders to transfer for further evaluation.

Review of records available revealed no documentation of the MOT to Facility B. She was admitted for medical treatment to Facility B.

In an interview with Staff #2 on 04/25/2025 at 2:50 PM in the conference room, she confirmed the above findings.

Based on review of video and patient records, and confirmed in interview, the facility failed to promote care in a safe setting. The facility failed to monitor patients per provider's orders and per facility policy for six of six patients (Patient #A, B, C, D, E, H) reviewed. Additionally, the facility failed to promote a safe and sanitary environment for its patients for four of four units observed.

A. Patient observation
B. Safe and sanitary environment

Findings included:
A. Review of the facility policy Patient Observation (Policy ID 12931622, effective 11/2024) stated "Observation levels can be increased or decreased by a provider's order. Observation Levels: A frequency or intensity of observation assigned to a patient during which a health care professional, or their designee, will observe a patient. The approved observation levels assigned are: Level I - General Observation All patients on this level are on every 15-minute observation, at a minimum. This is the minimum acceptable level for all patients; for patients at a lower risk. The location of the patient should be known to staff at all times but they are not necessarily within sight. Positive engagement with the patient is integral for this level of observation. Level II - Every 5 Minutes. All patients on this level are on every 5 minute observation, at a minimum. This is an increased level of observation for patients at an increased risk. The location of the patient should be known to staff at all times but they are not necessarily within sight. Positive engagement with the patient is integral for this level of observation. Level III - 1:1 Observation The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities. Staff member must remain in close proximity to the patient, to include patient bathing and toileting activities. Under these conditions, the patient's safety and protection outweighs his/her right to privacy. For bathing and toileting activities, staff of the same sex may be utilized. Staff will continuously monitor the patient's behavior and immediately report any changes in conditions of circumstances to the nurse. Staff is not to engage in personal activities such as reading, eating, phone use, or similar activity that could distract or otherwise interfere with the continuous observation of the patient. Documentation: Documentation of all observations will be completed in the patient's record per their ordered observation status. Staff will complete the patient observation record using a coding system described on the Patient Observation Monitoring Form. Staff will initial, date and/or time appropriate documentation in the designated areas for observation of a patient."

Review of patient physician orders revealed six patients (Patient #A, B, C, D, E, H) had orders for Q15, Q5, and/or 1:1 observation rounds.

Review of Patient #A, B, C, E's physician orders revealed an order for Q15 observation rounds

Review of Patient #D's physician orders revealed an order for Q5 observation rounds

Review of Patient #H's physician orders revealed an order for 1:1 observation rounds

Video review of Unit 200 from 4/20/25 at midnight to 4/21/25 5:15 AM revealed the following times that a tech made rounds for the above patients. No other times were observeed.

12:20 AM
1:00 AM
1:22 AM
1:39 AM
5:15 AM

In an interview with Staff #2 on 04/24/2025 at 10:50 AM in the meeting room, she awknowledged that the techs performed improper rounds at 1:22 AM and 1:39 AM.- the tech is observed to briefly open and shuts door. She also stated that the rounds performed in the video reviewed were inadequate.

In an interview with Staff #3 on 4/24/25 at 1:20 PM in the meeting room, he stated that techs are trained to go into the room (at night with a flashlight) and to visualize the patient and monitor their breathing for 2 breaths.

B. Safe and sanitary environment

Hospital policy Cleaning Patient Rooms (Policy ID 9826636, effective 11/2024) stated in part, " Any waste should be removed from patient rooms/bathrooms.
Dust all fixtures, ledges and surfaces in the room and bathroom above shoulder height. Begin at the door and work clockwise around the room.
Damp dust over bed tables, bedside tables, telephone, chairs, stools, ledges, light switches, lamps and spots on walls or cabinets with a hospital approved germicidal solution. Damp wipe the bed frame, both sides of the mattress, pillows and bed control with germicidal solution. Clean the bathroom as per procedure. Damp mop floor with a hospital approved germicidal solution. Begin at the farthest corner of room working backwards toward door including the bathroom and closet. Be sure to disinfect baseboards.

Surveyor tour of the facility on 04/24/2025 at 10:10 AM revealed the following environmental concerns at random patient rooms observed in the four units:
Unit 100
Dirty and rusted bath benches
Dirty bath assistance chairs
Full sized personal hygiene bottles
Thick layers of dust on cabinets and beds
Mildew in bathroom stalls
Biohazard trash inside room with red plastic bag
Seclusion room between Unit 100 and 200
Vulgar words scratched onto the padding on wall
Unit 200, 300, and 400
Trash in rooms
Bodily fluids on walls
Thick layers of dust on cabinets
Mildew in bathroom
Dirty linens
Standing water in bathroom and room

In an interview with Staff #3 on 04/24/2025 at 10:40 AM during the tour, he acknowledged that the facility could do a better job of maintaining the units. He also stated that staff do safety rounds in the patient rooms at each shift, but it does not include environmental checks.

In an interview with Staff #2, she stated that the above policy for patient room cleaning is for when patients are discharged or transferred. There is no other policy for monitoring for sanitary or clean patient rooms.