HospitalInspections.org

******************************************************
Based on interview, review of documentation in 4 of 6 medical records reviewed for admission nursing assessments (Patients 2, 3, 6, and 7), and review of policies and procedures it was determined the hospital failed to comply with State licensing requirements for nursing assessments and care plans in accordance with Oregon Administrative Rule (OAR) 333-510-0020(3), Nursing Care Management, that requires "The responsible [Registered Nurse (RN)] shall ensure that the following activities are completed: (a) Document the admission assessment of the patient within four hours following admission and initiate a written plan of care. This shall be reviewed and updated whenever the patient's status changes. (b) Develop and document within eight hours following admission a plan of care for the patient ..."

Findings include:

1. The policy and procedure titled "Nursing Assessment & Reassessment, [Inpatient]" dated as "effective 01/2023," and the version dated as "effective 11/2024," were reviewed. The two versions included the following direction that was not consistent with the hospital OAR that required the nursing admission assessment be completed, and a written plan of care initiated, within four hours of admission: "An assessment and admission summary note will be made into the medical record by a Nurse within eight hours of admission to the unit ... An initial [treatment/care plan] will be completed by a Registered Nurse within eight hours of admission to the unit."

2. Refer to Tag A-395, CFR 482.23(b)(3), regarding nursing services, that reflects that admission nursing assessments for Patients 2, 3, 6, and 7 were not completed within four hours of admission as required by the OAR.

3. Refer to Tag A-396, CFR 482.23(b)(4), regarding nursing services, that reflects that patient treatment/care plans for Patients 2, 3, 5, 6, and 7 were not initiated within four hours and completed within eight hours of admission as required by the OAR.

******************************************************

******************************************************
Based on interview, review of medical record documentation for 7 of 7 patients reviewed for admission, suicide risk, and fall risk nursing assessments (Patients 1, 2, 3, 4, 5, 6, and 7), review of incident documentation for 4 of 4 patients reviewed for fall incidents (Patients 1, 4, 5, and 6), and review of policies and procedures, it was determined that the hospital failed to ensure the Registered Nurse (RN) conducted timely and complete initial and ongoing assessment of patients, and failed to supervise care and services to prevent recurrence of incidents as follows:
* Nursing admission assessments were not completed within four hours of admission for Patients 2, 3, 6, and 7.
* Nursing admission assessments were unclear and incomplete for Patients 1, 2, 3, 5, 6, and 7.
* Suicide risk admission screenings, assessments, and interventions were not clear, complete, accurate, or documented for Patients 1, 2, 3, 4, 6, and 7.
* Fall risk assessments and reassessments were not timely or complete for Patients 1, 4, 5, and 6.
* Post-fall investigation and assessment to determine cause and prevent recurrence were not conducted for Patients 1, 4, 5, and 6.

Findings include:

1.a. The policy and procedure titled "Nursing Assessment & Reassessment, [Inpatient]" dated as "effective 01/2023," and the version dated as "effective 11/2024," were reviewed. The two versions included the following requirements:
* "An assessment and admission summary note will be made into the medical record by a Nurse within eight hours of admission to the unit."
* A daily nursing shift assessment and progress note "... will be completed on every shift by the Registered Nurse. A Reassessment will be completed by a Registered Nurse when a patient has an acute change in condition, fall, seizure, seclusion and/or restraint, or upon returning from being transported to another facility for medical treatment/clearance."
* "A Reassessment will be completed by a Registered Nurse when a patient has an acute change in condition, fall, seizure, seclusion and/or restraint, or upon returning from being transported to another facility for medical treatment/clearance."

Refer to Tag A-022, CFR 482.11(b), Licensure of Hospital, that reflects the hospital policy and procedure was not consistent with Oregon Administrative Rule (OAR) 333-510-0020(3), Nursing Care Management, that required "(a) Document the admission assessment of the patient within four hours following admission and initiate a written plan of care. This shall be reviewed and updated whenever the patient's status changes."

1.b. The policy and procedure titled "Suicide Risk Assessment" dated as "effective 03/2021," and the version dated as "effective 02/2025," were reviewed. The two versions included the following requirements:
* "Intake/Admitting Staff will screen all patients presenting for admission that identify specific patient characteristics that may indicate an increased risk of suicide. If indicated by the screening tool, a full suicide risk assessment will be conducted by the Intake Staff ... If the patient meets admission criteria, the results of this assessment will be communicated to the physician and the nursing staff on the unit ..."
* "Once the suicide risk assessment has been completed in Intake, the accepting RN on the unit will review and sign off on the suicide risk assessment indicating that they have reviewed it during the time they complete their nursing assessment. On the risk assessment, intake staff will document the individualized actions to take and precautions implemented which are applicable to the patient and the admitting RN will contact the physician for appropriate orders including the level of observation."
* Patients "having a greater suicidal risk than the patient community on the inpatient unit to which the patient is being admitted will be placed on suicide precautions with a doctor's admitting order. The level of observation for suicide precautions will be determined based on the immediacy/seriousness of the risk presented by the patient ... The Psychiatrist will assess suicide risk of each patient during the initial psychiatric evaluation."
* "All assessments shall be considered by the treatment team and incorporated into the patient's individualized [treatment/care plan] ..."
* "Reassessment of suicidality will occur at least twice daily for any patient on suicide precautions or who exhibits a sudden or significant change in mental status. All other patients will be screened at least daily in acute settings by the RN. This screen will be documented in the daily RN assessment/progress note ... The Psychiatrist/Provider will assess suicide [risk] of each patient during their daily visit and document in their progress note."
* "All reassessments shall be considered by the treatment team and incorporated into the patient's individualized [treatment/care plan] ..."

1.c. The policy and procedure titled "Fall Prevention Program" dated as "effective 01/2023," and the version dated as "effective 05/2024," were reviewed. The two versions included requirements that:
* "All patients will be screened using the Edmonson Fall Risk Assessment for fall potential during the initial nursing assessment. The Fall Risk Assessment will be completed within 2 hours of admission. Those patients who score 90 or above are placed on fall precautions and will receive education regarding their fall risk potential ... A patient may be placed on fall precautions at any time that a fall potential is identified by nursing staff. RNs will initiate fall precautions based on the patient's fall assessment or reassessed needs, including but not limited to change in medications, changes in mental status, change in self-care ability, or the patient has a fall or near fall."
* "Patients assessed at risk for falling are will [sic] then be assessed daily the [sic] Edmonson Psychiatric Fall Risk Assessment Tool."
* "Follow-up Post Fall" directions included a number of elements: "A. ... A patient's fall status will be documented in the medical record. B. Any patient who staff witnesses falling will, at a minimum, be assessed by a nurse for possible injury before being allowed to get up from the fall. C. Any patient who reports they have fallen (unwitnessed) will, at a minimum, be assessed by a nurse for possible injury. D. If a fall involves a possible head injury ... a neurological assessment and neurochecks should be considered ... F. The provider will be notified of all patient falls. G. Based on the cause of the fall any immediate environmental issue will be addressed and actions taken to increase patient or environmental safety." Under "Safety and Performance Improvement" the policy and procedure stipulated that "A. Incident Reports will be completed on all falls and reviewed by leadership in Flash meeting each day."

2.a. Review of Patient 1's medical record reflected that the patient arrived to the hospital on 01/27/2023 and was discharged on 02/06/2023. The course of the first few hours of the patient's encounter was unclear, and contradictory admission times were recorded. It was not clear when the patient was admitted to, and arrived on, the inpatient nursing unit. For example:
* The Patient Demographic Profile reflected the patient's "Admit Date/Time" was 01/27/2023 at 1900.
* The physician's orders reflected the patient was admitted on 01/27/2023 at 2111.
* The Patient Observation Rounds, Inpatient form dated 01/27/2023 reflected the patient "Arrived" at the hospital at 1730 and from 1745 through 2115 the every 15 minute entries reflected the patient was in an Intake/Assessment Room near the hospital lobby. At 2130 and 2145 entries reflected they were in a "Hall." The hall location was unknown. At 2200 and 2215 entries reflected they were in an "Exam Room." The exam room location was unknown. At 2230 entries reflected they were in a "Bathroom." The bathroom location was unknown. Beginning at 2245 the entries reflected the patient was in a "[Patient] Room" and "Appears Asleep" on their "[Left] side," presumably on the inpatient unit.

2.b. On 01/27/2023 at 1852 a "Qualified Mental Health Professional (QMHP)]" signed and dated the Columbia Lifetime Suicide Risk Assessment (CSRA) for Patient 1. The QMHP documented in the "Risk Formulation" section of the form that the patient's "suicide risk is ... Moderate ..." The "Interventions" section of the form that followed the "Risk Formulation" indicated it was "(to be completed by Unit RN following discussion with Provider.)" The section included the following elements and was entirely blank and not completed: "Observation level ... Other Interventions - Check all that apply below which will be implemented to maintain safety of patient ... [18 interventions listed]." The last element on the form stated "By signing this document the RN completing the Nursing Assessment/Admission attests they reviewed the Columbia Severity Rating Scale above and will implement appropriate interventions determined by provider to maintain safety of patient." The spaces for RN signature, date, and time were blank.

2.c. On 01/27/2023 at 2309 an RN signed and dated the initial Daily Nurse Progress Note. The note did not identify the time the patient arrived to the inpatient unit nor their condition at that time. There was no documentation in the medical record to reflect when, and who transported the patient from the intake/admission area near the hospital lobby to the inpatient nursing unit, and who received the patient on the inpatient nursing unit at what time.

2.d. On "1/28/22 [sic]" at 0122 an RN illegibly signed and dated the 17-page Nursing Admission Assessment for Patient 1. Assessment elements were not timely or were incomplete. For example:
* The "Suicide Risk Assessment" section of the form on Page 14 required that one of two choices be selected: "___ Reviewed and signed off on initial suicide assessment completed in intake Comments: OR ___ Completed [Assessing and Managing Suicide Risk (AMSR)] or [CSRA] (see suicide assessment form) Comments:" Neither choice was selected and there were no comments. Refer additionally to the finding above that the RN failed to complete the RN required sections of the CSRA that had been initiated by the QMHP in "intake" on 01/27/2023 at 1852.
* The "Fall Risk Assessment" section of the form on Page 16 reflected the patient's score was 66 and the RN recorded that "Yes, place on Fall Precautions." The assessment was completed more than two hours after the patient's admission (on 01/27/2023 at 2111), contrary to the "Fall Prevention Program" policy and procedure. Further, the specific fall risk precautions were not identified.
* Additionally, blank and incomplete sections of the assessment included: "Method of Arrival ... Height ... Weight ... Average hours of sleep per night ... Berlin Questionnaire to Screen for Obstructive Sleep Apnea ... Category 1 Score ... Category 2 Score ... [Body Mass Index (BMI)] [greater than] 30 ... Category 3 Score ... Berlin Questionnaire Final Result ... Dietician notification process completed [as criteria for Nutritional Consultation were identified as met] ... Learning preferences ... Sexual Aggression Risk ...:"

2.e. On 01/29/2023 at 1332 a fall risk reassessment for Patient 1 was completed and reflected an increased score from admission to 76. Subsequent reassessments reflected:
* On 01/30/2023 a daily fall risk reassessment was not completed.
* On 01/31/2023 a daily fall risk reassessment was not completed and the patient had a fall late that day.
* On 02/01/2023 at 1852 a fall risk reassessment was completed and reflected the score had further increased to 88.

