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Based on policy review, document reviews, medical record reviews, observation, and interview, the Hospital failed to inform, honor, protect, and promote patients' rights related to care in a safe setting.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) situation (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death).

On 10/26/22 at 1:55 PM, the President and Quality Manager were notified that an Immediate Jeopardy (IJ) was identified at A0144, the patient has the right to receive care in a safe setting, related to 42 CFR 482.13, requirements for the condition of participation of Patient Rights.

On 10/28/22 at 3:30 PM, an acceptable plan of removal POR was received and included the following:
Ascension Via Christi St. Joseph (AVCSJ) is committed to ensuring patients are cared for in a safe environment. We acknowledge recent surveyor findings that the hospital did not adequately ensure all patients on the Senior Behavioral Health Unit (SBHU) received care in a safe setting.

AVCSJ supports an individualized, comprehensive, multi-disciplinary, and clinician-led plan of care to ensure the health and safety of each patient. SBHU screens all patients for suicide risk utilizing evidence-based tools (including, but not limited to Columbia Suicide Severity Risk Scale) and clinical assessment to identify potential risks and thus take action to prevent self-harm upon presentation for evaluation and treatment.

In alignment with patients' individualized needs and surveyor observations we have taken the following actions:

Completed an environmental sweep of the unit and removed all non-indicated clinical equipment and supplies that could pose a ligature risk on 10/26/22. Existing power cords were shortened and securely fastened with zip ties to reduce slack to the extent reasonably practicable.

Implemented an environmental safety protocol throughout the unit, including every patient room, during every shift by SBHU associates to actively identify and remove any item that may pose a potential risk. SBHU associates were educated by nursing leadership through email and huddles on 10/26/22 and 10/27/22.

Behavioral health administration clarified "Suicide Prevention" policy on 10/26/22 to require 1:1 monitoring with continuous visual observation for patients assessed as high risk for suicide.

Education to SBHU associates and medical staff on the updated policy will be completed in written communication and or verbally by 10/28/22 or prior to next worked shift by nursing and medical staff leadership.

Validated documentation of clinical need on all Stryker Spirit Behavioral Health Beds on SBHU on 10/27/22.

Educated Medical Staff on the requirement for documentation of clinical need for use of a Stryker Spirit Behavioral Health Beds on 10/26/22 by the Chief Medical Officer.

On 10/27/22 Safety Officer confirmed that Stryker Spirit Behavioral Health Beds were in Ascension Via Christi St. Joseph the low locked position and that patients are unable to reposition the beds.

Educated SBHU clinical associates on Stryker Spirit Behavioral Health Bed functionality by nursing leadership by 10/28/22 or prior to next worked shift to ensure beds are always in the lowest locked position safest and most appropriate for patient care when not attended by SBHU associates.

Completed an additional Ligature Risk Assessment on SBHU on 10/27/22 by safety and behavioral health leadership.

All SBHU nursing and support staff will have keys on their person for immediate access to secured rooms. Room doors will never be locked on patients who are identified as a high suicide risk on continuous 1:1 monitoring.

Education to SBHU associates on the updated process will be completed in written communication and/or verbally on 10/28/22 or prior to next worked shift by nursing leadership.

Compliance Monitoring

The SBHU manager or their designee will conduct and document daily audits of the sweeper tool completion to ensure compliance with AVCSJ's process.

The SBHU manager or designee will conduct a daily review of patients clinically deemed high risk for suicide to ensure compliance with the updated policy and process.

The SBHU manager or designee will conduct a daily review of documentation of medical necessity for a hospital bed for newly admitted patients to ensure compliance with the updated policy.

Audits will be conducted for two consecutive weeks and beyond or until sustained compliance has been demonstrated.

A reassessment of ligature risk will be conducted after 6 months by the safety team. Any unmitigated findings will be escalated to behavioral health leadership.

The plan of removal actions were verified by surveyors prior to survey exit on 10/28/22 at 3:45 PM.


Findings Include:


1. The hospital failed to ensure patients with capacity or the patient's representative received the Important Message from Medicare (IMM) in advance of furnishing or discontinuing care and failed to inform each patient or patient's representative of the patient's rights in advance of furnishing or discontinuing patient care, or the opportunity to participate in scheduled group discussions. (See findings in tag A0117)

2. The hospital Risk Management failed to analyze and trend 60 patient grievances for the period of 02/01/22 to 10/23/22. The hospital Quality Assurance Process Improvement (QAPI) process failed to mitigate risks to patients through implementation of process improvement efforts related to patient grievances received. (See findings in tag A0119)

3. The hospital failed to ensure the patient with capacity and/or the patient's representative was provided with an informed consent of his/her health status and being able to request or refuse treatment. (See findings in tag A0131)

4. The hospital failed to ensure the patient's family member or representative was promptly notified of his/her admission to the hospital. (See findings in tag A0133)

5. The hospital failed to provide care in a safe setting on the Senior Behavioral Health Unit (SBHU) 6 East related to: insufficient staffing levels affecting all patients; failure to remove potential harmful items from the environment for patients on suicide precautions; and failure to develop and implement specific interventions for the prevention of assaults and/or falls for three patients on the SBHU 6E. (See finding in tag A0144).

6. The hospital failed to ensure patients were free of four bed rails utilized without a physician order for restraints. (See findings in tag A0159)

7. The hospital failed to administer medication as ordered by the physician for 2 patients reviewed and failed to ensure correct armband color to denote a drug allergy was present for one patient of ten medical records reviewed. (See findings in tag A0405).

Based on policy review, medical record review, and interview, the hospital failed to ensure patients with capacity or the patient's representative received the Important Message from Medicare (IMM) in advance of furnishing or discontinuing care for 4 patients (Patient (P) P2, P3, P4, P10) of 10 medical records reviewed. The hospital failed to inform each patient or patient's representative of the patient's rights in advance of furnishing or discontinuing patient care, or the opportunity to participate in scheduled group discussions for 4 patients (P1, P3, P5, and P6) of 10 patients. These failures had the potential for all hospitalized patients to not be informed of their Medicare rights related to covered services and services provided after discharge.


Findings Include:


Review of the facility policy titled, "Patient Rights and Responsibilities," revised 01/21/22, indicated the procedure was "Patient Education - Patients and/or families are educated about basic patient rights in the following manner: a. Written information containing a copy of patients' rights and patients' responsibilities related to their rights is provided upon admission. If the patient is a minor or incapacitated, the rights are communicated through a parent, guardian, or designated representative."


Patient 1

P1 was admitted on 08/30/22 as identified on the H&P; the form that included "Your Rights as a Hospital Inpatient" was signed on 08/31/22.

