The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

WELLBRIDGE HEALTHCARE FORT WORTH 6200 OVERTON RIDGE BLVD FORT WORTH, TX 76132 Aug. 6, 2021
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
.
The hospital failed to provide a safe environment for one of one adult patients (Patient #1) who engaged in sexual relation incident with a fell ow patient.

Findings Include

During Record Review on admission three days prior to the incident, Patient #1 had been psychiatrically assessed with increasingly worse self-care, a danger to herself due to marked decline in functioning and activities of daily living, thought blocking due to her intellectual development delay and nonsensical logic. Patient #1's staff evaluated Patient #1 to be on a developmental level of an early adolescent patient.

During Interviews Staff #6, Staff # 10, and Staff #12 evaluated Patient #1 to be ona devleopmented early adolescent patient.
\\
During Interviews with hospital Staff #1, , Staff #3, Staff # 7, Staff #8, Staff #13, and Staff #9 all indicated that sexual relations is not a part of the milieu, but they and the hospital investigation was closed due to the police stating the allegations were consensual and the hospital investigation was closed as a result.

During Interviews with hospital Staff #10, Staff #12 have confirmed that they were not interviewed as a result of the incident.

During Record Review of hospital Incident Event documentation Patient #1 confirmed along with Patient #2 that they participated in consensual sexual relations.

Policy

The hospital Patient Rights Policy dated 06/2021 reflected, "The policy of the Hospital is as follows:
1. Prohibit abuse and described the procedures for preventing and responding to allegations of abuse, neglect or mistreatment of a patient.
2. Abuse includes allegations related to verbal, physical and /or sexual abuse/unwanted touching ...
3. The Hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident ...Failure to report immediately a suspected abuse incident or cooperate in the appropriate investigations can result in corrective action.
4. Abuse is considered a grievance and shall be logged on the Complaint and Grievance form as well as adherence to the expectations outlined in policy ...

Patient Abuse, Neglect, and/or Mistreatment is defined as any incident of
physical, sexual ...us reported by the patient or family; or is witnessed,
reported.

11. Sexual Abuse includes any sexual overture made to a patient ...regardless of the patient's willingness to be involved. This includes, but is not limited to ...all forms of sexual harassment ...or sexual molestation.

The hospital Level of Observation and Hand off Communication dated 12/2020 reflected, "It is the policy of the facility to provide levels of observation in compliance with physician orders and prescribed protocols."

The hospital Policy on Abuse 'Patient Rights and Civil Rights' dated 06/2021, "The policy of the Hospital is as follows:
1. Prohibit abuse and describe the procedures for preventing and responding to allegations of abuse.
2. To identify the hospital's position regarding employees who are suspected of patient abuse, neglect and/or exploitation. Abuse includes allegations related to verbal, physical and/or sexual abuse/unwanted touching as referenced in the definitions section.
3. The hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident to hospital leaders and applicable state agencies. Failure to report immediately a suspected abuse incident or cooperate in the appropriate investigation can result in corrective action.
4. Abuse is conserved a grievance and shall be logged on the Complaint and Grievance form as well as adherence to the expectations outlined in policy.
- WB-ML 04-001Patient Complaint/Grievance Process
Definitions
1. Dependent Adult Any person who is between the ages of 18 and 64 who has physical mental limitations which restrict his or her ability to carry out normal activities or to protect his or her rights including, but limited to, persons who have physical or developmental disabilities ...
2. Disabled Person Any person with a physical, cognitive or developmental disability that substantially impairs the persons ability to proved adequately for the person's care or protection and who is 18 years of age or older or under 18 years of age and who has had the disabilities of minority removed or cannot perform their own activities of daily living.
8. Neglect/Mistreatment is the failure to or refusal by any person having the care or custody of another (child, elder and adult) to exercise the degree of which a reasonable person in a like position would exercise. Neglect includes, but not limited to:
b. Action(s) by an employee contrary to prescribed treatment:
l. Failure to intervene or protect a patient from abuse/mistreatment by
another (patient)
Patient Abuse, Neglect, and/or Mistreatment is defined by any incident of physical, sexual or verbal abuse, neglect and/or mistreatment that is reported by the patient or family, or is witnessed, reported, or suspected by an employee.
11. Sexual Abuse includes any sexual overture made to a patient verbally, non-verbally, or physically, regardless of the patient's willingness to be involved. This include, but is not limited to, verbal, sexually explicit language, all forms of sexual harassment, sexual assault, or sexual molestation.
13. WB-PC 09-001 A Abuse Checklist (Sample): Checklist utilized to ensure patient safety and prompt completion of immediate actions for abuse allegations.