2.f. On 01/31/2023 at 2300, two days after the last "daily" fall risk reassessment, incident and medical record documentation reflected that a "CNA found [Patient 1] laying on [their] bedroom floor and called for RN to come ... patient was alert and oriented. Patient complained of back pain and stated [they] did not know if [they] hit [their] head on the floor. Later, [they] said [they] might have hit [their] head and a small lump was noted on back of head." The documentation reflected "Injury caused by: Accident." The "Outcomes" were recorded as "Seizure" as "RN observed patient laying on the floor and having what appeared to be a minor seizure." However, there was no investigation information or assessment documentation to reflect that the cause of the patient being found on the floor had been determined, including whether a possible seizure caused the fall, or a seizure resulted when the patient hit their head during the fall. Since the fall was unobserved interview with the patient and observation of the environment in the room would be necessary to determine the cause of the fall. There was no indication that the patient had been interviewed about what happened in their room and how they ended up on the floor. There were no actions planned to prevent recurrence and to ensure patient safety except for "Patient was moved to a room closer to the nursing station." It was unclear how that would prevent a future fall.

2.g. During interview on 03/20/2025 beginning at 1530 with the Interim Chief Nursing Officer they confirmed findings for Patient 1.

3.a. Review of Patient 2's medical record reflected that the patient arrived to the hospital on 03/22/2023 and was discharged on 03/24/2023. The course of the first few hours of the patient's encounter was unclear, and contradictory admission times were recorded. It was not clear when the patient was admitted to, and arrived on, the inpatient nursing unit. For example:
* The Patient Demographic Profile reflected the patient's "Admit Date/Time" was 03/22/2023 at 1650.
* The physician's orders reflected the patient was admitted on 03/22/2023 at 1803.
* However, initial patient assessment information was recorded on 03/06/2023, 16 days prior, and on 03/22/2023 at 1140, several hours prior, to those admission dates and times.
* Further, the Patient Observation Rounds, Inpatient form dated 03/22/2023 reflected the following: The first entry was recorded in the column with the pre-printed time of "1530" and was written as "1530 [staff initials]." The patient's location was not specified as required by the form. From 1545 through 1700 the every 15 minute entries recorded reflected the patient was in a "PC" or "PL." The entries were not clearly written and there were no associated or matching "Location Codes" on the form for either PC or PL. From 1715 through 1815 the every 15 minute entries reflected the patient was in "4." There were no matching "Location Codes" on the form for "4." At 1845 the patient's location was recorded as "NS" for Nurse's Station. Beginning at 1900 the entries reflected the patient was in a "R" or "[Patient] Room." It was not clear when the patient arrived to the inpatient unit.

3.b. On 03/22/2023 at 1140, ~ four hours before the first entry was recorded on the Patient Observation Rounds form, and more than six hours prior to Patient 2's admission, the QMHP signed and dated a Standardized Intake Assessment and a CSRA. The QMHP documented in the "Risk Formulation" section of the form that the patient's "suicide risk is ... High ..." The QMHP wrote "Patient is a high risk for suicide ... patient endorsing current [suicide ideation] with plan, intent and access to means. Patient was recently admitted to [Cedar Hills Hospital] with similar presentation following a [suicide attempt] by crashing [their] car." The section for "Results Reviewed with Dr. ____" was blank. The "Interventions" section of the form that followed the "Risk Formulation" indicated it was "(to be completed by Unit RN following discussion with Provider.)" The section included the following elements and was entirely blank and not completed: "Observation level ... Other Interventions - Check all interventions that apply below which will be implemented to maintain safety of patient. Interventions chosen must be added to the [treatment/care plan]." Eighteen (18) interventions were listed on the form, none of which had been checked as selected. The last element on the form stated "By signing this document the RN completing the Nursing Assessment/Admission attests they reviewed the Columbia Severity Rating Scale above and will implement appropriate interventions determined by provider to maintain safety of patient." The spaces for RN signature, date, and time were blank.

3.c. The Patient Demographic Profile reflected that Patient 2 was discharged on 03/24/2023 at 1700, while the Patient Observation Rounds form for that day reflected "[Discharge at] 1615." The RN progress note for day shift on 03/24/2023 did not specify the time the patient was discharged from the inpatient unit prior to being "escorted to the front lobby."
* On 03/24/2023 at 1610, ~ 48 hours after the patient's arrival at the hospital and ~ five minutes prior to the patient's discharge from the inpatient unit, an RN signed and dated the 17-page Nursing Admission Assessment for Patient 2. As the assessment was completed two days after the patient's admission, instead of the required four hours after admission, it did not credibly identify the patient's condition, problems and needs on admission. Further, numerous assessment elements were incomplete. For example:
- The "Suicide Risk Assessment" section of the form on Page 14 required that one of two choices be selected: "___ Reviewed and signed off on initial suicide assessment completed in intake Comments: OR ___ Completed AMSR or [CSRA] (see suicide assessment form) Comments:" Neither choice was selected and there were no comments. Refer additionally to the finding above that the RN failed to complete the RN required sections of the CSRA that had been initiated by the QMHP during a "tele-assessment" prior to the patient's arrival to the hospital on on 03/22/2023 at 1140.
- Additionally, blank and incomplete sections of the assessment included: "Admitting Vital Signs ... Berlin Questionnaire ... Category 1 Score ... Category 2 [section including score] ... BMI [greater than] 30 ... Category 3 Score ... Last meal consumed ... Substance Abuse Assessment Audit C ... risk factors for violence/aggression ..."

3.d. During interview on 03/20/2025 beginning at 1235 with the Intake Director they confirmed findings for Patient 2.

4.a. Review of Patient 3's medical record reflected that the patient arrived to the hospital on 01/08/2025 and was discharged on 01/11/2025. The course of the first few hours of the patient's encounter was unclear, and contradictory admission times were recorded. It was not clear when the patient was admitted to, and arrived on, the inpatient nursing unit. For example:
* The Patient Demographic Profile reflected the patient's admission date/time was 01/08/2025 at 1335.
* The physician's order to admit the patient was written as 01/08/2025 at 1402.
* The Patient Observation Record & Milieu Groups form dated 01/08/2025 reflected the patient arrived to their room on the inpatient unit at 1445.

4.b. On 01/08/2025 at 1341 the Admission Intake RN completed a CSRA for Patient 3. The RN documented in the "Risk Formulation" section of the form that the patient's "suicide risk is ... Moderate ..." The "Interventions" section of the form that followed the "Risk Formulation" section included 18 preprinted interventions. The Intake RN checked that nine (9) of those were to be implemented. The last last section on the form stated "By signing this document the Unit RN completing the Nursing Assessment/Admission attests they reviewed the Columbia Severity Rating Scale above and will implement appropriate interventions determined by provider to maintain safety of patient." The spaces for the inpatient RN signature, date, and time were blank.

4.c. A "Precautions" form for Patient 3 contained no date. The "[Estimated Time of Arrival] to Unit: Time: ___" space was blank. At the bottom of the form the Intake RN had signed in the space for the staff "completing form" and had recorded the Intake staff time as 1350. However, there was no indication that the Unit RN responsible for receiving the patient on the inpatient unit had reviewed the "Precautions" as the "Name/Signature of Nursing Staff Receiving Form:" and "Time Form Received/Unit:" were blank.

4.d. On 01/08/2025 an "RN" dated the 12-page Nursing Admission Assessment for Patient 3. The signature in the "RN Signature" space was illegible and scrawling and did not include a credential. The time of the assessment and the signature was blank. There was no evidence it had been completed within the required four hours. Further, the assessment contained unclear, incomplete, and inaccurate information. For example:
* The "Suicide Risk Assessment" section of the form on Page 8 required that one of two choices be selected: "___ Reviewed and signed off on initial suicide assessment completed in intake Comments:" Under "comments" the RN wrote "already signed." However, that was inaccurate as the RN had not signed the CSRA that had been completed in Intake, nor had they signed the "Precautions" form as identified in the two findings immediately above.
* Under the "Potential for Sexual Victimization" the RN documented that "Yes" the patient had a "History of sexual victimization" and was a "Victim of sexual abuse." There was no further "Explanation/further detail" documented.
* Under the "Summary Risk Assessment" the RN documented that "Yes" the patient was at risk for "Suicide/Self Injury."
* Although the RN had documented "Yes" for "Potential for Sexual Victimization," under the "Summary Risk Assessment" the RN documented "No" risk for Sexual Victimization.

4.e. During interview on 03/20/2025 beginning at 1335 with the Intake Director they confirmed findings for Patient 3.

5.a. Review of Patient 4's medical record reflected that the patient arrived to the hospital on 01/17/2025 and was discharged on 02/05/2025. Suicide risk, fall risk, and post-fall screenings and assessments were not timely or complete.

5.b. The RN failed to ensure suicide risk screenings completed during the hospital stay for Patient 4 were clear and complete. For example:
* On 01/22/2025 a suicide risk screening was documented for the "0700 - 1900" shift that reflected the patient had answered "No" to the suicide risk screening questions.
* On 01/22/2025 the suicide risk screening documented on the next shift, "1900 - 0700," reflected that the patient answered "Yes" to five of the six suicide risk screening questions that were "In the time since your last assessment: Have you wished you were dead ... Have you actually had any thoughts of killing yourself? ... Have you been thinking about how you might do this? ... Have you had these thoughts and had some intention of acting on them? ... Have you done anything, started to do anything, or prepared to do anything to end your life? ..." The section under the screening questions reflected "If screens YES, initiate suicide precautions, contact physician, & perform [CSRA]. If screen is positive and/or higher than previous screen, call physician. Physician Name: _____ Time: _____." The physician name and the time of a call to the physician were blank. The narrative nursing notes associated with the "1900 - 0700" shift included no information related to the patient's changed suicide screening or that the physician had been notified.
* On 01/23/2025 the suicide risk screening for the "0700 - 1900" shift was completely blank. Although the patient had answered "Yes" in the screening conducted on the prior shift, a screening for the 0700 to 1900 shift was not done.
* On 01/24/2025 the suicide risk screening documented on the "0700 - 1900" shift reflected that the patient answered "Yes" to six of the six suicide risk screening questions. The section under the screening questions reflected "If screens YES, initiate suicide precautions, contact physician, & perform [CSRA]. If screen is positive and/or higher than previous screen, call physician. Physician Name: _____ Time: _____." The physician name and the time of a call to the physician were blank. The narrative nursing notes associated with the "0700 - 1900" shift included no information to reflect that the physician had been notified.

5.c. On 01/19/2025 at 0300 an RN signed and dated the admission fall risk assessment for Patient 4. The assessment was not conducted within two hours of admission. It reflected the patient was placed on fall risk precautions secondary to dependence on a wheelchair for mobility. However, the specific fall risk precautions were not specified.

5.d. Incident and medical record documentation reflected that Patient 4 had an unwitnessed fall during which they hit their "tailbone" on 01/23/2025 at 0253. The patient was transferred to a local hospital ED for evaluation of injuries and returned to the facility. There was no incident or medical record documentation to reflect an investigation or assessment to determine the cause of the fall and to plan actions/interventions to prevent recurrence.

5.e. During interview on 03/24/2025 beginning at 1400 with the Interim Chief Nursing Officer they confirmed findings for Patient 4.

6.a. Review of Patient 5's medical record reflected that the patient arrived to the hospital on 02/04/2025 and was discharged on 02/10/2025. The course of the first few hours of the patient's encounter, including the patient's actual admission time, was unclear. For example:
* The Patient Demographic Profile reflected the patient's "Admit Date/Time" was 02/04/2025 at 2222.
* A Patient Observation Record & Milieu Groups form reflected the patient was in an Intake/Assessment Room near the hospital lobby from 2200 until 2315; from 2315 to 02/05/2025 at 0015 they were in an unidentified "Hallway;" and at 0015 they were at an inpatient unit "Nurse Station."