On 10/25/22 at 8:00 AM interview and record review with Registered Nurse Clinical Informatics (RN CI) 3 of P1's medical record in its entirety, identified the following dates that P1 did not attend Group Therapy sessions, and there was no documentation in the Nursing progress notes or therapeutic notes regarding a reason for missing sessions: 09/16/22, 09/27/22, 09/28/22, 10/02/22, 10/05/22, 10/09/22, 10/12/22, 10/14/22, and 10/15/22.



Patient 2

Review of P2's physician "History and Physical (H&P)," dated 10/18/22 at 10:53 AM, failed to show any documentation related to whether the patient had capacity to sign an informed consent for treatment and acknowledgment of the IMM. The H&P showed a diagnosis of paranoid schizophrenia (severe mental illness characterized by delusions (firmly held beliefs in an altered reality), hallucinations (hearing, touching, seeing, smelling something not there), and paranoia (unrealistic distrust of others).

Review of P2's "Important Message from Medicare (IMM)," dated 10/21/22 at 10:21 AM, showed there was a verbal consent obtained from the guardian three days after admission. The document failed to show that name of the individual that acknowledged the IMM.


Patient 3

Review of P3's physician "H&P," dated 09/15/22 at 1:03 PM, failed to show any documentation related to whether the patient had the capacity to sign an informed consent for treatment and acknowledgment of the IMM. The H&P showed a diagnosis of Alzheimer's and dementia. Additional documentation on the H&P showed, "per RN arrival note 09/14: "Pt is awake and alert he/she verbalized he/she does not know why he/she is here, nor does he/she know where he/she is at."

Review of P3's "Important Message from Medicare (IMM)," dated 09/15/22 at 9:31 AM, showed P3 signed his/her IMM. There was no evidence provided by the facility that the patient's guardian or DPOA signed the IMM.

Review of P3's group therapy attendance showed P3 had only attended group therapy on 09/24/22 and 10/17/22. The facility was unable to provide documentation for why P3 had not attended the group therapy.

During an interview on 10/26/22 at 11:50 PM, RN CI 2 confirmed the findings in the medical record of P3 related to the failure to attend group therapy.


Patient 4

Review of P4's physician "H&P," dated 09/18/22 at 11:00 AM, failed to show any documentation related to whether the patient had capacity to sign an informed consent for treatment and acknowledgment of the IMM. The H&P showed a history of dementia and P4 was noted to be very confused. The physician documentation showed a diagnosis of major neurocognitive disorder (dementia).

Review of P4's "Important Message from Medicare (IMM)," dated 09/27/22 at 10:00 AM, nine days after admission, showed a verbal consent was obtained from a guardian. The document failed to show the name of the guardian acknowledging the IMM.


Patient 5

P5 was admitted on 09/18/22 as identified on the BEH (Behavior) Admission History; the "Admission Consent" form was signed by P5 on 09/19/22. P5 received a score of 14/30 on the Saint Louis University Mental Status (SLUMS) examination (detecting cognitive impairment and dementia). Scoring on the SLUMS examination identified a score of one to 19 as Dementia (P5 was functioning in the level of a person having Dementia).

On 10/25/22 at 11:00 AM interview and record review with RN CI3 of P5's medical record in its entirety, identified the following dates that P5 did not attend Group Therapy sessions, and there was no documentation in the Nursing progress notes or therapeutic notes regarding a reason for missing sessions: 09/18/22, 09/19/22, 09/20/22, 09/23/22, 09/24/22, 10/01/22, 10/02/22,10/08/22, 10/09/22, 10/15/22, 10/16/22, and 10/23/22.


Patient 6

P6 was admitted on 09/18/22 as identified on the BEH Admission History; on 09/18/22 received a score of 8/30 on the SLUMS Examination as functioning in the level of a person having Dementia; on 09/20/22 the granddaughter provided verbal consent on the "Admission Consent" form.

On 10/26/22 at 11:25 AM interview and record review with RN CI3 of P6's medical record in its entirety, identified the following dates that P6 did not attend Group Therapy sessions and there was no documentation in the Nursing progress notes or therapeutic notes regarding a reason for missing sessions: 09/20/22, 09/22/22, 09/25/22, 09/28/22, 10/02/22, 10/08/22, 10/09/22, 10/14/22, 10/15/22, 10/16/22, and 10/23/22.

Review of the "Behavioral Health Progress Note" on the item "Group attendance/participation this shift" included a response of "N/A" on seven of the above-mentioned dates (09/20/22, 09/25/22, 10/02/22, 10/08/22, 10/09/22, 10/15/22, and 10/16/22)." The progress note did not define N/A. The RN CI3 revealed there was no reason noted why attendance at a group activity would not be applicable.


Patient 10

Review of P10's physician "H&P," dated 10/19/22 at 7:13 AM, failed to show any documentation related to whether the patient had capacity to sign an informed consent for treatment and acknowledgment of the IMM The physician documentation showed a diagnosis of major neurocognitive disorder with paranoia.

Review of P10's " Important Message from Medicare (IMM)," dated 10/19/22 at 12:19 PM, showed P10 signed his/her IMM. The document failed to show the facility attempted to contact a guardian or representative for informed consent.


During an interview on 10/26/22 at 11:50 PM, RN Clinical Informatics (RN CI) 2 confirmed the above medical record findings for P2, P3, P4 and P10 related to the patients not receiving the IMM.

Based on policy review, document review, medical record review, and interview, the hospital Risk Management (RM) failed to analyze and trend 60 patient grievances for the period of 02/01/22 to 10/23/22 resulting in the hospital Quality Assurance Process Improvement (QAPI) committee's failure to develop and implement improvement efforts to mitigate risk related to patient grievances received as shown in the review of a grievance for Patient (P) 3. These failures had the potential to affect the quality and safety of patient care being provided for all hospitalized patients.


Findings Include:


Review of the policy titled, "Grievance Resolution/Patient Feedback/Complaint Resolution," revised 04/06/18, indicated the procedure was "m. Patient Satisfaction: 1. Staff is to be alert to expressions of complaints or dissatisfaction by patient and families/significant other ...These reports are sent to the Risk Management Department for trending purposes. a. When opportunities for improvement of services are identified, feedback is provided immediately to the staff person who can most appropriately make the improvements and to the appropriate manager." Continued review of the grievance policy showed, "The patient or their representative filing a grievance that was not resolved by staff present receives an acknowledgement (written or verbal), within seven (7) working days of receipt of the grievance. Verbal responses are provided by authorized representatives and the interaction is documented on the Feedback Ticket by the authorized representative. Written responses to the appropriate parties are sent by the Risk Management Department. If necessary, the written acknowledgement of a grievance includes a time frame for a complete response, not to exceed 30 working days, as well as hospital contact information. If the investigation is not or will not be completed within 30 working days, the Risk Management Department or designee will inform the patient or patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy. The hospital must attempt to resolve all grievances as soon as possible."