Suspected Abuse: First Responder/Supervisor Responsibilities
3. Notify the Director of Nursing (DON) Director of Nursing (CCO), Nursing Supervisor or clinical area Manager immediately in any instance or reported, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation. The Director Nursing (DON)/Director of Nursing (CCO, Nursing Supervisor or Clinical area Manager shall immediately notify Administrator on Call. Activate the Event Investigation Algorithm. Serious and Sentinel Event Investigation.
4. The first person to receive the report should document the allegation as an event report.
5. Contact the Divisional Director of Quality and Risk 24 hours/day, 7 days a week.
6. The Chief Executive Officer, Director of Quality Management, or their designee reviews federal and state reporting requirements.
Investigation Guidelines
1. Medical/Affiliate staff, the Chief Executive Officer will be consulted regarding the Medical Director's participation in the investigation.
3.) All investigations will be conducted under the guidance of the
Administrative staff who will, depending on the circumstance:
a. Seek information in a thorough, impartial, dignified, and confidential manner
b. Interview witnesses, including the charged individual(s) and obtained signed statements when appropriate
c. Assure that embarrassment of Patient(s) is avoided
d. Assess the patient's mental state and history in order to judge the accuracy of the patient's report.
f.) Investigate all other possible sources of information relating to the incident and/or the persons involved.
g. Make every effort to verify the information obtained
h. Cooperate fully with any legal investigation or proceedings
4. All investigations and resulting actin documentation will be
maintained in the Administrative office.
5. Any required reporting to licensing agencies (Board of Nurse Examiners) as mandated by law will be made by the Director of Nursing or the Director of Quality Management after consultation with the law department and Hospital Chief Executive Officer.
6. Release of all information to the proper authorities will be made as legally required and under the direction of the Chief Executive Officer.
7. The Chief Executive Officer will report to the Governing Board via appropriate channels, any instance of patient abuse, neglect, mistreatment and/or exploitation and the resultant corrective action.
8. Reports that are taken from patients and/or families are logged on the Complaint and Grievance form will be responded to, in writing, with findings and recommendations resulting from investigation within seven days of receipt of the form by the Chief Executive Officer.

The hospital Policy on Nursing Leadership Plan for Patient Care and Safety, dated 09/2020, "The policy of Kindred Behavioral Health hospitals is to ensure the following, The Leadership Nursing Plan for Patient care includes;
" Care that is directed toward the restoration of health, reaching the patient's full potential and improving each patient's quality of life.

MONITORING AND EVALUATIONS
1. To assure that patients receive appropriate nursing care and that consistent standards for the provisions of nursing care within the hospital are maintained, selected performance improvement indicators are used to monitor and evaluate the quality and appropriateness of nursing care provided throughout the hospital.

The hospital Policy on Intake and admitted d 02/2021 reflected, "The policy of Kindred Behavioral Health is to ensure the following;
1. The Behavioral Health Unit or Hospital shall have a written plan for assessment or clinical review of symptoms leading to the patient presenting for admission or to the referral."


The hospital Policy on Administration/Personnel "This policy describes the process for registered nurses, other non-advanced practice healthcare professionals and non-licensed individuals employed by Kindred Medical staff physician or group medical practice. This policy does not apply to licensed independent practitioners or Allied Health Professionals (such as physician assistants and nurse practitioners). Credentialing requirements for LIPs and AHPs."

The hospital Event and Incident Reporting dated 07/2020 reflected, "The policy of Kindred Behavioral Healthcare is to ensure the following:
2. Hospital personnel are responsible for reporting in a timely and
efficient manner, patient and visitor events ...
11. Examples of events reportable to the Event Reporting System
a. Level 4 (Sentinel) Events
1. A "Sentinel" event is any death or major permanent loss of
function (sensory, motor, physiologic or intellectual) not related to the natural course of the patient's illness or underlying condition (i.e., acts of commission or omission) ...
ii. Level 4 includes, but not limited to, any "sentinel event" defined
by joint commission. Level 4 also refers to any unexpected
occurrence involving death or serious physical or psychological
injury, or risk thereof, not related to the natural course of the
patient's illness or underlying ...
Examples of Level 4 include:
d) allegations of physical or sexual abuse."
VIOLATION: PATIENT SAFETY Tag No: A0286
The hospital Failed to ensure the Standadre Standard: Program Scope. (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events .... 482.21(c) Standard: Program Activities ... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. 482.21(e) Standard: Executive Responsibilities. The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established.