6.b. On 02/05/2025 an RN signed the 12-page Nursing Admission Assessment for Patient 5. Assessment elements were unclear and incomplete. For example:
* The same RN illegibly signed and dated the signature spaces on page 12 of the assessment two times. The date and time of the first signature was "0214 02/05/2025." For the second signature "0127 02/05/2025." It was not clear when the assessment was fully completed.
* The "Fall Risk Assessment" section of the form on Pages 10 and 11 was incomplete. The "Age" risk factor that assigned points based on the age of a patient was blank. The points for the patient's age should have been "8" for age "less than 50." The "Fall Risk = Score" was blank. The total point for the elements of the assessment had not been calculated, including the missing "age" points. However, the RN recorded there was "need for Fall Risk Precautions" and they checked the box next to "Yes, place on Fall Precautions." It was unclear if the fall risk assessment was completed within two hours of admission as the time of admission was not clear. Further, the specific fall risk precautions were not specified.
* Additionally, blank and incomplete sections of the assessment included: "Temperature ... History of Present Illness [unclear and said only: since age 7] ... Respiratory: ... Unintentional weight change (weight loss or gain) of 10 lbs. over patient 3 months [unclear whether loss or gain] ... Has the patient used any substances within the past 12 months [unclear as No was checked, but the RN also recorded 'THC,' the active ingredient in marijuana] ... Medical Condition Patient/Family Educational Needs ... Fall Risk Assessment [as described above] ..."
* The "RN Initials" or "LPN Initials" required for every section of the assessment had not been entered and were blank.

6.c. Incident and medical record documentation reflected that Patient 5 fell from a stool to the floor on 02/05/20205 at 0745. There was no incident or medical record documentation to reflect an investigation or assessment to determine the cause of the fall and to plan actions/interventions to prevent recurrence.

6.d. During interview on 03/24/2025 beginning at 1420 with the Interim Chief Nursing Officer they confirmed findings for Patient 5.

7.a. Review of Patient 6's medical record reflected that the patient arrived to the hospital on 02/23/2025 and was discharged on 03/03/2025. The course and timeline of the patient's encounter in the facility was not clearly documented and not readily identifiable. Including and beginning with the arrival time to the facility, the initiation and completion time of the intake process, the time of admission to the hospital, and the arrival time onto the inpatient unit. For example:
* The Patient Demographic Profile reflected the patient's "Admit Date/Time" was 02/23/2025 at 0337.
* The Date and Arrival Time on the Cedar Hills Hospital Face Sheet was blank.
* Multiple admission consents and forms completed during the intake process were dated 02/23/2025 but none were timed.
* Physician's orders reflected "Admit Status: Voluntary Start Time: 2/22/25 [sic] 10:14 ."
* An RN progress note signed on 02/23/2025 at 1801 reflected "Pt Admitted [approximately] 1145 when arriving to unit."
* A Patient Observation Record & Milieu Groups form reflected the patient "arrive [sic]" to the building the previous day on 02/23/2025 at 1015, was in an Intake/Assessment Room near the hospital lobby from from 1015 until 1145, and was in a "Room" at 1145.

7.b. On 02/23/2025 at 1115 the Intake RN signed and dated the CSRA for Patient 6. The RN documented in the "Risk Formulation" section of the form that the patient's "suicide risk is ... Moderate ..." The "Interventions" section of the form that followed the "Risk Formulation" section included "Interventions ... Check all that apply below which will be implemented to maintain safety of patient ... [10 of 18 interventions were checked]." The last element on the form stated "By signing this document the Unit RN completing the Nursing Assessment/Admission attests they reviewed the Columbia Severity Rating Scale above and will implement appropriate interventions determined by provider to maintain safety of patient." The spaces for RN signature, date, and time were blank.

7.c. On 02/23/2025 at 1815 an RN signed the 12-page Nursing Admission Assessment for Patient 6. The assessment was not completed within four hours of admission and assessment elements were unclear and incomplete. For example:
* The "Suicide Risk Assessment" section of the form on Page 8 required that one of two choices be selected: "___ Reviewed and signed off on initial suicide assessment completed in intake Comments: OR ___ Completed AMSR or [CSRA] (see suicide assessment form) Comments:" Neither choice was selected and there were no comments. Refer additionally to the finding above that the RN failed to complete the RN required sections of the CSRA that had been initiated by the RN in "intake" on 02/23/2025 at 1115.
* The "Fall Risk Assessment" section of the form on Pages 10 and 11 was incomplete. The "Age" risk factor that assigned points based on the age of a patient was blank. The points for the patient's age should have been "8" for age "less than 50." The "Fall Risk = Score" was blank. The total point for the elements of the assessment had not been calculated, including the missing "age" points. The assessment was completed more than two hours after admission.
* Additionally, blank and incomplete or unclear sections of the assessment included: "History of Present Illness [unclear and said only: Since before 13 yr. now 19 yr.] ... Current Level of Monitoring: [both One-to-One and every 15 minutes were checked] ... [Pain] Duration [for back, right ankle, right great toe pain] ... [Pain] Description [for back, right ankle, right great toe pain] ... What helps alleviate the pain? ... Average hours of sleep per night ... Category 1 Score ... Category 2 Score ... BMI [greater than] 30 ... Category 3 Score ... Tobacco Use Screening ... Is the patient years or older? [If] Yes (complete Tobacco Screening [section not completed although required for this patient who was older than 18 years] ... Learning Preferences ... History of sexual victimization: [Yes response, Indicators/potential section not completed] ..."

7.d. There were no daily fall risk assessments documented in Patient 6's medical record for the duration of the patient's hospitalization.

7.e. Patient 6 had multiple falls during their hospitalization. There was no incident or medical record documentation to reflect investigation or assessment of each fall to determine the cause and to plan actions/int

******************************************************
Based on interview, review of medical record and incident documentation for 7 of 7 patients (Patients 1, 2, 3, 4, 5, 6, and 7), and review of policies and procedures it was determined that the hospital failed to ensure the Registered Nurse (RN) developed and implemented treatment/care plans for the patients that were completed timely on admission and as changes of condition occurred, and were clear and complete as follows:
* Admission treatment/care plans were not timely or complete
* Treatment/care plans did not clearly address suicide risk, fall risk, and other identified/assessed risks.
* Treatment/care plans were not updated as changes of patient occurred

Findings include:

1. The policy and procedure titled "Nursing Assessment & Reassessment, [Inpatient]" dated as "effective 11/2024" required that "An initial treatment plan will be completed by a Registered Nurse within eight hours of admission to the unit. The initial Treatment Plan will address both behavioral and medical problems identified by the admitting nurse during the Nursing Admission Assessment."

2. Review of Patient 1's medical record reflected that a physician's orders to admit the patient was written on on 01/27/2023 at 2111. The patient was discharged on 02/06/2023. The initial nursing admission assessment was completed on "1/28/22 [sic]" at 0122. The "Summary Risk Assessment" section of the nursing assessment identified patient problems and needs and included the following risks: "Suicide/Self Injury ... Fall Risk ... Seizure ... Medically Compromised ... Sexual Victimization Risk ..."

The Master Treatment Plan, Part 1 was dated as completed by an RN on 01/27/2023 at 2215, prior to the completion of the 17-page nursing admission assessment that was completed on "1/28/22 [sic]" at 0122. The pre-printed treatment/care plan did not include clear, complete, and patient-specific problem statements, goals, and interventions. For example:
* There was no pre-printed problem on the treatment/care plan for "Suicide Risk" and that problem was not written in elsewhere on the treatment/care plan. For the pre-printed problem of "Danger to Self" there were only two pre-printed "Interventions" checked as applicable: "Encourage patient to seek out staff if having thoughts of harming self ... [every] day and evening shift/as needed" and "Removal of personal items to prevent self-injurious behavior ... Upon admission." The pre-printed problem of "Self-injurious" was checked as "None" which indicated that was not a problem. There was no other information related to the patient's suicide risk, including interventions specific to the Suicide Precautions that were ordered by the physician.
* There was no pre-printed problem on the treatment/care plan for "Fall Risk" and that problem was not written in elsewhere on the treatment/care plan. For the pre-printed problem of "Special Needs ... Walker, Wheelchair" there were no patient goals identified, and the following pre-printed "Interventions" were checked as applicable: "Encourage patient to ask for staff assistance as needed ... Provide assistance with ambulation and transferring ... Refer to Fall Treatment Plan ... Upon Admission ..." That was the extent of the treatment/care plan for Fall Risk. There was no "Fall Treatment Plan" in the medical record. There was no other information related to the patient's Fall Risk, including interventions specific to the Fall Risk Precautions that were ordered by the physician.
* For "Risk of Victimization ... Sexual" the treatment/care plan consisted of one intervention of "Encourage patient to seek out staff if feeling unsafe ... [every] day and evening shift." There was no other information related to the patient's Sexual Victimization Risk, including interventions specific to the Sexual Victimization Precautions that were ordered by the physician.
* For "Seizures" and "Medically Compromised" there was similarly minimal and non-patient specific information and no references to interventions specific to the "Seizure Protocol" and "Medically Compromised Risk" physician's orders.

Although the patient experienced seizures and falls during the hospitalization, and their fall risk reassessment scores increased, the treatment/care plan did not reflect any patient-specific and individualized updates after the initial development on 01/27/2023 at 2215. The medical record included a one page Individual Problem Treatment Plan form for a "Problem: Bipolar 2 disorder" with a problem date of 01/31/2023. It included one intervention that minimally referenced the patient's Suicide Risk as "Daily assessment regarding suicidality ... At least 2 times per day at medication pass." It was not signed or dated and did not reflect who generated it. There were no other changes of updates made to the treatment/care plan.

3. Review of Patient 2's medical record reflected that a physician's order to admit the patient was written on 03/22/2023 at 1803. The patient was discharged on 03/24/2023 at 1615. On 03/24/2023 at 1610, ~ 48 hours after the patient's arrival at the hospital and ~ five minutes prior to the patient's discharge, an RN signed and dated the 17-page nursing admission assessment. The "Summary Risk Assessment" section of the form on Page 17 reflected that the patient was identified at risk for "Suicide/Self Injury."

The Master Treatment Plan, Part 1 was dated as completed by an RN on 03/24/2023 at 1600, prior to the completion of the 17-page nursing admission assessment that was completed on 03/24/2023 at 1610, and ~ 48 hours after the patient's admission. Although the treatment/care plan box for "Danger to Self" had been checked, the plan in its entirety was generally minimal, and not individualized to include patient-specific and complete interventions. In addition, the treatment/care plan was not credible as it did not reflect the patient's problems and needs upon admission as required and was written immediately prior to the patient's discharge. The Patient Observation Rounds form for 03/24/2023 reflected the patient's "[Discharge at] 1615," five minutes after the treatment/care plan had been created.

4. Review of Patient 3's medical record reflected that a physician's order to admit the patient was written on 01/08/2025 at 1402. The patient was discharged on 01/11/2025.

On 01/08/2025 an "RN" dated the 12-page nursing admission assessment. The signature in the "RN Signature" space was illegible and scrawling and did not include a credential. The time of the assessment and signature was blank. The assessment reflected the patient's problems and needs included "Potential for Sexual Victimization" and "Suicide/Self Injury."

The generic Initial Nursing Treatment Plan was not signed, dated, or timed by an RN. Those spaces on Page 4 of the plan were blank. The plan included the problems for "Suicidal/Self Injurious" and "Risk of Victimization: Physical - Sexual." However, there were no patient-specific goals or interventions for either problem, including eight (8) of the nine (9) suicide risk interventions identified on the suicide risk assessment completed by the Intake RN on 01/08/2025 at 1342 (Refer to Tag A-395 for patient 3).

5. Review of Patient 4's medical record reflected that the patient was admitted to the inpatient unit on 01/17/2025 at 2215. On 01/19/2025 at 0300 an RN signed and dated the admission fall risk assessment. It reflected the patient was placed on fall risk precautions secondary to dependence on a wheelchair for mobility.

The patient's treatment/care plan was not individualized to include patient-specific and complete interventions to address the patient's assessed fall risk. Under the section of the patient treatment/care plan titled "mobility treatment plan," nor elsewhere on the plan, was there any reference to the patient's fall risk and fall risk precautions.