Review of the facility grievance log showed the Durable Power of Attorney (DPOA) for P3 filed a grievance on 02/21/22 related to care issues, including concerns related to P3's tremors and a request for a Neurology consult.


Review of P3's physician "H&P," dated 09/15/22 at 1:03 PM, showed P3 had been admitted to the Senior Behavioral Health Unit (SBHU) 6E on 09/14/22 and was still on the unit at the time of medical record review on 10/25/22.


On 02/21/22 the Patient Advocate sent an email to P3's social worker (SW), Registered Nurse (RN), Nurse Manager (NM) and the Risk Manager (RM) to make them aware of the caller's statements and concerns.

Continued review of the grievance showed that on 02/24/22 at 9:06 AM, the RM documented the following related to P3's DPOA's concerns with tremors and wanting a neurology consult for his/her father. "We also discussed his resting tremors the COULD be indicative of Parkinson's Disease and that we would be in agreement to start a low dose Sinemet (medication used to treat Parkinson's disease). He/she is against this and would like a Neurology consult. We would want nothing more than to do the same. I explained that Neurology does not do consults in our Hospital. He/she was adamant that he/she would get a Neurologist to see him/her. The doctor and I are not disagreeing with a Neurology consult but that would need to wait until he/she can be seen as outpatient. He/she said that he/she would pursue through the Hospital administrator."

P3's DPOA called the facility Patient Advocate on 02/25/22 at 3:43 PM stating he/she was not satisfied with the information provided by the Social Worker (SW), physician, or nursing leader. "...I suggested that he/she contact his/her father's primary care physician (PCP) to get guidance on how to proceed with whatever option she would like to pursue. She was not happy but understood."

A final letter was sent to P3's DPOA on 04/04/22, greater than 30 days after the grievance was received. The letter indicated the facility did not provide neurology consults and the DPOA would have to pursue outpatient neurology services after discharge related to P3's tremors.

There was no evidence provided that the facility had resolved the DPOA's grievance related to the care and treatment provided to P3 within 30 days. The facility failed to provide evidence that the DPOA was notified that the hospital was still working to resolve the grievance and that the hospital would follow-up with a written response within a stated number of days.

During an interview on 10/26/22 at 12:30 PM, the RM confirmed the facility had received 60 patient grievances from 02/01//22 through 10/23/22. The RM stated the grievances had not been analyzed for trends related to categories of concerns or by nursing unit/hospital department. The RM stated he/she only reports total number of grievances to the Quality/Patient Safety/Governing Board Committees. The RM confirmed he/she was unable to say how many of the grievances may have been related to patient safety concerns or the quality of care provided.

Based on policy review, record review, and interview, the Hospital failed to ensure the patient with capacity and/or the patient's representative was provided with an informed consent of his/her health status and being able to request or refuse treatment for 4 patients (Patient (P) P2 P3, P4, P10 ) of 10 medical records reviewed. These failures have the potential for all hospitalized patients to not know of their right to be informed of his/her health status, to be involved in care planning and treatment, and to be able to request or refuse treatment.


Findings Include:


Review of the policy titled, "Behavioral Health - Patient Management," revised 05/03/19, indicated "4. Consent A. Adults 1. Adults with decisional capacity must sign consent for treatment prior to admission to any of the BH (behavioral health) services. "Confidentiality Code Waiver," "Permission to Disclose Health Information to Individual that May Be Involved in the Patient's Care," and at times "Consent for Disclosure of Treatment and Medical Record Information" will be offered to patient at the admission ...C. Telephone Consent 1. Telephone consent may be obtained when the appropriate guardian is not available in person. The phone consent must be heard and documented on the medical record by two staff. The person supplying phone consent will be informed that a written signature must follow within 24 hours. If the person for some valid reason cannot physically get to the unit to provide written signature, they may send a fax."

Review of the policy titled, "Informed Consent," revised 05/05/20, showed, "Informed consent must be obtained in writing before an invasive medical or surgical procedure or treatment involving significant risks that is performed by a physician or appropriately privileged professional ...B. The patient signing the consent form must be of legal age ...The following individuals acting as surrogate decision maker may give consent/authorization for treatment in the following order: 1. An adult patient with decision-making capacity 2. Court appointed guardian 3. Agent named under a Durable Power of Attorney for Healthcare Decisions (DPOA HCD) 4. Patient's spouse provided the spouse had decision-making capacity 5. Adult child of the patient ...F. Individuals as outlined in Section B above may provide consent for adults without decision-making capacity and who are unable to authorize treatment for themselves ...Definitions: A. Decision-making capacity - The ability to understand the nature and consequences of a decision about treatment option and the ability to make and communicate a decision based on that understanding ...D. Informed consent - a physician or trained allied health professionals conversating with the patient or patient's surrogate decision maker that includes potential benefits, risks, and side effects of the patient's proposed care, treatment, and services; the likelihood of the patient achieving his or her goals; any potential problems that might occur during recuperation; and reasonable alternatives to the patient's proposed care, treatment, and services. The discussion encompasses risks, benefits, and side effect related to the alternatives, and the risks related to not receiving proposed care, treatment, or services ... G. Surrogate decision maker - Someone legally appointed to make decisions on behalf of another. The decision maker can be a family member, or someone not related to the individual served or patient. A surrogate decision-maker makes decisions when the individual serviced, or patient is without decision-making capacity or when the individual served, or patient has given permission to the surrogate to make decisions."

During an interview on 10/26/22 at 5:30 PM, the Senior Behavioral Health Unit (SBHU) Director was asked to confirm that the Saint Louis University Mental Status (SLUMS) score was used to determine capacity as that was what the surveyors had been told throughout the three-day survey. The SBHU Director stated, "we do not use the SLUMS score, the physician determines capacity and documents this in the physician history and physical (H&P) performed at the time of admission."


Patient 2

Review of P2's physician "History and Physical (H&P)," dated 10/18/22 at 10:53 AM, failed to show any documentation related to whether the patient had capacity to sign an informed consent for treatment. The H&P showed a diagnosis of paranoid schizophrenia (a serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning and can be disabling).

Review of P2's "Admission Consent, Promise to Pay for Services and Agreement of Insurance Benefits" showed a verbal consent was obtained on 10/21/22, but failed to show the name of the person that consented to P2's treatment. Additionally, the document failed to show the signature of the person providing informed consent within 24 hours.


Patient 3

Review of P3's physician "H&P," dated 09/15/22 at 1:03 PM, failed to show any documentation related to whether the patient had the capacity to sign an informed consent for treatment. The H&P showed a diagnosis of Alzheimer's (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Additional documentation on the H&P showed, "per RN arrival note 09/14: "Pt is awake and alert he/she verbalized he/she does not know why he/she is here, nor does he/she know where he/she is at."

Review of P3's "Admission Consent, Promise to Pay for Services and Agreement of Insurance Benefits," dated 08/11/22, prior to the patient arriving on the SBHU, showed the patient signed the consent. There was not a consent signed by P3's guardian or durable power of attorney (DPOA).