'Findings Include:

During Record Review Patient #1's medical record hospital failed to provide an ongoing program that tracked adverse patient events for one of one Patients (Patient #1) who agreed to engage in a sexually intimate incident with a male patient Patient #2 on the unit and determined the extent of consensus that Patient #1, a patient diagnosed with intellectual and developmental delays, was able to provide.

During Interview with hospital Staff #9, Staff #9 indicated that the hospital did not follow its own Policy. The hospital did not follow its own Policy of ensuring Patient Safety, The hospital Administration failed to follow its own Policy in conducting thorough investigation to ensure identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events .... 482.21(c) Standard: Program Activities ... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established.

Policy
The hospital Patient Rights Policy dated 06/2021 reflected, "The policy of the Hospital is as follows:
1. Prohibit abuse and described the procedures for preventing and responding to allegations of abuse, neglect or mistreatment of a patient.
2. Abuse includes allegations related to verbal, physical and /or sexual abuse/unwanted touching ...
3. The Hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident ...Failure to report immediately a suspected abuse incident or cooperate in the appropriate investigations can result in corrective action.
4. Abuse is considered a grievance and shall be logged on the Complaint and Grievance form as well as adherence to the expectations outlined in policy ...

Patient Abuse, Neglect, and/or Mistreatment is defined as any incident of
physical, sexual ...us reported by the patient or family; or is witnessed,
reported.

11. Sexual Abuse includes any sexual overture made to a patient ...regardless of the patient's willingness to be involved. This includes, but is not limited to ...all forms of sexual harassment ...or sexual molestation.

The hospital Policy on Abuse 'Patient Rights and Civil Rights' dated 06/2021, "The policy of the Hospital is as follows:
1. Prohibit abuse and describe the procedures for preventing and responding to allegations of abuse.
2. To identify the hospital's position regarding employees who are suspected of patient abuse, neglect and/or exploitation. Abuse includes allegations related to verbal, physical and/or sexual abuse/unwanted touching as referenced in the definitions section.
3. The hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident to hospital leaders and applicable state agencies. Failure to report immediately a suspected abuse incident or cooperate in the appropriate investigation can result in corrective action.
4. Abuse is conserved a grievance and shall be logged on the Complaint and Grievance form as well as adherence to the expectations outlined in policy.
- WB-ML 04-001Patient Complaint/Grievance Process
Definitions
1. Dependent Adult Any person who is between the ages of 18 and 64 who has physical mental limitations which restrict his or her ability to carry out normal activities or to protect his or her rights including, but limited to, persons who have physical or developmental disabilities ...
2. Disabled Person Any person with a physical, cognitive or developmental disability that substantially impairs the persons ability to proved adequately for the person's care or protection and who is 18 years of age or older or under 18 years of age and who has had the disabilities of minority removed or cannot perform their own activities of daily living.
8. Neglect/Mistreatment is the failure to or refusal by any person having the care or custody of another (child, elder and adult) to exercise the degree of which a reasonable person in a like position would exercise. Neglect includes, but not limited to:
b. Action(s) by an employee contrary to prescribed treatment:
l. Failure to intervene or protect a patient from abuse/mistreatment by
another (patient)
Patient Abuse, Neglect, and/or Mistreatment is defined by any incident of physical, sexual or verbal abuse, neglect and/or mistreatment that is reported by the patient or family, or is witnessed, reported, or suspected by an employee.
11. Sexual Abuse includes any sexual overture made to a patient verbally, non-verbally, or physically, regardless of the patient's willingness to be involved. This include, but is not limited to, verbal, sexually explicit language, all forms of sexual harassment, sexual assault, or sexual molestation.
13. WB-PC 09-001 A Abuse Checklist (Sample): Checklist utilized to ensure patient safety and prompt completion of immediate actions for abuse allegations.