Incident and medical record documentation reflected the patient had an unwitnessed fall during which they hit their "tailbone" on 01/23/2025 at 0253. The patient was transferred to a local hospital ED for evaluation of injuries and returned to the facility. There was no incident or medical record documentation to reflect an investigation or assessment to determine the cause of the fall and to plan actions and care plan interventions to prevent recurrence. The patient treatment/care plan was not updated after the patient's actual fall.

6. Review of Patient 5's medical record reflected that the patient's "Admit Date/Time" was 02/04/2025 at 2222. The patient was discharged on 02/10/2025. On the nursing admission assessment signed by an RN on 02/05/2025 at 0127 and on 02/05/2025 at 0214, the section titled "Summary Risk Assessment" on page 11 reflected that the patient's problems and needs included "Fall Risk." Further, incident and medical record documentation reflected that Patient 5 fell from a stool to the floor on 02/05/20205 at 0745.

A generic Initial Nursing Treatment Plan was initiated for Patient 5, however it was not signed, dated, or timed by the individual who generated it. Although fall risk was identified as a problem for the patient on admission, there was no treatment/care plan to address fall risk. Further, there were no investigations of the causes of the patient's fall to plan actions and care plan interventions to prevent recurrence. A treatment/care plan for falls had not been developed after the fall the patient experienced.

7. Review of Patient 6's medical record reflected that a physician's order to admit the patient was written on "2/22/25 [sic - 02/23/2025]" at 10:14. The patient was discharged on 03/03/2025. On the nursing admission assessment completed on 02/23/2025 at 1815, the section titled "Summary Risk Assessment" on Page 11 reflected that the patient's problems and needs included the following risks: "Suicide/Self Injury ... Fall Risk ... Elopement ... Sexual Victimization Risk ..."

On 02/23/2025 at 1836 an RN signed the 4-page Initial Nursing Treatment Plan for Patient 6. It was not clear or complete and did not include all problems identified for Patient 6 on an initial suicide risk assessment completed on 02/23/2025 at 1115 and on the nursing admission assessment. Those problems were not addressed on the treatment/care plan. For example:
* The patient treatment/care plan did not identify or address the "Fall Risk" problem at all.
* The patient treatment/care plan did not identify or address the "Elopement" problem at all.
* The "Risk of Victimization ... Sexual" problem had two pre-printed interventions that were vague, not patient-specific, and fully insufficient. Those were "Encourage patient to seek out staff if feeling unsafe" and "Discuss with patient fears related to past traumas." There were no interventions related to the prevention of sexual victimization for Patient 6 during their hospitalization by other individuals in the hospital.
* Interventions identified on the treatment/care plan for the problem "Suicidal/Self Injurious" did not align with the interventions identified on the initial suicide risk assessment conducted on admission. The following interventions that the Unit RN stated "will be implemented to maintain patient safety" on the initial suicide risk assessment (Refer to Tag A-395 for Patient 6) were not identified on the treatment/care plan:
- "Linen restriction"
- "Plastic silverware and paper products for plates/bowls"
- "Daily contraband checks"
- "Observe for any command hallucination and report to RN/medication nurse"
- "Clothing restriction - no more than 3 sets of clothes in room"
- "Monitor patient response to ... visitors"
- "Observe for resistance to answering questions during suicide reassessments"
* The "Treatment Modality" and "Frequency/Duration" of care plan interventions for the "Suicidal/Self Injurious" problem were not specified or completed.
* The 2-page Multidisciplinary Master Treatment Plan dated 02/24/2025 consisted of an incomplete listing of patient problems that did not include falls or elopement, it contained no patient goals and no interventions.

Review of incident and medical record documentation for Patient 6 reflected the patient had multiple falls during the hospital stay (Refer to Tag A-395 for Patient 6). Although fall risk was identified as a problem for the patient on admission, there was no treatment/care plan to address fall risk. Further, there were no investigations of the causes of the patient's falls to plan actions and care plan interventions to prevent recurrence. The treatment/care plan had not been updated after any of the falls the patient experienced.

8. Review of Patient 7's medical record reflected that a physician's order to admit the patient was written on 02/25/2025 at 1138. The patient was discharged on 02/28/2025.

On 02/26/2025 at 1648, more than ~ 29 hours after admission, an individual illegibly signed their name with no credential on the "RN Signature/Initials/Credentials" line on the 12-page nursing admission assessment. On Page 11 of the nursing admission assessment, the section titled "Summary Risk Assessment" reflected that the patient's problems and needs included risks for "Suicide/Self Injury ... Sexual Victimization Risk ...".

The Initial Nursing Treatment Plan was signed by an RN on 02/26/2025 at 1652. The plan included the problems for "Suicidal/Self Injurious" and "Risk of Victimization: ... Sexual." There were no patient-specific goals or interventions for either problem. Those consisted only of several pre-printed generic goals and interventions that had been checked.

9. During interviews at the time of record reviews on 03/20/2025 beginning at 1230 and on 03/24/2025 beginning at 1300 with the Interim Chief Nursing Officer and Intake Director they confirmed that patient treatment/care plans were not timely, clear, or complete.

******************************************************

******************************************************
Based on interviews and review of medical record documentation for 7 of 7 patients (Patients 1, 2, 3, 4, 5, 6, and 7), it was determined the hospital failed to ensure that medical record documentation was clear, complete, accurate and properly authenticated to protect the integrity of the medical records and to establish an accurate timeline for the care and services provided:
* The records did not clearly and accurately describe the course of the patient's hospitalization from the time of their arrival through discharge.
* Patient assessments and screenings were conducted and documented before the patient arrived at the hospital.
* Screenings, admission consents, advance directive acknowledgements, assessments and evaluations, physician orders, and other forms were incomplete or contained unclear or inaccurate entries.
* Entries had been written over or scratched out to render the original entry unreadable.
* All entries had not been authenticated, dated, and timed.
* The authors of entries had not legibly and accurately authenticated (with qualified credentials), dated, and timed their entries.
* Patients who were not Medicare Beneficiaries (Patients 3 and 7) had been provided with and signed the "Important Message from Medicare."

Findings include:

1. Review of Patient 1's medical record reflected that the course of the first few hours of the patient's encounter was unclear; contradictory arrival, intake, and admission times were recorded; consent forms, intake assessments, and nursing assessments were incomplete and unclear; and the authors of entries failed to legibly sign, date, and time their entries. For example:
* A "Cedar Hills Hospital Face Sheet" identified the patient's arrival date was 01/26/2023. The "Arrival Time" was blank.
* The "Patient Demographic Profile" reflected the patient's "Admit Date/Time" was 01/27/2023 at 1900.
* The physician's orders reflected the patient was admitted on 01/27/2023 at 2111.
* The "Assessment Service Disclosure ... Consent to Assessment" form was signed and dated "1-26-23" by the patient and showed that the "Witness" who illegibly signed the form had written over the patient's date entry and altered the dated to "1-27-23." The times of the signatures for consent were not recorded.
* The "Advance Directive ... Acknowledgement" was signed and dated "1/26/22" by the patient and showed that the "Staff" who illegibly signed the form had written over the patient's date entry and altered the dated to "1/27/23." The times of both the patient and staff entries were recorded as 1917 by the staff person.
* The "Lay Caregiver Consent Form" was completed but the spaces for name and signature of the patient were blank. Although there was no patient signature, a staff "Witness" signed and dated the form as having witnessed the patient's completion and signature of the consent.
* The "Financial Agreements and Acknowledgements" form was signed and dated "1/26/22" by the patient on two sections of the form. It showed that the staff "Witness" had written over the patient's date entry and altered the dated to "1/27/23" on both of those sections. The times of both the patient and staff entries were recorded as 1917 by the staff person.
* The "Consents and Conditions of Treatment" form was signed and dated "1-26-23" by the patient. It showed that the staff "Witness" had written over the patient's date entry and altered the dated to "1-27-23." The times of both the patient and staff entries were recorded as 1915 by the staff person.
* There were no explanations by the "Staff Witness" for the consistent alterations to the dates that the patient wrote they signed the forms.
* The "Medical Screening Examination Part 1" form signed by a Registered Nurse (RN) on 01/27/2023 at 1938 reflected the patient's "Date of Arrival" was "01/27/2022 [sic]."
* The "Standardized Intake Assessment" contained three signatures dates and times of completion. On Page 1 of 8 the form was signed and dated by an RN on 01/27/2023 a 1945. On Page 3 of 8 the form was signed and dated with an illegible signature, no credential, and an incomplete date on "1/27" at 1739. On Page 8 of 8 the form was signed and dated with an illegible signature and credential of "QMHP " (Qualified Mental Health Professional) on 01/27/2023 at 1852.
* The "Columbia Lifetime Suicide Risk Assessment" was signed an dated by a "QMHP" on 01/27/2023 at 1852. The QMHP documented in the "Risk Formulation" section of the form that the patient's "suicide risk is ... Moderate ..." The following "Interventions" section of the form indicated it was "(to be completed by Unit RN following discussion with Provider.)" The section that included the following elements was entirely blank and not completed: "Observation level ... Other Interventions - Check all that apply below which will be implemented to maintain safety of patient ... [18 interventions listed]." The last element on the form stated "By signing this document the RN completing the Nursing Assessment/Admission attests they reviewed the Columbia Severity Rating Scale above and will implement appropriate interventions determined by provider to maintain safety of patient." The spaces for RN signature, date, and time were blank.
* The "Patient Observation Rounds, [Inpatient]" form dated 01/27/2023 reflected the patient "Arrived" at the hospital at 1730, and from 1745 through 2115 the every 15 minute entries reflected the patient was in an Intake/Assessment Room near the hospital lobby. At 2130 and 2145 entries reflected they were in a "Hall." The hall location was unknown. At 2200 and 2215 entries reflected they were in an "Exam Room." The exam room location was unknown. At 2230 entries reflected they were in a "Bathroom." The bathroom location was unknown. Beginning at 2245 the entries reflected the patient was in a "[Patient] Room" and "Appears Asleep" on their "[Left] side," presumably on the inpatient unit.
* There was no documentation to reflect who transported the patient, and when, from the intake/admission area near the hospital lobby to the inpatient unit they were transported to, and who received the patient on the inpatient unit and at what time. The initial narrative inpatient nursing note on a "Daily Nurse Progress Note" was dated and timed on 01/27/2023 at 2309, but does not identify when the patient arrived to the inpatient unit and what room they were assigned and oriented to.