Patient 4

Review of P4's physician "H&P," dated 09/18/22 at 11:00 AM, failed to show any documentation related to whether the patient had capacity to sign an informed consent for treatment. The H&P showed a history of dementia and was noted to be very confused. The physician documentation showed a diagnosis of major neurocognitive disorder (describe the symptoms of a large group of diseases causing a progressive decline in individual's functioning. It is an umbrella term describing a decline in memory, intellectual ability, reasoning, and social skills, as well as changes in normal emotional reactions) (dementia).

Review of P4's "Admission Consent, Promise To Pay for Services and Agreement of Insurance Benefits," dated 09/27/22 at 10:10 AM, showed a verbal consent was obtained from a guardian nine days after admission. The document failed to show the name of the guardian that provided the verbal consent nine days after admission. Additionally, the document failed to show the signature of the person providing informed consent within 24 hours of providing the verbal consent.


Patient 10

Review of P10's physician "H&P," dated 10/19/22 at 7:13 AM, failed to show any documentation related to whether the patient had capacity to sign an informed consent for treatment. The physician documentation showed a diagnosis of major neurocognitive disorder (describe the symptoms of a large group of diseases causing a progressive decline in individual's functioning. It is an umbrella term describing a decline in memory, intellectual ability, reasoning, and social skills, as well as changes in normal emotional reactions) with paranoia (thinking and feeling like you are being threatened in some way, even if there is no evidence, or very little evidence, that you are).

Review of P10's "Admission Consent, Promise to Pay for Services and Agreement of Insurance Benefits," dated 10/19/22 at 12:19 PM, showed P10 signed his/her informed consent for treatment. The document failed to show the facility attempted to contact a guardian or representative for informed consent.


During an interview on 10/26/22 at 11:50 PM, Registered Nurse Clinical Informatics (RN CI) 2 confirmed the findings in the medical records of P2 P3, P4, and P10.

Based on policy review, record review, and interview, the Hospital failed to ensure the patient's family member or representative was promptly notified of his/her admission to the hospital for 1 patient (Patient (P) 5) of 10 medical records reviewed. This failure increases the risk of patients being admitted to the hospital without consultation with their family or representative.


Findings Include:


Review of the facility policy titled, "Patient Rights and Responsibilities," revised 01/21/22, indicated the procedure was "Patient Education - Patients and/or families are educated about basic patient rights in the following manner: a. Written information containing a copy of patients' rights and patients' responsibilities related to their rights is provided upon admission. If the patient is a minor or incapacitated, the rights are communicated through a parent, guardian, or designated representative."

Review of the policy titled, "Informed Consent," revised 05/05/20, showed, "Informed consent must be obtained in writing before an invasive medical or surgical procedure or treatment involving significant risks that is performed by a physician or appropriately privileged professional ...B. The patient signing the consent form must be of legal age ...The following individuals acting as surrogate decision maker may give consent/authorization for treatment in the following order: 1. An adult patient with decision-making capacity 2. Court appointed guardian 3. Agent named under a Durable Power of Attorney for Healthcare Decisions (DPOA HCD) 4. Patient's spouse provided the spouse had decision-making capacity 5. Adult child of the patient ...F. Individuals as outlined in Section B above may provide consent for adults without decision-making capacity and who are unable to authorize treatment for themselves"


Patient 5

Review of the "Ascension Via Christi St Joseph SBH [Senior Behavior Health]" Face Sheet (patient information, guarantor information, contact information, primary insurance, and encounter information), revealed P5 was transferred from the hospital to the "Senior Behavior Health Unit" (SBHU) on 09/18/22 at 5:37 AM with an "Admit Reason: SUICIDE ATTEMPT."

Review of the "BEH [Behavioral Health] Admission History" dated 09/18/22, P5 was admitted on 09/18/22 with diagnoses to include schizophrenia (mental illness of hallucinations [hearing, seeing, tasting objects not there), spectrum disorder (developmental disorder), and impulse control deficit. The "H&P," dated 09/18/22, identified, "She threw cigarettes, and it has burned down the house." "Mental Status Examination: This patient is alert, makes good eye contact. Admits to hearing voices, no evidence of catatonia [inability to move normally]."

Review of the Saint Louis University Mental Status (SLUMS) examination (detecting cognitive impairment and dementia) revealed P5 received a score of 14 out of 30. Scoring on the SLUMS examination identified a score of one to 19 as Dementia (P5 was functioning in the level of a person having Dementia).

Review of the "Admission Consent" form revealed P5 signed the form with a typed date of 09/19/22 at 12:23 PM and a line drawn across the time, replaced with the time of "1300" [1:00 PM].

Review of P5's "Admission Consent, Promise to Pay for Services and Agreement of Insurance Benefits" was signed by P5 on 09/19/22 with an Ascension Representative on 09/19/22 at 1:00 PM. The "Ascension Via Christi Important Message from Medicare" form that included "Your Rights as a Hospital Inpatient" was signed by P5 on 09/19/22 at 3:00 PM.

Review of a "Social Services Progress Note," dated 09/19/22 at 3:10 PM, revealed the social worker met with P5's twin daughters and documented "They report that P5 burned down her home, there is no home to go back to. SW [social worker] discussed placement and what insurance can pay for." This was the first contact with a family representative following admission.

There was no admission notification consent signed by P5's representative or durable power of attorney (DPOA). There was a "Durable Power of Attorney for Healthcare Decisions" form dated 04/07/22 naming one of P5's daughters as DPOA. There was no acknowledgement of a phone consent signed by two staff members located on the admission consent.


During an interview and review of P5's medical record on 10/24/22 at 1:00 PM, Registered Nurse Clinical Informatics (RN CI) 3 confirmed that P5 signed her admission paper, the scoring of the SLUMS Examination indicates dementia, and the above medical record findings.

Based on observation, policy review, document review, and interview, the Hospital failed to provide care in a safe setting on the Senior Behavioral Health Unit (SBHU) 6 East related to: 1. insufficient staffing levels affecting all patients; 2. The hospital failed to remove potential harmful items from the environment for 3 (Patient (P)1, P5, and P9 of 3 patients on suicide precautions; and 3. The hospital failed to develop and implement specific interventions for the prevention of assaults and/or falls for 3 patients (P4, P5, P7) of 3 patients observed on the SBHU 6E.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) situation (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death).


Findings Include:


1. The hospital failed to provide sufficient staffing levels.

Review of the "Behavioral Health - Patient Management," policy dated 05/3/19, section titled, "Patient Observation Levels" item b included the following: "Periodic Observation- Level 1:
15-minute checks are conducted in varied incremental patterns within the set time parameters."