Suspected Abuse: First Responder/Supervisor Responsibilities
3. Notify the Director of Nursing (DON) Director of Nursing (CCO), Nursing Supervisor or clinical area Manager immediately in any instance or reported, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation. The Director Nursing (DON)/Director of Nursing (CCO, Nursing Supervisor or Clinical area Manager shall immediately notify Administrator on Call. Activate the Event Investigation Algorithm. Serious and Sentinel Event Investigation.
4. The first person to receive the report should document the allegation as an event report.
5. Contact the Divisional Director of Quality and Risk 24 hours/day, 7 days a week.
6. The Chief Executive Officer, Director of Quality Management, or their designee reviews federal and state reporting requirements.
Investigation Guidelines
1. Medical/Affiliate staff, the Chief Executive Officer will be consulted regarding the Medical Director's participation in the investigation.
3.) All investigations will be conducted under the guidance of the
Administrative staff who will, depending on the circumstance:
a. Seek information in a thorough, impartial, dignified, and confidential manner
b. Interview witnesses, including the charged individual(s) and obtained signed statements when appropriate
c. Assure that embarrassment of Patient(s) is avoided
d. Assess the patient's mental state and history in order to judge the accuracy of the patient's report.
f.) Investigate all other possible sources of information relating to the incident and/or the persons involved.
g. Make every effort to verify the information obtained
h. Cooperate fully with any legal investigation or proceedings
4. All investigations and resulting actin documentation will be
maintained in the Administrative office.
5. Any required reporting to licensing agencies (Board of Nurse Examiners) as mandated by law will be made by the Director of Nursing or the Director of Quality Management after consultation with the law department and Hospital Chief Executive Officer.
6. Release of all information to the proper authorities will be made as legally required and under the direction of the Chief Executive Officer.
7. The Chief Executive Officer will report to the Governing Board via appropriate channels, any instance of patient abuse, neglect, mistreatment and/or exploitation and the resultant corrective action.
8. Reports that are taken from patients and/or families are logged on the Complaint and Grievance form will be responded to, in writing, with findings and recommendations resulting from investigation within seven days of receipt of the form by the Chief Executive Officer.

The hospital Policy on Nursing Leadership Plan for Patient Care and Safety, dated 09/2020, "The policy of Kindred Behavioral Health hospitals is to ensure the following, The Leadership Nursing Plan for Patient care includes;
" Care that is directed toward the restoration of health, reaching the patient's full potential and improving each patient's quality of life.
MONITORING AND EVALUATIONS
1. To assure that patients receive appropriate nursing care and that consistent standards for the provisions of nursing care within the hospital are maintained, selected performance improvement indicators are used to monitor and evaluate the quality and appropriateness of nursing care provided throughout the hospital.

The hospital Policy on Administration/Personnel "This policy describes the process for registered nurses, other non-advanced practice healthcare professionals and non-licensed individuals employed by Kindred Medical staff physician or group medical practice. This policy does not apply to licensed independent practitioners or Allied Health Professionals (such as physician assistants and nurse practitioners). Credentialing requirements for LIPs and AHPs."

The hospital Event and Incident Reporting dated 07/2020 reflected, "The policy of Kindred Behavioral Healthcare is to ensure the following:
2. Hospital personnel are responsible for reporting in a timely and
efficient manner, patient and visitor events ...
11. Examples of events reportable to the Event Reporting System
a. Level 4 (Sentinel) Events
1. A "Sentinel" event is any death or major permanent loss of
function (sensory, motor, physiologic or intellectual) not related to the natural course of the patient's illness or underlying condition (i.e., acts of commission or omission) ...
ii. Level 4 includes, but not limited to, any "sentinel event" defined
by joint commission. Level 4 also refers to any unexpected
occurrence involving death or serious physical or psychological
injury, or risk thereof, not related to the natural course of the
patient's illness or underlying ...
Examples of Level 4 include:
d) allegations of physical or sexual abuse."
VIOLATION: NURSING CARE PLAN Tag No: A0396
Tthe hospital failed to ensure that one of one patients (Patient #2) had a current treatment plan to meet the patient's need.

Findings Include:

During Staff Interviews, Patient #2 had made advances to two female patients prior to engaging in a sexual relationship with an intellectually delayed patient who functioned at a developmental level of an early adolescent patient. Patient #2's care plan had not been updated to prevent any sexual acting out behavior.