2. Review of Patient 2's medical record reflected that the course of the first few hours of the patient's encounter was unclear; contradictory arrival, intake, and admission times were recorded; consent, intake, admission, assessment, physician orders, and discharge documentation was not timely and incomplete and unclear; and the authors of entries failed to legibly sign, date, and time their entries. For example:
* The "Patient Demographic Profile" reflected the patient's "Admit Date/Time" was 03/22/2023 at 1650.
* The physician's orders reflected the patient was admitted on 03/22/2023 at 1803.
* However, initial patient assessment information was recorded on 03/06/2023, 16 days prior, and on 03/22/2023 at 1140, several hours prior, to those admission dates and times.
* Further, the "Patient Observation Rounds, [Inpatient]" form dated 03/22/2023 reflected the following: The first entry was recorded in the column with the pre-printed time of "1530" and was written as "1530 [staff initials]." The patient's location was not specified as required by the form. From 1545 through 1700 the every 15 minute entries recorded reflected the patient was in a "PC" or "PL." The entries were not clearly written and there were no associated or matching "Location Codes" on the form for either PC or PL. From 1715 through 1815 the every 15 minute entries reflected the patient was in "4." There were no matching "Location Codes" on the form for "4." At 1845 the patient's location was recorded as "NS" for Nurse's Station. Beginning at 1900 the entries reflected the patient was in a "R" or "[Patient] Room." It was not clear when the patient arrived to the inpatient unit.
* The "Advance Directive ... Acknowledgement" signed and dated 03/22/2023 at 1730 by both the patient and "Staff" had not been completed. None of the sections on the form had been filled out.
* The "Authorization for Release of Protected Health Information," signed by the patient but not dated or timed, and signed by a "Witness" on 03/22/2023 at 1720 had not been completed. Although the form stated "This form must be completed in full before signing," none of the sections on the form had been filled out.
*The "Lay Caregiver Consent Form" was not completed. Neither of the boxes for "I hereby voluntarily give my consent to Cedar Hills Hospital to contact my identified lay caregiver and authorize them ..." and for "I do not authorize or give my consent for a lay caregiver" were checked. However, the "Witness" wrote "declined" in the space for the patient's name and signature. It was unclear whether that meant the patient "declined" to authorize a lay caregiver or "declined" to sign the form.
* The "Prescriber Inpatient Admission Order" form reflected an RN initiated a page of admission orders for Patient 2 as a "TORB" (Telephone Order Read Back). The RN recorded the physician's name and the date 03/22/2023. However the time the RN took the telephone order from the physician was not recorded on the form including in the space for "Time." Further, the physician failed to countersign the telephone order until 04/17/2023 at an illegible time.
* The "Admission Patient Medication Reconciliation/Orders" form contained an order for one medication. The RN initiated the medication order as a "TORB". The RN recorded the physician's name and the date 03/22/2023. However the time the RN took the telephone order from the physician was not recorded on the form including in the space for "Time." Further, the physician failed to countersign the telephone order until 04/17/2023 at an illegible time.
* The "Visual Cue Sheet" for Patient 2 was not complete. It did not reflect the date it was completed and additionally lacked the following signatures and times: "[Estimated Time of Arrival] to Unit ... Vital Signs: Time Taken ... Pain ... Name / Signature of Nursing Staff Receiving Form ... Intake to Unit Communication: Time Form Submitted / Intake ... Time Form Received / Unit."
* The "Home Medication Tracking" form reflected that "3 bottles" of medications were "Sealed" by staff who signed the form on 03/23/2023 at 0630. It also reflected that the medications were placed in "Storage in Supervisor Office." At the bottom of the form in the margin an individual wrote "3/23/23 [initials]."
It was unclear what the medications were and why they were not removed from the possession of this patient at high risk for suicide until the day following the patient's admission.
* The "Patient Property Inventory" form was signed by the patient but not dated or timed, and signed by "staff" on 03/23/2023 at 0620, the day following the patient's admission. It reflected that numerous "Contraband" and "Valuables" items were removed from the patient's possession and it was not clear if the patient was in possession of those items until the date and time on the form.
* The psychiatrist "Discharge Summary" reflected the "Discharge Date" was 03/24/2023, the "[dictation date and time]" was 03/24/23 at 1433, and the psychiatrist electronically signed the summary on 03/27/2023 at 1232. The brief summary reflected the patient "came in again after the recent discharge with worsening mood and suicidal thoughts ... was placed on suicide precautions ... Patient today reports doing well and is wanting to discharge ... denying hopelessness or suicidal thoughts ... has been invisible in the milieu and appears to be able to take care of [their] basic needs ... reports the plan is for [them] to go back to [their] friends. [They] overall [feel] comfortable with [their] plan. [They are] in no distress and there are no delusions or hallucinations and [they are] adamantly denying any thought of wanting to hurt [themselves] ... [Patient] is not suicidal ... not likely going to benefit from prolonged hospitalization and is not holdable." The summary was otherwise incomplete and unclear. For example:
- The "Condition at Discharge:" space was blank.
- The summary stated only "Discharge Instructions: Please see social worker's discharge summary for comprehensive details. Briefly, patient has got appointments coming up." The psychiatrist included no patient-specific discharge instructions in their summary.
- The "Discharge Destination:" space was blank.
- In the "Psychosocial and Contextual Factors:" section was recorded only "Living situation." It was entirely unclear what that meant.
- It did not reflect that information identified in the RN's Progress Note dated 03/24/2023 at 1211 that "[Patient] describes mood as 'don't feel good.' [Patient] refused [morning antipsychotic medication] Latuda" had been evaluated prior to discharge. Refer to Tag A-395 for Patient 2.
* Regarding discharge from the hospital the "Patient Demographic Profile" reflected that patient was discharged on 03/24/2023 at 1700, while the "Patient Observation Rounds" form for that day reflected "[Discharge at] 1615." The RN progress note for day shift on 03/24/2023 did not specify the time the patient was discharged from the inpatient unit prior to being "escorted to the front lobby."

3. Review of Patient 3's medical record reflected that intake, consent, and discharge forms were incomplete and unclear, and that the authors of entries failed to legibly sign, date, and time their entries. For example:
* The "Assessment Service Disclosure ... Consent to Assessment" form was signed and dated "1/8" by the patient. The "Witness" signature was entirely illegible and was dated 01/08/2025. The times of the signatures for consent were not recorded.
* The "Advance Directive ... Acknowledgement" was signed and dated 01/08/2025. However the "Staff Signature" was entirely illegible.
* The "Lay Caregiver Consent Form" section for "This authorization is effective between the following dates ..." was not completed. The times of the signatures of the patient and the "Witness" were not recorded.
* It was unclear why Patient 3, who was not a Medicare Beneficiary, had been directed to sign an "Important Message from Medicare" form on 01/08/2025.
* The "Patient Property Inventory" form was signed by the patient but not dated or timed, and signed illegibly by "staff" on 01/08/2025. The time the form was completed by staff was not recorded.
* The "Discharge Valuables Disposition" section on the "Patient Property Inventory" form was signed by the patient but not dated or timed, and signed illegibly by "staff" on 01/11/2025. The time the form was completed by staff was not recorded.

4. Review of Patient 6's medical record reflected that intake and consent forms had been completed but not signed, dated, and timed. For example:
* The "Assessment Service Disclosure ... Consent to Assessment" form was signed and dated 02/23/2025 by the patient. However, the entry was not timed and there was no "Witness/Clinician" signature, date, and time.
* The "Advance Directive ... Acknowledgement" had been completed. However, it was not signed, dated, and timed by the "Patient" and "Staff."
* The "Lay Caregiver Consent Form" was completed. However, it was not signed, dated, and timed by the "Patient" and "Staff."
* The "Consents and Conditions of Treatment" form was signed and dated 02/23/2025 at 1030 by the patient. However, it was not signed, dated, and timed by "Cedar Hills Staff."

5. Review of Patient 7's medical record reflected that intake and consent forms were incomplete and unclear, and that the authors of entries failed to legibly sign, date, and time their entries. For example:
* The "Advance Directive ... Acknowledgement" signed and dated 02/25/2025 by both the patient and illegibly by "Staff" had not been completed. None of the sections on the form had been filled out. Further, the time of the signature entries were not recorded.
* The "Consents and Conditions of Treatment" form was signed and dated 02/25/2025 by the patient, but was not timed. The name, signature, date, and time of the "Witness" was illegible.
* The "Notice of Privacy Practices" was signed and dated by the patient, but was not timed.
* The "Assessment Service Disclosure ... Consent to Assessment" form was signed and dated 02/25/2025 by the patient. However, the entry was not timed. The signature of the "Witness" was illegible and was not dated and timed.
* It was unclear why Patient 7, who was not a Medicare Beneficiary, had been directed to sign an "Important Message from Medicare" form on 02/25/2025.

6. For Patients 1, 2, 3, 4, 5, 6, and 7 refer to the findings under Tags A-395, A-396, A-802, A-1631, A-1640, and A-1715. The findings under those tags reflect that documentation of multidisciplinary (nursing, psychosocial, psychiatric) assessments, reassessments, treatment/care plans, and discharge planning and other discharge forms was not timely, clear, legible, or complete; and that all entries were not legibly signed, dated, and timed by the qualified authors of the entries.

7. During interviews at the time of record reviews on 03/20/2025 beginning at 1230 and on 03/24/2025 beginning at 1300 with the Interim Chief Nursing Officer and Intake Director they confirmed that medical record documentation was not timely, clear, or complete.

******************************************************

******************************************************
Based on interview, review of medical record documentation for 3 of 3 patients assessed at risk for suicide who were reviewed for discharge planning (Patients 2, 3, and 7), and review of policies and procedures, it was determined that the hospital failed to ensure an organized and comprehensive discharge planning process that included regular re-evaluation of the patient's condition through the date of discharge and that changes of the patient's discharge problems and needs resulted in modifications to the discharge plan as applicable. Discharge planning assessment, re-evaluation, safety planning, and other processes by the multi-disciplinary team prior to and on the date of discharge reflected unclear and incomplete documentation in the following areas:
* Discharge Needs Assessments
* Discharge Safety Plans / Safety Crisis Plans
* Discharge Risk Assessments
* Physician Discharge Orders
* Aftercare Plans
* Discharge Summaries

Findings include:

1.a. The policy and procedure titled "Suicide Risk Assessment" dated as "effective 03/2021," and the version dated as "effective 02/2025," were reviewed. The two versions required that:
* "Discharge planning for the patient identified as being at risk for suicidality shall follow normal discharge planning protocols as outlined in the facility's Discharge Planning policy and procedures. In addition, the following are to be completed: - Pre-discharge suicide assessment - Discharge/Firearms Safety Plan - Education specific to suicide risk."
* "Pre Discharge Suicide Assessment: ... Prior to discharge, an RN and/or Therapist ... will perform an assessment of the patient's level of suicidality. This reassessment shall include: [Four elements listed]."
* "On the day of discharge the physician is to perform a comprehensive assessment of the patient's suicide risk. The assessment should include: [Six elements listed]."
* "Suicide Prevention/Safety Plan: ... The Treatment Team is to begin formulation of the Discharge Safety Plan upon admission. Patients and family members, or others as identified as support systems by the patient, should be invited and allowed to participate in the formulation of the plan. Elements of the plan should include, but are not limited to: ... List of names of those involved in the Discharge Safety Plan ... Potential Triggers/Specific Contingency Plans ... An overview of protective factors - including coping strageties [sic] and strategies for distraction and support ... Names and number of key contacts (outpatient providers, next level of care providers, crisis hotlines, community and peer support groups ... Instructions regarding lethal weapons/firearms that the patient may have access to upon discharge. ... Safe storage and management of all medications ... Warnings to abstain from the use of alcohol or other illicit substances ... The contents of the Discharge Safety Plan are to be clearly communicated to the patient, family members as appropriate, next level of care, and any others that the patient identifies prior to or upon discharge ... The [physician] is to review, approve and sign off on the Discharge Safety Plan prior to discharge."

1.b. The policy and procedure titled "Suicide Precautions" dated as "effective 01/2023," and the version dated as "effective 05/2024," were reviewed. The two versions required that "Any patient on 'Suicide Precaution' that requests an early discharge is to receive a face-to-face assessment by the attending or on-call provider. If the patient is assessed to be at current risk of suicide, they are to be placed on an involuntary hold."

1.c. The policy and procedure titled "Discharge Criteria" dated at "effective 12/2022" was reviewed. It required that "The goals of treatment have been substantially met at this level of care ... and a discharge plan is in the [sic] place that meets any continuing needs. The patient's identified 'lay-caregiver' has been notified of planned discharge, has been educated on the aftercare plan for the patient, and the communications has been properly documented. Follow up goals and treatment plans for a lesser level of care have been established. Releasing or transferring the patient to a less intensive level of care does not pose a threat to him/her, others, or property."

1.d. The policy and procedure titled "Routine Discharge Process, [Inpatient]" dated as "effective 09/2020," and the version dated as "effective 01/2024," were reviewed. The two versions required that "On the day prior to the scheduled date of discharge, the Primary Therapist meets with the patient and completes the discharge 'Risk Assessment' form. The patient is given education on suicide and relapse prevention and the completed 'My Safety / Crisis Plan' is reviewed with the Therapist. The Social Services section of the 'Aftercare Plan' is completed and reviewed with the patient .... On the day of discharge, the patient is seen by a Provider and a 'Face-to-Face Risk Assessment' is completed ..."