During an interview on 10/24/22 at 10:00 AM, Registered Nurse (RN) 2 revealed, the hospital was "not meeting the matrix of staffing; pull in extra staff." The Senior Behavior Health Unit (SBHU) Director stated, "the manager will work the floor, pull from other units if needed and use resource pool. All leaders picked up shifts during the last two weeks. We average three to four RNs and two Patient Care Technicians (PCTs). We will pull off the floor to be a sitter or resource pool."

Review of the document titled, "SBH Staffing Grid," dated 10/04/21, showed the following staffing matrix for SBHU 6 East:

Census 22-25 - 5 Registered Nurses (RNs), 3 Certified Nursing Assistants (CNAs)
Census 17-21 - 4 RNs, 3 CNAs

Review of the unit "SBH Staffing Grid" compared to actual staffing and census for the SBHU 6E for the period between 10/02/22 and 10/23/22 (a total of 22 days) showed the following:

Day shift the unit was short RNs for 15 days, PCTs 20 days, 1:1 Sitter 14 days and on the night shift the unit was short PCTs 18 days and a Sitter 16 days.

The following days indicate when the unit was short staffed for patients requiring 1:1 observation:

Sitters 1:1 Days short days: 10/01/22 - 1; 10/02/22 - 1; 10/04/22 - 1; 10/06/22 - 1; 10/07/22 - 2; 10/11/22 - 1; 10/12/22 - 1; 10/13/22 - 1; 10/16/22 - 3; 10/17/22 - 2; and 10/20/22 - 2

Sitters 1:1 Nights short: 10/03/22 - 1; 10/05/22 - 1; 10/06/22 - 1; 10/13/22 - 1; 10/14/22 - 1; 10/15/22 - 1; 10/16/22 - 2; 10/17/22 - 1; 10/18/22 - 2; 10/20/22 - 1; 10/22/22 - 1; and 10/23/22 - 1.

Further review of the staffing grid revealed no staff were available for 1:1 observation on the day shift on 10/07/22 and 10/20/22.

During an interview on 10/26/22 at 9:15 AM, the SBHU 6E Nurse Manager 2 confirmed that on 10/16/22 the facility was utilizing one staff member to observe four patients in different rooms that were on 1:1 observation. The SBHU 6E Nurse Manager 2 confirmed that on 10/16/22 on the 7:00 AM to 7:00 PM shift there were four rooms (603, 630, 631, 605) housing patients that required a 1:1 sitter and only one sitter was available to monitor these four patients.

On 10/25/22 from 2:24 PM to 2:56 PM (32 minutes), this surveyor observed the monitor to view 15-minute checks of all bedrooms. During the 32 minutes of observation, the following bedrooms with patients in each room received one check/observation of staff entering the patients' bedroom: Rooms 602, 603, 621, 622, 624, 626, 629 and 631. RN CI 3 verified that each of these rooms housed a patient.

On 10/26/22 at 3:15 PM interview with Charge RN regarding ensuring 15-minute checks, stated, "We don't have anyone at the desk, to help with rounds [to include 15-minute checks]."

On 10/25/22 at 9:30 AM, interview and record review with Registered Nurse Clinical Informatics (RN CI) 3 of P1's 10/2022 physician orders and "Medication Administration Record (MAR)" identified Risperidone (medication used to treat behavioral problems) 1.5 milligrams (mg) daily [at 9:00 PM] was administered at 10:49 PM on 10/05/22 and the Risperidone was administered on 10/08/22 at 10:43 PM with a reason, "Nursing Judgment and short of staff."

During an interview on 10/26/22 at 3:00 PM, with Charge RN regarding the late times of administration of medication, he/she revealed, "definitely short of staff. It is not a quick delivery and [depends on] how cooperative people are [during administration of medication]."

During an interview on 10/25/22 at 3:00 PM, with PCT 1 regarding staffing, he/she stated, "lately, frequently two on; sometimes by self a couple of hours until they pull someone; only happened twice since February."

During an interview on 10/25/22 at 3:50 PM, with RN1 regarding staffing revealed, "staffing is always a concern. They say we can't get help when there is not any to have. They ask what's not safe; I respond, can't keep them from falling. They came up with some help. A lot of time there are two PCTs on the floor, requires four; RNs will help toilet and feed the patients."


2. The hospital failed to remove potential harmful items from the environment for patients on suicide precautions.

Review of the document "Welcome Patient Rights," dated 02/21, the section "YOU HAVE A RIGHT TO" ..."Receive care in a safe setting."

Review of the facility policy titled, "Suicide Prevention," revised 04/14/20, showed "C. Mitigation strategies for patients identified as a risk for suicide may include: 2. Patients at risk of suicide are placed in a safer environment. Environmental risk assessments identify features in the physical environment that could be used to attempt suicide. Necessary actions are taken to minimize the risk(s) a. Inpatient behavioral health units: Ligature "resistant" environment. Removal of potentially harmful items if patient is at risk of utilizing items to harm self (remove or modify access to means of suicide) ...c. Inpatient ...health care setting that provide care to those at risk of harm to self or others ..."Safer" environment. Remove objects from the room that can be used for self-harm ...Potential risks include but are not limited to those from ligature, sharp, harmful substances, access to medications...plastic bags (for suffocation), oxygen tubing, bell cords, etc. 3. Patient Observation (Observation Levels) ...c. There a three types of observation levels. Level of observation is based on clinical rationale, suicide risk assessment and care team assessment ...III. Level III: Within arms-length (i.e., toileting, bathroom and patient sleeping) a. Requires that a staff member be within the arms-length of a patient to immediately intervene to prevent any self-harming behaviors."


Observation on 10/24/22 at 9:45 AM, while on tour of the SBHU 6E unit, three patients (Patient (P)1, P5, and P9 were on suicide precautions. All three patients had medical beds with four side rails and electrical cords that could be used for strangulation and hanging. These findings were confirmed by the Quality Manager (QM) at the time of the tour.


Review of an untitled and undated spreadsheet that identified the patients residing in the Behavioral Health Unit, revealed the "Reason for Visit" for the patients was as follows :


Patient 1

P1 - "Depression, Suicide Ideation, Insomnia, ESRD and Hyperkalemia,"

Review of the "History and Physical (H&P)" revealed P1 was admitted on 08/30/22 and "patient made statements that she wanted to die stating that her plan would be to overdose on medications." Further review of the "H&P" revealed "Upon arriving to the psych unit: [P1] stated, she has been unable to sleep for 5 nights and thought she would just take a bunch of pills to facilitate sleep." In the same H&P report, "RN [Registered Nurse] reports: [P1] has been aggressive and violent, currently in 4 pt [point] restraints." Initial Plan included: "Will support, stabilize, and monitor pt [patient] in a reasonably safe environment. SW [Social Worker] will attempt to obtain collateral information from family or patient's support system-explore guardianship if needed. SW will complete a psychosocial assessment and develop discharge plan for social concerns found during the assessment. Medical consult, Nephrology consult."