Policy
The hospital Patient Rights Policy dated 06/2021 reflected, "The policy of the Hospital is as follows:
1. Prohibit abuse and described the procedures for preventing and responding to allegations of abuse, neglect or mistreatment of a patient.
2. Abuse includes allegations related to verbal, physical and /or sexual abuse/unwanted touching ...
3. The Hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident ...Failure to report immediately a suspected abuse incident or cooperate in the appropriate investigations can result in corrective action.
4. Abuse is considered a grievance and shall be logged on the Complaint and Grievance form as well as adherence to the expectations outlined in policy ...

Patient Abuse, Neglect, and/or Mistreatment is defined as any incident of
physical, sexual ...us reported by the patient or family; or is witnessed,
reported.

11. Sexual Abuse includes any sexual overture made to a patient ...regardless of the patient's willingness to be involved. This includes, but is not limited to ...all forms of sexual harassment ...or sexual molestation.

The hospital Level of Observation and Hand off Communication dated 12/2020 reflected, "It is the policy of the facility to provide levels of observation in compliance with physician orders and prescribed protocols."

The hospital Policy on Abuse 'Patient Rights and Civil Rights' dated 06/2021, "The policy of the Hospital is as follows:
1. Prohibit abuse and describe the procedures for preventing and responding to allegations of abuse.
2. To identify the hospital's position regarding employees who are suspected of patient abuse, neglect and/or exploitation. Abuse includes allegations related to verbal, physical and/or sexual abuse/unwanted touching as referenced in the definitions section.
3. The hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident to hospital leaders and applicable state agencies. Failure to report immediately a suspected abuse incident or cooperate in the appropriate investigation can result in corrective action.
4. Abuse is conserved a grievance and shall be logged on the Complaint and Grievance form as well as adherence to the expectations outlined in policy.
- WB-ML 04-001Patient Complaint/Grievance Process
Definitions
1. Dependent Adult Any person who is between the ages of 18 and 64 who has physical mental limitations which restrict his or her ability to carry out normal activities or to protect his or her rights including, but limited to, persons who have physical or developmental disabilities ...
2. Disabled Person Any person with a physical, cognitive or developmental disability that substantially impairs the persons ability to proved adequately for the person's care or protection and who is 18 years of age or older or under 18 years of age and who has had the disabilities of minority removed or cannot perform their own activities of daily living.
8. Neglect/Mistreatment is the failure to or refusal by any person having the care or custody of another (child, elder and adult) to exercise the degree of which a reasonable person in a like position would exercise. Neglect includes, but not limited to:
b. Action(s) by an employee contrary to prescribed treatment:
l. Failure to intervene or protect a patient from abuse/mistreatment by
another (patient)
Patient Abuse, Neglect, and/or Mistreatment is defined by any incident of physical, sexual or verbal abuse, neglect and/or mistreatment that is reported by the patient or family, or is witnessed, reported, or suspected by an employee.
11. Sexual Abuse includes any sexual overture made to a patient verbally, non-verbally, or physically, regardless of the patient's willingness to be involved. This include, but is not limited to, verbal, sexually explicit language, all forms of sexual harassment, sexual assault, or sexual molestation.
13. WB-PC 09-001 A Abuse Checklist (Sample): Checklist utilized to ensure patient safety and prompt completion of immediate actions for abuse allegations.