2.a. Review of Patient 2's medical record reflected that on 03/22/2023 at 1803 a physician ordered that the patient be admitted to the hospital. The patient was discharged on 03/24/2023. The record reflected that documentation regarding evaluation and re-evaluation of the patient's discharge needs and condition prior to discharge was not clear and complete.

2.b. A Discharge Needs Assessment was dated 03/24/2023, the date of discharge, was untimed, and was signed on the "Discharge Planner" signature line by an individual who did not identify their credentials. The assessment was primarily incomplete and unclear. For example:
* The section titled "Current Mental Health/Substance Abuse Treatment" was incomplete:
- "Current Outpatient Psychiatrist [answered Yes]." The spaces for referral source yes or no, provider name, phone number, dated last seen, and release of information yes or no, were blank.
- "Current Outpatient Therapist [answered Yes]." The spaces for referral source yes or no, provider name, phone number, dated last seen, and release of information yes or no, were blank.
- "Current Medical Provider [answered Yes]." The spaces for referral source yes or no, provider name, phone number, dated last seen, and release of information yes or no, were blank.
- "Other ___ Yes __ No." The spaces for referral source yes or no, provider name, phone number, dated last seen, and release of information yes or no, were blank.
* The section titled "Discharge Planning Needs" was incomplete. None of the information under the subsections titled "Intensive Treatment ... Psychiatry ... Counseling ... Medical Care ..." had been completed.
* Under the section titled "Self Care Abilities," the response entered for the question "Does the patient have the capability to follow discharge planning instructions independently?" was "Maybe." There was no assessment or explanation for that answer. Further, at the bottom of that section was a space to record a "Summary of alterations/adjustments in discharge planning needed to address any concerns noted above." That space was blank.
* Under the section titled "Transportation Plan" the response to the question "What form of transportation did the patient utilize to arrive at the facility?" was "Friend's car." The response to the next question "What method of transportation will be used to transport the patient at discharge? was "friend will [pick up]." There was no more information to ensure safe discharge for this patient assessed at high risk of suicide, such as where the patient was to be discharged to, the name of the friend, etc.
* Under the section for "Discharge Planner Notes" there was nothing written.

2.c. A My Safety Crisis Plan form was dated 03/24/2023, was untimed, and was unclear and incomplete. For example:
* The plan had spaces for three signatures. The documentation reflected the patient had not signed the plan nor received a copy of it. The "Patient" signature line was blank. The "Support Person" signature line was blank. The "Staff" signature line was illegibly signed by a "CSWA" (Clinical Social Work Associate), was dated 03/24/2023, and was untimed.
* The checkbox to indicate that the patient had "Received Copy" of the safety plan was blank and not checked. The safety plan for this patient identified as high suicide risk on admission two days prior was unclear and incomplete and it was not evident that the patient had participated in the development of it. For example:
* Under the section for "Things to do ... goals for healthy/recovery behavior" was recorded 1. do better 2. take [medications] 3. go to therapy." "Do better" is not a goal and it was not clear what "do better" meant for this patient identified as high risk for suicide two days prior. It was not clear if that was the patient's verbiage as there was no indication that the patient was involved in development of the safety plan. If they were involved the appropriate response from the CSWA would have been to elicit from the patient a specific, measurable goal.
* Under the section for home safety the space for "______ does not have access to: Prescription medications ... Weapons ..." was not completed. In the space for "______ verified that these items have been secured/removed from the home" was written a first name only of a person. In the open space under that statement was written the first name only of a second person. The "Relationship to the Patient" was not completed. The information "Verified ... on ______ (Date)" was not completed.

2.d. A Clinical Staff Discharge Risk Assessment was signed and dated by a physician on 03/24/2023 at an illegible time. The form contained entries that were altered, unclear, or incomplete. For example:
* Both "Yes" and "No" were checkmarked for the question "Were weapons, lethal medications, or other lethal means of self-harm verified to be secure in the home?" The "No" checkmark had been altered with a cross out line.
- The answer to "If Yes, who has verified ..." was written as "[First name only]'s friend." An illegible entry was written over the top of the "If Yes, ..." verbiage on the form.
- The answer to "If No, explain:" was written as "Pt verified, No collateral given." That entry was altered with a cross out line.
- There were two illegible staff signatures that each had possible "CSWA" credentials. In the "Date/Time:" space there was only one date for the two signatures, 03/24/2023. There were two times recorded as "1045 1352."
- It was not clear who was responsible for what entries.
* The question "Does the patient have a history of suicide attempt(s) and/or self-harm within 30 days post discharge from treatment" was not answered either "Yes" or "No."
* The question "Was the patient on suicide precautions or heightened observations for suicidal ideation or self-injurious behaviors in the past 24 hours?" was answered "No." However, physician's orders were in place for "Suicide Precautions" and "Self Harm Risk" precautions from 03/22/2023 at 1803 through through "12/31/99 [sic]" at 2359.
* The question "Any new intensified stressors identified within the last 24 hours (If Yes, describe)" was not answered with "Yes" or "No."
* The question "Any newly identified situations/changes that may cause an increase in risk state when back in the community (if Yes, describe)" was not answered with "Yes" or "No."
* The question "Patient report is credible/consistent/reliable? (If Yes, describe)" was answered as "Yes," however the description space that followed was blank.
* The "Risk Status/State ... Compared to the time of admission, the patients [sic] risk state is ... Lower ... Compared to other patients typically managed in the community with same or similar diagnosis, the patient's risk status is ... Similar ..." However, the following space for "Factors for the clinical determination:" was blank.

2.e. A "[physician/nurse practitioner] Discharge Order" was dated 03/24/2024 and was incomplete and illegible. For example:
* The two-word, handwritten entry under the "Psychosocial and Contextual Factors" was illegible.
* The checkbox for "Discontinue all Precautions" was not checked.
* The entry for the "Number of antipsychotic medication at discharge:" had been altered and written over at least twice and was severely illegible.
* The checkbox was marked for "Patient may take home all medications brought from home after visual inspection by [physician/nurse practitioner]." However, the following instruction had not been followed or documented: "Signature of prescriber doing visual inspections. Reviewed ____ [medications]: __________ [physician/nurse practitioner]."
* The spaces for "Diet" and "Activity Restriction" had not been completed.
* The physician's signature was dated 03/24/2023 but the time of the entry was illegible.

2.f. An undated and untimed Aftercare Plan, Inpatient form was signed in the "Social Services Staff Signature" space with an illegible signature and no credentials. The plan was primarily incomplete. For example:
* The 1/2 page section of the "Discharge Instructions" contained seven (7) subsections that were completely blank. None of the pre-printed selections were checked and there was no narrative.
* The 1/3 page section of the "Discharge Acknowledgements" contained eight (8) items that required a checkmark. The following statement stated "By initialing, I agree to the above checked items and acknowledge that staff has fully answered any questions that I have about these acknowledgements." There was a set of initials, however, it was unclear if the initials were written by the patient and they were not dated or timed. None of the eight (8) items were checked.
* The following items that required a checkmark if completed throughout the Aftercare Plan had not been checked:
- "Tobacco Use Treatment"
- "Community Resource Handbook Was Provided to The Patient"
- "Crisis Safety Plan was Provided To Patient"
- "Suicide/Relapse Education Was Provided To Patient"

2.g. A psychiatrist Discharge Summary reflected the "Discharge Date" was 03/24/2023, the "[dictation date and time]" was 03/24/23 at 1433, and the psychiatrist electronically signed the summary on 03/27/2023 at 1232. The brief summary reflected the patient "came in again after the recent discharge with worsening mood and suicidal thoughts ... was placed on suicide precautions ... Patient today reports doing well and is wanting to discharge ... denying hopelessness or suicidal thoughts ... has been invisible in the milieu and appears to be able to take care of [their] basic needs ... reports the plan is for [them] to go back to [their] friends. [They] overall [feel] comfortable with [their] plan. [They are] in no distress and there are no delusions or hallucinations and [they are] adamantly denying any thought of wanted to hurt [themselves]."
* The "Condition at Discharge:" space was blank.
* The summary stated "Discharge Instructions: Please see social worker's discharge summary for comprehensive details. Briefly, patient has got appointments coming up."
* The "Discharge Suicide Risk Assessment" section of the summary reflected that the "[Patient] is not suicidal ... not likely going to benefit from prolonged hospitalization and is not holdable."
* The "Discharge Destination:" space was blank.
* In the "Psychosocial and Contextual Factors:" section was recorded "Living situation." It was entirely unclear what that meant.

2.h. A Daily Progress Note initialed by an RN was dated 03/24/2023 at 1211 and reflected "Denies having any thoughts on [suicidal ideation/homicidal ideation] ... describes mood as 'don't feel good' ... refused [morning] Latuda [antipsychotic] ... [heart rate] 124 ..."

The next entry was the last Daily Progress Note initialed by the RN dated 03/24/2023 at 1635. There was no nursing assessment or further information related to the previous note about the patient's "mood" and their statement that they didn't feel good, particularly in conjunction with their refusal of their morning antipsychotic, and a significantly increased heart rate when their heart rate had ranged between 77 to 97 on 03/22/2023 and 03/23/2023 since admission. There was no nursing reassessment of these aspects of the patient's condition before discharge. Further, there was no documentation to reflect the RN had reported that information to the psychiatrist. However, the note reflected that the patient was "[discharged] routinely in stable condition. Discharge process completed by charge RN. All [discharge] paperwork and aftercare plan was handed. [Patient] was given opportunity to ask question [sic]. [Patient] escorted to the front lobby." There was no indication in the note that the "[discharge] paperwork and aftercare plan" had been thoroughly reviewed with the patient as the RN documented that they simply "handed" the documents to the patient.

2.i. A Social Services Progress Note signed by a "PsyD" (Doctor of Psychology) on 03/28/2023 at 1342 reflected that the day prior on 03/27/2023 at 1645, three days after Patient 2's discharge, the patient's parent "called to inform us that [Patient 2] completed suicide '13 hours ago.' [They] expressed frustration with Cedar Hills Hospital ... as well as expressing anger ... at one point [they] expressed a belief that our goal for [Patient 2's] most recent hospitalization was to discharge [them] as quickly as possible." There was no other information on that note. However, an incident report was generated for follow-up and the hospital subsequently conducted a Root Cause Analysis investigation.

2.j. During interview on 03/20/2025 beginning at 1235 with the Intake Director they confirmed findings for Patient 2.

3.a. Review of Patient 3's medical record reflected that on 01/08/2025 at 1402 a physician ordered that the patient be admitted to the hospital. The patient was discharged on 01/11/2025 at 1105. The record reflected that documentation regarding evaluation and re-evaluation of the patient's discharge needs and condition prior to discharge was not clear and complete.

3.b. A My Safety Crisis Plan form was dated 01/10/2025, was untimed, and was unclear and incomplete. For example:
* The plan had spaces for three signatures. The "Patient" name was recorded and was dated 01/10/2025. However the time of the plan and that entry was not recorded. The "Support Person" signature line was blank. The "Staff" signature line was blank.
* The checkboxes to indicate that the patient had "Received Copy" of the safety plan was blank and not checked.
* Under the section for "Things to do ... goals for healthy/recovery behavior" was recorded 1. Go to therapy. 2. take medication. 3. Routine." It was not clear what "Routine" meant for this patient. It was not evident that any staff had reviewed the plan with the patient. If they had the appropriate response from the staff would have been to elicit from the patient a specific, measurable goal.