Review of the "Care Plan," initiated on 09/01/22, included the following outcomes related to suicide ideation: "Psychological Impairment - Mood Care Plan," "Identifies Triggers Leading to Self-Harm," "Self-Harming Behavior," "Identifies Effective Coping Strategies," "Demonstrates Mood Stabilization," Self-Harm, Suicide Risk Plan of Care Review," "Verbalizes Decrease, Absence of Suicidal Ideas."

Observation on 10/24/22 from 10:30 AM to 11:10 AM showed all 25 beds, including P1's, had four side rails, electrical cords zip tied together and regular bed linens that could be utilized by a patient to strangle or hang him/herself when tied to the bed rails.


Patient 5

Review of the "H&P" revealed P5 was admitted on 09/18/22 with the diagnostic impression: "schizophrenia [mental illness resulting in hallucinations (seeing, hearing, tasting things not present) and delusions (firmly held beliefs that are not real)], spectrum disorder [developmental disability] and impulse control deficit." Mental Status examination included, "admits to hearing voices, insight is poor, judgment is poor. The patient claims her house caught fire. She threw some cigarettes, and it has burned down the house." The "Social Services Progress Note" from 09/19/22 at 3:10 PM, identified the social worker met with P5's twin daughters; "They report that P5 burned down her home, there is no home to go back to."

Review of the Saint Louis University Mental Status (SLUMS) examination (detecting cognitive impairment and dementia) revealed a score of 14 out of 30. Scoring on the SLUMS examination identified a score of one to 19 as Dementia (P5 was functioning in the level of a person having Dementia).

Review of the "Care Plan" for P5's outcomes that address suicide tendencies included the following: "Exhibits No Attempts to Self-Harm", "Identifies Triggers Leading to Self-Harm" Demonstrates Effective Coping Skills, and "Psychological Impairment-Mood Care Plan." Interventions included, "Assess for Changes in Mood," "Address for Signs of Delusions or Hallucinations."

Observation on 10/24/22 from 10:30 AM to 11:10 AM showed all 25 beds, including P5's, had four side rails, electrical cords zip tied together and regular bed linens that could be utilized by a patient to strangle or hang him/herself when tied to the bed rails.



Patient 9

Review of the "H&P," 10/21/22, revealed P9 was admitted on 10/21/22; diagnosis assessment/plan included: major depressive disorder, hypertension, multiple sclerosis, peripheral vascular disease. The H&P plan identified, "Precautions: suicide, elopement." "P9 states that she has nowhere to find peace, no rights, and no sense of herself anymore. She anticipates smoking being banned at her living facility which was her final straw. She smoked half a pack of cigarettes today." P9 made statements, "I don't want to live anymore and reported she thought about motoring her (wheelchair) into the lake."

Plan of Care for P9 was initiated on 10/21/22 included the following: "Psychological Impairment - "Mood Care Plan," "Demonstrates Effective Coping Skills. Intervention included: "Assess and Observe the Ability to Demonstrate Safe Behavior," "Assess Changes in Mood," Address any Signs of Delusions or Hallucinations."

Observation on 10/24/22 from 10:30 AM to 11:10 AM showed all 25 beds, including P9's, had four side rails, electrical cords zip tied together and regular bed linens that could be utilized by a patient to strangle or hang him/herself when tied to the bed rails. P9 also had a gown with ties and a pull tab alarm, that was hooked to the patient gown, and was approximately 14 inches long which all could be used for self-strangulation or hanging.


During the tour in the presence of the Senior Behavioral Health Unit (SBHU) Director on 10/24/22 from 10:30 AM to 11:10 AM, the patients' bedroom doors were locked from the outside.... On 10/24/22 at 10:30 AM, the SBHU Director revealed the reason for the locked doors, "we have wanderers." Additionally, during the tour, it was observed that all 25 rooms had bed electrical cords, rooms 612 and 632 had call light cords, room 632 had a Walkman with a cord and room 629 had oxygen tubing.

All twenty-five rooms were locked from the outside and required key entry, potentially slowing response time if a patient attempts to self-harm him/herself. On 10/26/22, during a tour of the Behavioral Health Unit from 9:10 AM to 9:55 AM, one staff tried to open a patient's door with one of the keys on his/her key chain, it did not open the door; on the second try, with another key, he/she was able to open the patient's bedroom. In case of an emergency, it is imperative to be able to access the patients in a timely manner.

Review of a hospital document titled "Senior Behavioral Health Guidelines," revised 04/01/19, identified "Plastic bags are not allowed."

On 10/24/22 at 10:30 AM, observation of room 611 revealed there was a plastic bag in the wardrobe. The SBHU Director stated, "there are no plastic bags."

On 10/26/22 at 9:10 AM observation of room 613 revealed a plastic lunch bag.


3. The hospital failed to develop and implement specific interventions for the prevention of assaults and/or falls.

Review of the "Ascension Via Christi Fall Prevention Agreement," revised 10/2014, identified, "Because you have been identified as someone who could be at risk for falling, we will be taking the following fall-prevention steps: using a yellow wristband, gown and treated socks to make sure that all care team members are aware of your fall risk."

Review of the "Patient Armband Colors: Work Instructions" dated 03/19/21, included the following: "Identification Armband: A band that is white in color and contains identifying information about the patient such as name, medical record, and date of birth. Color-coded wristband: a band that alerts care givers to specific patient conditions. Allergy-red armband, Fall Risk-yellow armband."

On 10/24/22 at 10:00 AM, interview, RN2 revealed, patients in the unit wear arm bands, fall risk patients wear a yellow armband; yellow gown, and yellow socks in bed; there are 15-minute checks, cameras in all rooms, alarms on beds, and telemonitors. Fall-risk monitor is remote only in the patients' room. Everyone is on q15 minutes [every 15 minutes] check, documented on each patients' medical record.


Patient 4

On 10/24/22 at 10:30 AM, observation of P4 in his/her bedroom, he/she was wearing a blue and white gown with strings/laces in the front to close the gown. He/she has a diagnosis of dementia and was a fall risk.

P4 was not wearing a yellow gown to indicate fall precautions per policy.


Patient 7

On 10/24/22 at 10:50 AM and 10/25/22 at 1:55 PM, observation of P7 in the hallway revealed a fall-risk patient was not wearing a yellow arm band but was wearing yellow socks. Review of the "Behavioral Health Team Meeting" on 10/19/22 included the current plan of care, "High Risk Fall Management:" Takes Action to Control Condition Specific Risks, High Fall Risk Activity Precautions, and Verbalizes Understanding Fall Related Personal Risks." P7's fall risk score was not documented.


Patient 5

Review of P5's "H&P," on 09/18/22, identified the diagnostic impression: "schizophrenia, spectrum disorder and impulse control deficit." The Behavioral Health Team Meeting on 09/19/22 for P5 identified "At risk for falls."