Suspected Abuse: First Responder/Supervisor Responsibilities
3. Notify the Director of Nursing (DON) Director of Nursing (CCO), Nursing Supervisor or clinical area Manager immediately in any instance or reported, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation. The Director Nursing (DON)/Director of Nursing (CCO, Nursing Supervisor or Clinical area Manager shall immediately notify Administrator on Call. Activate the Event Investigation Algorithm. Serious and Sentinel Event Investigation.
4. The first person to receive the report should document the allegation as an event report.
5. Contact the Divisional Director of Quality and Risk 24 hours/day, 7 days a week.
6. The Chief Executive Officer, Director of Quality Management, or their designee reviews federal and state reporting requirements.
Investigation Guidelines
1. Medical/Affiliate staff, the Chief Executive Officer will be consulted regarding the Medical Director's participation in the investigation.
3.) All investigations will be conducted under the guidance of the
Administrative staff who will, depending on the circumstance:
a. Seek information in a thorough, impartial, dignified, and confidential manner
b. Interview witnesses, including the charged individual(s) and obtained signed statements when appropriate
c. Assure that embarrassment of Patient(s) is avoided
d. Assess the patient's mental state and history in order to judge the accuracy of the patient's report.
f.) Investigate all other possible sources of information relating to the incident and/or the persons involved.
g. Make every effort to verify the information obtained
h. Cooperate fully with any legal investigation or proceedings
4. All investigations and resulting actin documentation will be
maintained in the Administrative office.
5. Any required reporting to licensing agencies (Board of Nurse Examiners) as mandated by law will be made by the Director of Nursing or the Director of Quality Management after consultation with the law department and Hospital Chief Executive Officer.
6. Release of all information to the proper authorities will be made as legally required and under the direction of the Chief Executive Officer.
7. The Chief Executive Officer will report to the Governing Board via appropriate channels, any instance of patient abuse, neglect, mistreatment and/or exploitation and the resultant corrective action.
8. Reports that are taken from patients and/or families are logged on the Complaint and Grievance form will be responded to, in writing, with findings and recommendations resulting from investigation within seven days of receipt of the form by the Chief Executive Officer.

The hospital Policy on Nursing Leadership Plan for Patient Care and Safety, dated 09/2020, "The policy of Kindred Behavioral Health hospitals is to ensure the following, The Leadership Nursing Plan for Patient care includes;
" Care that is directed toward the restoration of health, reaching the patient's full potential and improving each patient's quality of life.
MONITORING AND EVALUATIONS
1. To assure that patients receive appropriate nursing care and that consistent standards for the provisions of nursing care within the hospital are maintained, selected performance improvement indicators are used to monitor and evaluate the quality and appropriateness of nursing care provided throughout the hospital.

The hospital Policy on Intake and admitted d 02/2021 reflected, "The policy of Kindred Behavioral Health is to ensure the following;
1. The Behavioral Health Unit or Hospital shall have a written plan for assessment or clinical review of symptoms leading to the patient presenting for admission or to the referral."

The hospital Policy on Care Coordination and Discharge Planning dated 07/2021 reflected, "The Hospital adheres to the principles of integrated care across disciplinary practice. Each patient is assigned to a treatment team comprised of a psychiatrist, a registered nurse, and a therapist. A Board-certified (or eligible) psychiatrist will be available for supervision to the treatment team and participates directly in the treatment team meetings. Consultants are called as necessary. The objective of assessment is comprehensive, coordinated evaluation with a minimum of repetitive examination or query in order to maintain patient dignity and reduces stress. Consequently, each discipline's scope of assessment is formalized, delineated and conceptualized as a critical part of the total picture, aimed at representing the patient's needs and strengths. The comprehensive evaluation is then translated into a formal treatment plan with maximal involvement of the patient significant others, and other providers as indicated. The plan includes behavioral goals, strategies and timelines, as applicable, and given the short term, stabilization objective of the unit, serves- in effect - as the discharge plan. Emphasis will be placed on 'discharge readiness' so that patient family, and caregivers can all assist in the projection of the discharge date and plan."

The hospital Policy on Administration/Personnel "This policy describes the process for registered nurses, other non-advanced practice healthcare professionals and non-licensed individuals employed by Kindred Medical staff physician or group medical practice. This policy does not apply to licensed independent practitioners or Allied Health Professionals (such as physician assistants and nurse practitioners). Credentialing requirements for LIPs and AHPs."

The hospital Event and Incident Reporting dated 07/2020 reflected, "The policy of Kindred Behavioral Healthcare is to ensure the following:
2. Hospital personnel are responsible for reporting in a timely and
efficient manner, patient and visitor events ...
11. Examples of events reportable to the Event Reporting System
a. Level 4 (Sentinel) Events
1. A "Sentinel" event is any death or major permanent loss of
function (sensory, motor, physiologic or intellectual) not related to the natural course of the patient's illness or underlying condition (i.e., acts of commission or omission) ...
ii. Level 4 includes, but not limited to, any "sentinel event" defined
by joint commission. Level 4 also refers to any unexpected
occurrence involving death or serious physical or psychological
injury, or risk thereof, not related to the natural course of the
patient's illness or underlying ...
Examples of Level 4 include:
d) allegations of physical or sexual abuse."