3.c. A "[physician/nurse practitioner] Discharge Order" document was dated 01/10/2025 and was incomplete and illegible. For example:
* The one-word, handwritten entry under the "Psychosocial and Contextual Factors" was illegible.
* The entry for the "Number of antipsychotic medication at discharge:" had been altered and was illegible.
* The checkbox was marked for "Patient may take home all medications brought from home after visual inspection by [physician/nurse practitioner]." However, the following instruction had not been followed or documented: "Signature of prescriber doing visual inspections. Reviewed ____ [medications]: __________ [physician/nurse practitioner]."
* The physician's signature was dated 01/10/2025 but the time of the entry was illegible.

3.d. An After Care/Discharge Plan Part 1 form was dated 01/10/2025 and was incomplete and illegible. For example:
* The "Reason for Admission" was an illegible one-word entry.
* The "Tobacco Cessation Medication at Discharge" section was not completed, including the option for "[not applicable]."
* The physician's signature was dated 01/10/2025 but the time of the entry was illegible.

3.e. An After Care/Discharge Plan Part 2 form was illegibly signed by a "QMHP" (Qualified Mental Health Professional) and was dated 01/10/2025 at 1351, ~ three (3) hours AFTER the patient signed and dated the plan on 01/10/2025 at 1053. It was not clear whether the QMHP had completed the plan after the patient signed the document or if the QMHP had reviewed the plan together with the patient. Further the plan was incomplete. For example:
* The "Other Aftercare Services/Referrals" sections had not been completed and was blank, including those pre-printed elements that included a "[not applicable]" option or choice.
* The "Family Involvement" section specified "Was family meeting held? ___ Yes ___ No ___ [not applicable] Date: ___ Time:___ If not, why note: _____ Participants: _____." That section had not been completed and was blank
* The "Patient Understanding of Discharge Plan" contained the following four elements that were all unchecked and provided further questions about whether the QMHP had reviewed the plan together with the patient:
- "___ The patient was clinically unstable or the patient/caregiver was unable to comprehend the information."
- "___ Patient/Family able to verbalize discharge instructions."
- "___ Patient/family verbalizes understanding of when/how to seek further treatment."
- "___ Educational materials provided to patient re: ___________."

3.f. On Page 3 of an Aftercare Plan, Inpatient was the "Discharge Acknowledgements" and "Discharge Resources." At the bottom of the page was a "Patient Signature," a significantly illegible and scrawling "Social Services Staff Signature" with no credential, and a "Nurse Signature." None of the signatures had been dated and timed, and the date and time the form had been completed was not recorded.

3.g. During interview on 03/20/2025 beginning at 1335 with the Intake Director they confirmed findings for Patient 3.

4.a. Review of Patient 7's medical record reflected that on 2/25/25 at 1138 a physician ordered that the patient be admitted to the hospital. The patient was discharged on 02/28/2025. The record reflected that documentation regarding evaluation and re-evaluation of the patient's discharge needs and condition prior to discharge was not clear and complete.

4.b. A Healthcare Disparity ... Screening/Discharge Plan reflected that the "Screening Completed by:" a Professional Counselor Associate (PCA) on 02/26/2025 at 1720. It reflected that the "Discharge Resources" information was "Completed by:" an individual with no credentials on 02/28/2025 at 1337. The spaces for "Patient signature at Discharge: ___ Time: ___ Date: ___" had not been completed and were blank.

4.c. A My Safety Crisis Plan form had been signed and dated by the patient on 02/28/2025 and illegibly signed by a "MSW" (Medical Social Work) staff. However, the times of the plan completion and signatures were not recorded. The first name of the patient's parent was written on the "Support Person" line and was dated 02/28/2025. That line also reflected that the support person "received copy" of the plan. However, the MSW had written the name of the support person and therefore it was not clear whether the support person participated in the plan review with the patient and MSW in-person at the facility.

4.d. An After Care/Discharge Plan form was illegibly signed by an "MSW" on 02/28/2025 at 1258. The name of the patient was written in the "Patient" space but the date and time spaces were blank. The plan was not clear or complete. For example:
* The "Other Aftercare Services/Referrals" sections had not been completed and was blank, including those pre-printed elements that included a "[not applicable]" option or choice.
* The "Copy of Suicide Prevention Handouts given? ___ Yes ___ No ___ [not applicable]" had not been completed. None of those choices were checked.
* The "Family Involvement" section specified "Was family meeting held? ___ Yes ___ No ___ [not applicable] Date: ___ Time:___ If not, why not: _____ Participants: _____." The not applicable box was checked but it was not clear why this was not applicable as there was reference to family throughout the record.
* The "Patient Understanding of Discharge Plan" contained the following four elements that were all unchecked and therefore it was unclear whether the MSW had reviewed the plan together with the patient:
- "___ The patient was clinically unstable or the patient/caregiver was unable to comprehend the information."
- "___ Patient/Family able to verbalize discharge instructions."
- "___ Patient/family verbalizes understanding of when/how to seek further treatment."
- "___ Educational materials provided to patient re: ___________."

4.e. On Page 3 of an Aftercare Plan, Inpatient form was the "Discharge Acknowledgements" and "Discharge Resources." At the bottom of the page was a "Patient Signature," a "Social Services Staff Signature" with no credential, and an illegible "Nurse Signature." None of the signatures had been dated and timed, and the date and time the form had been completed was not recorded.

4.f. During interview on 03/20/2025 beginning at 1430 with the Intake Director they confirmed findings for Patient 7.

******************************************************

******************************************************
Based on interview, review of medical record documentation for 5 of 5 patients reviewed for social services (Patients 1, 2, 3, 6, and 7), and review of policies and procedures, it was determined the hospital failed to ensure the director of social services monitored and evaluated the quality and appropriateness of social services furnished by social services staff in the following areas:
* Failure to conduct psychosocial and suicide risk intake screening and assessments timely and in-person after the patient's arrival to the hospital.
* Failure to conduct timely, clear and complete psychosocial assessments after the patient's admission, including for patients identified with suicide risk.
* Failure to supervise intake processes when conducted by staff from other disciplines.
* Failure to develop clear and complete treatment/care plans in conjunction with the multi-disciplinary team.
* Failure to conduct timely, clear, and complete discharge assessment and planning.

Findings include:

1. The policy and procedure titled "Assessment of Patients, [Inpatient]" dated as "effective 12/2021," and the version dated as "effective 04/2024," were reviewed. The two versions included the following requirement: "Following review of previous assessment not noting any discrepancies, the psychosocial history is obtained from the patient, family, and/or significant others by a clinical social worker and is in the patient's record within seventy-two (72) hours of the patient's admission. The assessment will contain the following information: [14 elements were listed]."

2.a. Review of Patient 2's medical record reflected that on 03/22/2023 at 1803 a physician ordered that the patient be admitted to the hospital. The patient was discharged on 02/06/2023. The record reflected that social services admission psychosocial assessment and intake documentation was not timely, clear, or complete. For example:

2.b. On 03/06/2023 at 1400 the 7-page admission Psychosocial Assessment was signed, dated, and timed by a "PsyD intern" or a psychologist intern. That was 16 days BEFORE Patient 1's admission. It was illegibly cosigned by a "CSWA" who originally recorded a date of 03/08/2023 at 1545. However, the "8" in the date had been altered as a "6" was written over it. The assessment was unclear and incomplete. Examples include:
- The "Behavior: ___ Danger to Self ___ Danger to Others ___ Gravely Disabled ___ Other: ___" section had not been completed and was blank.
- In response to the question "Is patient able to return to previous residence/placement?" the answer was "Yes." A corresponding note reflected "[patient] is paid through 3/15/23 at current room-for-rent, but has no whey [sic] to continue paying - Will be homeless after 3/15/23."
- The following question was "Does patient need housing, alternative placement, or further assessment? ___ Yes ___ No." Neither box was checked.
- Under the section "Individual(s) to Be Involved with Care" were spaces to identify up to four individuals with "Name/Relationship/Phone." No individuals were identified. A corresponding note reflected only "[patient's parent] in arizona - however [patient] called [parent] on 3/06/23 (today) and said that [their parent] told [them they] should 'figure it out in portland.' Therefore [parent] isn't involved in treatment."
- The "Family History/Patient's Relationship with Family/Significant Other" section had not been completed and was blank.
- Under the section for "Pertinent Religious and Cultural Factors" was written only "unknown." It was unclear how that would have been "unknown" if the assessment was being completed with the patient.
- Under the section for "Educational History" was written only "unknown." It was unclear how that would have been "unknown" if the assessment was being completed with the patient.
- Under the section for "History of Abuse" was written only "unknown." It was unclear how that would have been "unknown" if the assessment was being completed with the patient.
- Under the section for "Current Community Resources" the checkbox for "Prior Psychiatric Hospitalization" was checked as "Yes." However the "Dates ___ Facility Name ___" were not completed. Nor were the other elements in that section.
- "Prior Psychiatric Medication(s)" was checked as "Yes." However, those medications were not identified. The rest of that section was blank.
- Under the sections for "Substance Abuse Assessment" and "Detox/Withdrawal History" was written only "unknown."
- Under the section for "Support System" there were no "___ Family ___ Friends ___ Spiritual Organizations ___ Therapist/Counselor" identified. A corresponding note reflected "[patient's parent and grandparent] are unsupportive. no other family members known."

2.c. On 03/22/2023 at 1140, approximately four hours before the first entry was recorded on the Patient Observation Rounds form to reflect the patient had physically arrived in the building, a "QMHP" signed and dated the Standardized Intake Assessment. The Standardized Intake Assessment was unclear and incomplete. For example:
* The following sections of the assessment were not completed: "Patient Preferred Name ... Emergency Contact/Support Person ... Religion ... Occupation ... Patient Search/Portable Metal Detector Completed by: ___ ... Does patient have a Primary Care Provider ... Vital Signs ... Allergies ... Health and Communicable Disease ... Fall Risk ... Medical Screen Completed by: ___ ... Substance Use History ... Assessment Reviewed with: Via: ___ Phone ___ In Person ... Date ___ Time ___ ..."
* In the section titled "Accompanied By:" the QMHP recorded "Therapist." There was no explanation and no details to describe what and who that meant.
* In the section titled "Medications" the QMHP wrote "See Med Screening." There was no explanation for that entry.
* In the section titled "Current Mental Status" the QMHP recorded "[Unable to Assess]" for the elements of "Appearance ... Movement ...Visual Contact." There was no documentation to explain why the QMHP was "unable to assess" those visual elements of the patient's presentation.
* In the section titled "Assessment Reviewed with: ... Provider" the QMHP wrote "Defer to admission." There was no explanation for that entry.
* On the last page of the assessment the "QMHP" wrote "Disposition ... Admission scheduled for 3/22 [at] 1600 to [inpatient level] ... Patient presented as guarded and withdrawn during tele-assessment and was unable to contract for safety."

There were no provisions for intake "tele-assessments" in the hospital's policies and procedures. Further, there was no documentation in the record to reflect the location of Patient 2 during the "tele-assessment," how this patient at "high risk" for suicide and who had attempted suicide by crashing their car was to be transported to the hospital more than four hours after the assessment, and who was to accompany the patient to the hospital. Having assessed the patient at "high risk" for suicide, the QMHP failed to document a plan and actions to ensure the patient's safety prior to the patient's arrival at the hospital.

2.d. On 03/24/2023 at 1041, the day of the patient's discharge from the hospital, a 1-page BioPsychosocial Assessment - Update form was illegibly signed by an individual who failed to identify their "credentials." It was illegibly co-signed by a "CSWA" on 03/24/2023 at 1057. The "Update" was unclear. For example: It reflected there were no changes to the "previous psychosocial assessment 3.6.23," however, it also reflected that the same [parent] identified in the 03/06/2023 assessment who had been uninvolved and "unsupportive" was the only person to be involved. The "Update" did not constitute the required comprehensive psychosocial assessment and there were no provisions for a psychosocial assessment "update" in the policy and procedure.

2.e. During interview on 03/20/2025 beginning at 1235 with the Intake Director they confirmed findings for Patient 2.