Review of the "High Risk Fall Prevention and Management Plan of Care," dated 09/19/22, included the following: "Patient Remains free from Falls and Injury, Verbalizes Understanding of Fall Risk/Precautions, Caregiver Verb [verbalizes] Understand [understanding] Fall Risk Care, Takes Action Control Fall Risk, Adherence to Fall Risk Specific Precautions Needs further teaching."

On 10/24/22 at 11:05 AM, observation of P5 ambulating with a rolling walker in the hallway, a fall-risk patient, was wearing a white not yellow arm band.

During an interview on 10/25/22 at 11:10 PM while reviewing incident reports, the Director of Risk Management (RM) was asked how many falls had occurred in the last 12 calendar months, 10/01/21 to 10/01/22 on the SBHU 6E. The RM Director stated there had been 128 patient falls and 27 resulted in harm with injury. The Director of RM was asked how many assaults had occurred and he/she stated there had been 25 during that timeframe. When the Director of RM was asked what had been done to prevent falls, he/she stated the surveyor would have to check with the Quality Manager or Quality Director. When asked what the details of the assaults were and what had been done, the Director of RM stated he/she would have to review the details of the 25 assaults and get back to the surveyor. When asked what information the Governing Body (GB) received about these incidents, the Director of RM stated he/she only reports total numbers in a system report to the GB. He/she stated the GB does not receive details such as unit or nature of the assault.

On 10/25/22 at 1:00 PM, the Regional Director of QM was asked about what had been done to prevent assaults and falls on the SBHU 6E. The Regional Director of QM stated he/she did not have any process improvements to provide for the 25 incident reports related to assaults. When asked what had been done to prevent and/or mitigate the 128 falls and 27 with harm/injury on the SBHE 6E falls, the Regional Director of QM provided the surveyor with a fall prevention newsletter dated 10/21/22. The fall prevention newsletter showed: "Tip of the week: ensure staff know which patients are fall risk patient for the unit and call virtual safety for cameras on your campus ...Bundle Highlight: Check the bed before leaving the room: Is the be all the way down on the floor? Is the head of the bed in the correct position? Is the bed alarm on? Are the wheels locked? Are the safety rails up?" The Regional Director of QM was unable to provide any fall prevention mitigation strategies that were specific to the SBHU 6E.

Based on document review, observation, and interview, the Hospital failed to ensure patients were free of four bed rails utilized without a physician order for restraints for 3 patients (Patients (P)1, P5, and P9) of 10 medical records reviewed. This failure has the potential to increase the risk of injury to patients attempting to transfer out of bed.


Findings Include:


On review of the "Ascension Via Christi Falling Prevention Agreement," 10/2014, located in the admission packet of documents, included, "Because you have been identified as someone who could be at risk for falling, we will be taking the following fall-prevention steps: keeping three side rails up whenever you are in bed."

Review of the "Falling Prevention Agreement" revealed consent was signed by P1 on 08/31/22, P5 on 09/19/22, and by P9 on 10/20/22.


Patient 1

Review of the "History & Physical (H&P)" revealed P1 was admitted on 08/30/22 with identified diagnosis of end-stage renal disease, schizophrenia (severe mental illness with hallucinations [hearing, seeing, tasting objects not present] and delusions [firmly held beliefs that are not real]), and hypertension. The "patient made statements that she wanted to die stating that her plan would be to overdose on medications."

Review of the "Plan of Care," initiated on 09/02/22, identified "Fall Risk Special Condition or Injury" with the outcomes, "Takes Action to Control Condition Specific Risks," "High Risk Fall Activity Precautions," "Verbalizes Understanding Fall Related Personal Risks," "Patient informed of Special Condition Fall Risk, "Patient Remain Free from Falls and Injury, "Caregiver Verb [verbalizes] Understand Fall Risk Care," "Takes Action to Control Fall Related Risks," "Adherence to Fall Risk Specific Precautions, and "Identifies Home Fall Prevention Strategies," with an intervention of "Fall Risk Alert System in Place." The plan of care included a daily recording from 09/14/22 through 10/24/22, of P1's "Morse Fall Risk Score:" at 40 (medium risk for falls is a score of 25 through 44).

On 10/24/22 at 11:10 AM during a tour of the Unit, P1 was observed in bed with four side rails in the upright position.


Patient 5

Review of the "H&P" revealed P5 was admitted on 09/18/22 with diagnoses including "schizophrenia, spectrum disorder (developmental disorder), and impulse control deficit." On 09/19/22, P5 received a score of 14/30 on the Saint Louis University Mental Status (SLUMS) examination (detecting cognitive impairment and dementia). Scoring on the SLUMS examination identified a score of one to 19 as Dementia (P5 was functioning in the level of a person having Dementia).

The Behavioral Health Team Meeting dated 09/19/22 for P5 identified "At risk for falls." The Physician Order on 09/18/22 identified, "Fall Intervention High Risk."

The "High Risk Fall Prevention and Management" plan of care on 09/19/22 included the following: "Patient Remains free from Falls and Injury," "Verbalizes Understanding of Fall Risk/Precautions," "Caregiver Verb [verbalizes] Understand [understanding] Fall Risk Care," "Takes Action Control Fall Risk," "Adherence to Fall Risk Specific Precautions Needs further teaching."

On 10/25/22 at 1:35 PM, observation revealed P5 lying in bed in his/her bedroom with four side rails in the upright position.


Patient 9

Review of the "H&P" revealed P9 was admitted on 10/21/22 with diagnoses including major depressive disorder, hypertension, multiple sclerosis, and peripheral vascular disease. The "H&P" plan identified, "Precautions: suicide ideation's, elopement." "P9 states that she has nowhere to find peace, no rights, and no sense of herself anymore. P9 made statements, "I don't want to live anymore and reported she thought about motoring her (wheelchair) into the lake."

There was no documentation in P9's physician's orders from 10/21/22 or plan of care about being at risk for falls. The plan of care only addressed "Psychological Impairment - Mood Plan of Care," and the related outcomes. P9 was a new admission at the 10/24/22 start of the survey.

On 10/24/22 at 11:10 AM during a tour of the Unit, P9 was observed in bed with four side rails in the upright position.

During an interview on 10/24/22 at 10:30 AM, the Director of Senior Behavior Health Unit (SBHU), revealed there is an enabler [side rails] on all behavioral unit beds and the ability to raise and elevate the bed. It is a "standard expectation" on this unit.

During an interview on 10/25/22 at 3:35 PM, the Patient Care Technician (PCT2), revealed that "for fall-risk patients, we put up (raise) side rails, one at the top and two side rails, bed alarm and pull alarm."

Based on document review, observation, and interview, the Hospital failed to 1. administer medication as ordered by the physician for 2 patients (Patient (P)1 and P5) reviewed and 2. failed to ensure correct armband color to denote a drug allergy was present for one patient (P5) of ten medical records reviewed during the survey. The failure to administer medication as ordered and ensure patients are wearing the correct armband color has the potential to increase the risk of drug adverse effects for all 25 patients residing at the Behavioral Health Unit.


Findings Include:


Review of the "Medication Administration and Regulation" policy, revised on 09/16/21 included the following information: "At the bedside utilize the electronic medication scanning bar code to verify the right patient, drug, dose, time, and route prior to medication administration. Identification of the right patient requires a minimum of two (2) nursing approved identifiers: Patient's Name and Date of Birth. These identifiers are stated by the patient/read from the armband and scanned with a barcode reader from the armband."


1. The hospital failed to administer medication as ordered by the physician.


Patient 1

On 10/25/22 at 9:30 AM, interview and record review with Registered Nurse Clinical Informatics (RN CI)3 of P1's 10/2022 physician order and "Medication Administration Record (MAR)" identified the following:

Risperidone (medication used to treat behavioral problems) 1.5 milligrams (mg) daily (9:00 PM), was administered on 10/05/22 at 10:49 PM, 1 hour and 49 minutes after the scheduled 9:00 PM time; and the Risperidone was administered on 10/08/22 at 10:43 PM with a reason, "Nursing Judgment and short of staff."

Bumetanide (treats fluid retention and high blood pressure) 2 mg oral tablet at 9:00 AM and 2:00 PM, was administered on 10/01/22 at 5:39 PM, three and one-half hours after the scheduled 2:00 PM time.

Atorvastatin (treats high cholesterol) 40 mg once daily at bedtime (9:00 PM), was administered on 10/05/22 at 10:49 PM, 1 hour and 49 minutes after the scheduled 9:00 PM time.


Patient 5

On 10/26/22 at 11:00 AM, interview and record review with the RN CI3 of P5's 10/2022 physician order and "MAR" identified the following:

Diclofenac (reduces swelling and pain) 1 percent (%) topical gel BID (two times a day) at 9:00 AM and 9:00 PM, was administered on 09/21/22 at 12:18 PM, 3 hours and 18 minutes after the scheduled 9:00 AM time; 09/22/22 at 12:11 PM, 3 hours and 11 minutes after the scheduled 9:00 AM time; 09/27/22 at 1:17 AM, 4 hours and 17 minutes after the scheduled 9:00 PM time; and 09/28/22 at 11:08 PM, 2 hours and 8 minutes after the scheduled 9:00 PM time.

Aripiprazole (antipsychotic medication) 10 mg daily (9:00 AM) was administered on 09/19/22 at 2:11 PM, 5 hours and 11 minutes after the scheduled 9:00 AM time.


During an interview on 10/26/22 at 2:35 PM, Charge Registered Nurse (RN) regarding the late times, he/she revealed there was no mention of medications being administered late in the nursing notes. Charge RN revealed, "can't explain the reason for delay.

In a subsequent interview on 10/26/22 at 3:00 PM, Charge Registered Nurse (RN) revealed, "definitely short of staff. It is not a quick delivery and [depends on] how cooperative people are [during administration of medication]. Encourage people not to use "Nursing Judgment" [as a reason for a change in time of administering medication. There are drop down options or other to select [electronic software program], so we understand [the reason for delay]."


2. The hospital failed to ensure the correct armband identification was on a patient to denote a drug allergy.

Review of the "Patient Armband Colors: Work Instructions" policy dated 03/19/21, included the following: "Identification Armband: A band that is white in color and contains identifying information about the patient such as name, medical record, and date of birth. Color-coded wristband: a band that alerts care givers to specific patient conditions. Allergy-red armband ... Staff applying an identification (ID) armband verifies with the patient/family that the information on the ID band is correct. It is the responsibility of the Registered Nurse assigned to the care of the patient to ensure that the correct identification armband and appropriate color-coded wristband are in place on the patient at all times."

Observation on 10/24/22 at 11:05 AM, showed P5 ambulating with a rolling walker in the hallway, a fall-risk patient, was wearing a white arm band; it did not include allergies. P5 stated, "I am allergic to Codeine."

Review of the 09/18/22 physician's "Consultation Note, Final Report" revealed P5 had an allergy to codeine.
P5 was not wearing a red armband to denote an allergy.

Based on policy review, document review, and interview the hospital infection prevention and control program failed to employ methods for preventing and controlling the transmission of 14 hospital acquired COVID 19 infections on the Senior Behavioral Health Unit (SBHU) 6 East. This deficient practice places patients at risk for hospital acquired infections.

Findings Include:

Review of the policy titled, "Infection Prevention and Control Program (IPAC)," revised 02/03/22, showed, "4. The Infection control officer (s) is responsible to identify, investigate, report, prevent and control infections and communicable diseases and provide primary leadership in the following activities: ...h. Lead the investigation of any outbreaks and implement infection control policies and procedures to control the spread of the disease, including, as warranted and practicable, but not limited to: isolation infectious patients, co-horting patient infection with same pathogen, co-horting staff. i. Mitigate risks contributing to healthcare-associated infections ...o. Maintain a log of incidents related to infections and communicable diseases, including healthcare-associated infections (HAI) and infections ...p. Institute surveillance, prevention, and control measure or studies deemed necessary and appropriate when there is reason to believe that any patient or associate may be in danger from a potential or actual exposure to or outbreak of a communicable or infectious disease ...Infection Prevention and Control Committee 1. The IPAC Committee acts as an advocate for the prevention and control of infections in the hospitals."

Review of the infection control log for patients positive for COVID-19 from 02/01/22 to 09/27/22 on the Senior Behavioral Health Unit (SBHU) 6 East, the log showed 22 patients with COVID-19 infections of which eight were present on admission (POA) and 14 were infections acquired after hospitalization, known as hospital acquired infections (HAI's).

During an interview on 10/26/22 at 8:40 AM, the Infection Preventionist (IP) stated that all patients admitted to the SBHU 6 East were tested for the presence of COVID-19 infections on admission. The IP stated the facility utilized PCR testing with a 45-minute turnaround time for results. When asked about the 14 patient infections that occurred after admission, the IP stated he/she thought the source of those infections were visitors and not the other COVID-19 positive patients on the unit. The IP confirmed that many of the patients on the unit are confused and have dementia and there was the possibility that they could have wandered out of their rooms exposing other patients. The IP confirmed that he/she did not investigate the source of the COVID-19 infections. When asked if any of these infections were reported to the IPAC Committee, the IP stated, "I don't believe we reported any of these infections."

Review of the document titled, "Infection Prevention and Control Committee," dated April 27, 2022, and July 27, 2022, showed no reports were provided to the Committee for the SBHU 6E COVID-19 HAI's.