3.a. Review of Patient 3's medical record reflected that on 01/08/2025 at 1402 a physician ordered that the patient be admitted to the hospital. The patient was discharged on 01/11/2025 at 1105. The record reflected that the admission psychosocial assessment was not clear, or complete. For example:

3.b. On 01/10/2025 at 1500 the 7-page Psychosocial Assessment for Patient 3 was dated and timed. However, the author(s) of the assessment were not clear, and the assessment was unclear and incomplete. Examples include:
* Written in the spaces for "Family of Origin ... Family Dynamics ... Current Relationship Stressors/Concerns ... Pertinent Religious and Cultural Factors ... Developmental History/Milestones ... Sexual Activity" was "[Patient] did not disclose." It was not clear whether the patient had refused to answer those questions or the questions had not been asked.
* The space for "Educational History" was primarily incomplete and only "Some College" was checked off.
* Under the section for "Current Financial Stressors" the "Patient Denies" checkbox was not checked. However, the space for explanation or description of the stressors was blank.
* Under the section for "Current Work Stressors" the "Patient Denies" checkbox was not checked. However, the space for explanation or description of the stressors was blank.
* Under the "Support System" section "Family" was generically identified but the space for a response to "Family/significant other concerns related to psychosocial issues/illness" had not been completed. The space was blank.
* The question "How has patient's mental status affected their ability to participle in social activities and/or utilize support system?" had not been answered. The space was blank.
* All of the entries handwritten under the sections for "Anticipated Social Work Role in Treatment" and the "Anticipated Social Work Role in Discharge Planning" had a less bold characteristic than other entries on the assessment form as if the documentation on that page, under those section, had been photocopied from another record. Because of the difference in characteristics it was not clear if those entries were written by the same individual that wrote the other parts of the assessment.
* Similarly, under the "Assessment Completed By:" section the author's name, signature, and "CSWA, MSW" credentials had that same less bold characteristic as if the signature was also a photocopy. While the "Date/Time" written as 01/10/2025 at 1500 had a bold appearance as if it was an original written entry.

3.c. During interview on 03/20/2025 beginning at 1335 with the Intake Director they confirmed findings for Patient 3.

4.a. Review of Patient 7's medical record reflected that on 2/25/25 at 1138 a physician ordered that the patient be admitted to the hospital. The patient was discharged on 02/28/2025. The record reflected that the intake suicide screening and assessment documentation was not complete, accurate, or clear. For example:

4.b. On 02/25/2025 at an illegible time the eight (8) page Standardized Intake Assessment form for Patient 7 was illegibly signed by an unidentifiable writer/author. The suicide risk screening tool was on Page 2. The writer/author had not completed the screening completely and accurately as follows:
* For "Has the patient exhibited any risk for suicide (ideations, plans, behaviors) in the past 6 months?" The answer was "Yes" and the form directed to "Describe:" However, there were only two unidentifiable and illegible marks or initials recorded. There was no description of the suicidal behaviors.
* Question 1 of the screening, "Have you wished you dead or wished you could go to sleep and not wake up?" was answered "Yes."
* Question 2 of the screening, "Have you actually had any thoughts of killing yourself?" was answered "Yes."
* Question 3 of the screening, "Have you been thinking about how you might do this?" was answered "Yes."
* Questions 4 and 5 were answered "No."
* Question 6 of the screening, "Have you ever done anything, started to do anything, or prepared to do anything to end your life?" was answered "Yes."
* Question 6 second part, "If Yes ... Was this within the past three months:" was answered "No."
* Under "Level of Risk" the writer/author selected "If answered Yes to questions #1 and/or #2, No to questions #3, 4, 5, 6 - Low Risk." However, that was incorrect as the patient had answered "Yes" to Questions 1, 2, 3, and 6.
* Under "Level of Risk" for "Moderate Risk" was described as "Yes to question #3 and/or Lifetime #6." The screening instructions in the case of "Moderate Risk" was to "Complete Lifetime Suicide Risk Assessment."
* The full suicide risk assessment was not required for "Low Risk" and therefore the writer/author did not complete it. There was no evidence of the suicide risk assessment in the medical record.

4.c. The Nursing Admission Assessment completed and signed illegibly by an unidentifiable writer/author on 02/26/2025 at 1648, reflected the nursing risk assessment identified the patient to have "Suicide/Self Injury" risk and "Sexual Victimization Risk." The Nursing Treatment/Care Plan signed by an RN on 02/26/2020 at 1652 included problems for "Suicidal/Self Injurious" and "Risk of Victimization: ... Sexual."

4.d The Psychosocial Assessment completed and signed on 02/26/2025 at 1720 by a Professional Counselor Associate (PCA) stated that "[Patient] reported [they are] not currently suicidal." There was no assessment of the patient's suicide risk identified on the initial screening during intake, and the nursing assessment and treatment/care plan completed within the hour prior to the Psychosocial Assessment.

4.e. The two-page Multi-disciplinary Master Treatment Plan was signed by the PCA on 02/26/2025 at 1545, prior to the completion of the Psychosocial Assessment. The only problem identified on the plan was dated 02/25/2025 and was "Mood instability." There was a corresponding Treatment Plan Problem Sheet for the problem of "Mood Stability." The Treatment Plan did not address the inconsistencies related to the patient's suicide risk, nor did it include the problem of sexual victimization.

4.f. During interview on 03/20/2025 beginning at 1430 with the Intake Director they confirmed findings for Patient 7.

5. For Patients 1, 2, 3, 6, and 7 refer to the findings under Tag A-438 that reflects intake and admission consents and documents were not fully and clearly completed, signed, and dated/timed.

6. For Patients 2, 3, and 7 refer to the findings under Tag A-802 that reflects that social services staff failed to ensure that discharge planning processes including assessment and re-assessment of patient condition and discharge needs from admission through the date of discharge were coordinated, clear, and complete.

******************************************************

******************************************************
Based on interview, review of medical record documentation for 3 of 3 patients assessed at risk for suicide who were reviewed for psychiatric evaluations (Patients 2, 3, and 7), and review of policies and procedures, it was determined the hospital failed to ensure the psychiatrists documented clear, complete, comprehensive, and timely psychiatric evaluations within 24 hours as required by the hospital's policy and procedure.

Findings include:

1.a. The policy and procedure titled "Assessment of Patients" dated as effective "12/2021" was reviewed. It included the following: "... a psychiatrist or physician will complete a psychiatric evaluation, including: [45 elements listed]." The revised policy and procedure titled "Assessment of Patients" dated as effective "04/2024" was reviewed. It included the following: "Within the first twenty-four (24) hours of the patient's admission to the unit, psychiatric services will complete a psychiatric evaluation, including: [45 elements listed]. The psychiatric evaluation will be dictated and initially documented on the Preliminary Psychiatric Evaluation form ... The Preliminary Psychiatric Evaluation form will contain essential information needed to assist in the formation of the multidisciplinary treatment plan."

1.b. During interviews with the Intake Director on 03/20/2025 beginning at 1230 and with the Interim Chief Nursing Officer on 03/24/2025 beginning at 1300 it was confirmed that the hospital policy prior to the 04/2024 written policy and procedure revision was that psychiatric evaluations were to be completed within 24 hours of admission.

2. Review of Patient 2's medical record reflected that on 03/22/2023 at 1803 a physician ordered that the patient be admitted to the hospital. The patient was discharged on 03/24/2023.

The record did not contain a psychiatric evaluation.

The first and only psychiatrist progress note in the record reflected the "Date of Visit" was 03/23/2023 and the "[dictation date and time]" was recorded as 03/23/2023 at 1209. The brief note was electronically signed by the psychiatrist on 03/24/2023 at 1048. In the "History" section the psychiatrist documented that "Patient came in again with complaints of suicidal thoughts. When seen today, patient reports that it was a 'mistake' ... denies suicidal thoughts adamantly." The "Assessment and Plan" included "At this time, patient reports doing well and is wanting to discharge ... we will work on safety planning ... [patient] is encouraged to talk to social worker on aftercare plan. Likely discharge is going to be in the next day or two." However, the psychiatrist had not completed the comprehensive initial psychiatric evaluation that was required within 24 hours of admission to fully evaluate and assess the patient's psychosocial state and status and suicide risk that had been assessed as "high" during initial intake the day prior.

3. Review of Patient 3's medical record reflected that on 01/08/2025 at 1402 a physician ordered that the patient be admitted to the hospital. The patient was discharged on 01/11/2025 at 1105.

A one-page Preliminary Psychiatric Evaluation form contained incomplete, unclear, and illegible information. For example:
- In the space for "Time of Service" was written 01/09/2025 and an illegible time.
- In the space for "Allergies" was written one illegible word.
- In the space for "Psychiatric Diagnoses" was written "MDD" for Major Depressive Disorder.
- In the space for "Psychosocial and Contextual Factors" was written one illegible word, possibly "multiple."
- In the space for "Treatment Plan (Abbreviated)" was written two illegible words, possibly "mult [something]."
- In the space for "Risk Assessment Overview" was written one illegible word, possible "mult [sic]."
- The time the psychiatrist signed the form was illegible.
.
The four-page Psychiatric Evaluation Assessment was not timely and was electronically signed by the psychiatrist as completed on 01/09/2025 at 2111, ~ 31 hours after admission.

4. Review of Patient 7's medical record reflected that on 2/25/2025 at 1138 a physician ordered that the patient be admitted to the hospital. The patient was discharged on 02/28/2025.

A one-page Preliminary Psychiatric Evaluation form was signed by the psychiatrist on 02/26/2025 at 1100. It contained incomplete and unclear information. For example:
- The "Admission Date" space was blank.
- In the space for Evaluation Date was written a partial date "2-26."
- The "Time of Service" space was blank.
- The "Psychiatric Diagnoses" space was blank.
- The "Psychosocial and Contextual Factors" space was blank.
- The "Treatment Plan (Abbreviated)" space was blank.
- In the space for "Risk Assessment Overview" was written "mod." However, it was unclear what that meant and what risk was being referred to.
- There were a few short words written in the margins. It was unclear what those meant.
- The time the psychiatrist signed the form was illegible.

The five-page Psychiatric Evaluation Assessment was not signed, dated, or timed to reflect when it was completed. On Page 1 the evaluation the date and time was recorded as 02/26/2025 at 1100. However, On Page 5 there was no dictation date and time, and it was not signed and dated and timed by the physician. The physician signature line was blank. Further, an entry reflected "Scribed for and in the presence of [physician's name]." Yet, the name and signature of the scribe and the date and time they completed the scribing was not recorded. In the white space of the Page 5 there was a handwritten dated "3/12/25" with illegible marks on either side of it. It was not evident what the date and the illegible marks meant nor who made them. There was no evidence to reflect that the psychiatric evaluation had been fully completed within 24 hours.

5. During interview at the time of record reviews on 03/20/2025 beginning at 1235 with the Intake Director they confirmed that comprehensive psychiatric evaluations for Patients 2, 3, and 7 were not documented, not timely, clear, or complete.

******************************************************

******************************************************
Based on interview, review of medical record and incident documentation for 7 of 7 patients (Patients 1, 2, 3, 4, 5, 6, and 7), and review of policies and procedures it was determined that the hospital failed to ensure the multi-disciplinary team developed and implemented treatment/care plans for the patients that were completed timely on admission and as changes of condition occurred, were individualized, and were clear and complete as follows:
* Admission treatment/care plans were not timely or complete and did not clearly address suicide risk, fall risk, and other identified/assessed risks.
* Treatment/care plans were not updated as changes of patient occurred.

Findings include:

1. For Patients 1, 2, 3, 4, 5, 6, and 7 refer to the findings under Tag A-396 and Tag A-1715 that reflects treatment/care plans were not timely, clear, or complete; did not clearly address suicide risk, fall risk, and other risks identified, were not developed in coordination with all multi-disciplinary team members; and had not been updated when changes of patient condition occurred.

******************************************************