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The Hospital was out of compliance for the Condition of Participation Patient Rights.

Based on a review of medical records, Hospital policies, and interviews, the Hospital failed to follow their hospital-wide grievance and complaint process for 1 Patient (#3) out of a total sample of 10 patients in response to a patient grievance related to a medication incident. Patient #3 received extra doses of lithium (a mood stabilizer medication used to treat and prevent episodes of mania and depression in people with bipolar disorder) from 12/10/24-12/15/24; subsequently Patient #3 developed symptoms of lithium toxicity and was transferred to an outside hospital for treatment.

Cross Reference:

482.13 (a)(2) Patient Rights: Response to Grievances (0119)

The Hospital was out of compliance for the Condition of Participation for Nursing Services.

Based on a review of security footage, medical records, Hospital Policies, and staff interviews, the Hospital failed to ensure staff followed established policies and procedures in managing Nurse #1's conduct.

On 1/29/25, multiple staff observed Nurse #1 acting unprofessionally and inappropriately during patient care, including telling Patient #4, "You deserved to be hit in the face [by another patient]," during a restraint application. Despite witnessing Nurse #1's inappropriate behavior, staff failed to document the incident, in violation of policy. As a result, the Hospital documented a Final Written Warning to Nurse #1; However, Nurse #1 returned to work before meeting with leadership to review and acknowledge the corrective actions, in violation of policy.

On 2/11/25, Nurse #1 was again involved in an incident where staff and patients witnessed him using excessive force and unapproved techniques during a physical altercation with Patient #1. Staff reportedly asked him multiple times to leave the elevator, but he was noncompliant. Nurse #1 was suspended immediately and terminated on 2/17/25, following an internal investigation.

Cross Reference: Nursing Services: Supervision of Contract Staff (Tag 398).

Based on a review of medical records, Hospital policies, and interviews, the Hospital failed to follow their hospital-wide grievance and complaint process for 1 Patient (#3) out of a total sample of 10 patients in response to a patient grievance related to a medication incident. Patient #3 received extra doses of lithium (a mood stabilizer medication used to treat and prevent episodes of mania and depression in people with bipolar disorder) from 12/10/24-12/15/24; subsequently Patient #3 developed symptoms of lithium toxicity and was transferred to an outside hospital for treatment.

Findings included:

Review of Hospital Policy titled ' Complaint Process ' , approved 10/24, indicated:

-The purpose is to establish a mechanism by which to impartially receive, investigate, review, and process Patient Complaints, Patient Grievance, and/or any issues regarding Human Rights.

- Any person may make a complaint to the Person in Charge regarding an incident or condition involving a client which he or she determines to be dangerous, illegal, or inhumane.

- Unless a complaint is resolved, the Responsible Person shall undertake or within two days of the complaint, assign the matter for fact finding, which shall be completed within ten days of assignment.

- The written decision shall contain findings of fact and conclusions, and any actions to be taken.

-Responsibilities of the Responsible Person: issue a decision accepting the findings of fact and recommended conclusions, identifying corrective actions to be taken, if any, and designating who is responsible for carrying out such actions.

Patient #3 was admitted to the Hospital in December 2024 with bipolar disorder, anxiety and active mood instability.

Review of Patient #3 ' s medical record indicated that on 12/5/24, Patient #3 was started on lithium 450 milligrams (mg) Extended Release (ER) by mouth (PO) twice daily (BID). Review of Behavioral Health Inpatient Provider Progress Note dated 12/9/24 indicated that Patient #3 continued to experience emotional distress with ongoing symptoms of depression and anxiety with poor sleep, low appetite, and significant difficulty focusing and concentrating. Nurse Practitioner (NP) #1 documented a planned medication adjustment to increase Patient #3 ' s lithium to 1200 mg PO at bedtime. An order for lithium 1200 mg PO at bedtime was entered on 12/9/24 at 4:02 P.M. with a start date of 12/10/24. The order was verified by Pharmacist #1 on 12/10/24 at 8:47 A.M. Further review of Patient #3 ' s medical record failed to indicate the Patient ' s order for lithium 450 mg ER twice daily was discontinued after the new order was placed. Patient #3 received the following medications:

12/10/24: lithium 450 mg ER at 9:25 A.M. and 8:36 P.M., and lithium 1200 mg at 8:36 P.M.

12/11/24: lithium 450 mg ER at 9:31 A.M. and 8:48 P.M., and lithium 1200 mg at 8:49 P.M.

12/12/24: lithium 450 mg ER at 10:04 A.M. and 8:48 P.M., and lithium 1200 mg at 8:48 P.M.

12/13/24: lithium 450 mg ER at 9:09 A.M. and 8:19 P.M. and lithium 1200 mg at 8:19 P.M.

12/14/24: lithium 450 mg ER at 9:43 A.M. and 8:17 P.M. and lithium 1200 mg at 8:17 P.M.

12/15/24: lithium 450 mg PO ER at 9:34 A.M. and 8:56 P.M. and lithium 1200 mg at 8:56 P.M.

Review of Behavioral Health Provider Progress Note dated 12/13/24 indicated Patient #3 reported some physical discomfort, including twitching and shakiness, which Patient #3 attributed to lithium. Review of Behavioral Health Provider Progress Note dated 12/16/24 indicated Patient #3 reported persistent muscle spasms, particularly when attempting to sleep and that the spasms involved contraction of Patient #3 ' s entire leg or arm. Review of Behavioral Health Provider Progress Note dated 12/17/24 indicated Patient #3 ' s lithium level was critically high at 2.5 (normal levels range from 0.6-1.2.) and Patient #3 reported blurred vision and muscle twitching. Due to concerns of potential lithium toxicity, Patient #3 was sent to an outside hospital Emergency Department (ED) for further evaluation and treatment. On 12/18/24, Patient #3 was re-admitted to the Hospital after being treated in the ED for the elevated lithium level. Review of Behavioral Health Clinic Provider Progress Note dated 12/23/24 indicated Patient #3 reported an incident involving lithium, which led to an overdose and subsequent visit to the ED.

Review of the Hospital ' s investigation indicated Patient #3 contacted the Hospital on 4/29/25 to report concerns regarding receiving a double dosage of his/her lithium. Review of the Hospital ' s response to Patient #3, dated 5/5/25, indicated that Patient #3 ' s complaint of being given a double dose of lithium for several days was substantiated, and that because of this error, the Hospital had made changes to the electronic medical record (EMR). The Hospital ' s response indicated the pharmacist had added ' flags ' to lithium as orders as well as to lithium lab results that instruct the viewer to double check and verify the provider ' s orders.

During an interview on 7/24/25 at 9:31 A.M., Pharmacist #1 said she verified the new order for lithium 1200 mg for Patient #3. She said after a review of the grievance related to the toxicity event, she requested that a ' flag ' be added in patient ' s charts to document the lithium level prior to administration of the medication. She said she believed this new process had been implemented.

During an interview on 7/24/25 at 12:56 P.M., the Chief Nursing Officer (CNO) said there were hard stops added to the Electronic Medical Record (EMR) and further said no flags or alerts had been added to the lithium ordering and administration process after this event.

During an interview on 7/24/25 at 12:22 P.M., the Chief Executive Officer (CEO) said the error laid with pharmacy but further said that ultimately providers are responsible for what they order. The CEO said a Root Cause Analysis (RCA) was not done for this event as it was treated strictly as a pharmacy error.

During interviews on 7/24/25 at 12:45 P.M. and throughout the survey, the Director of Quality said she believed there was no formal investigation after the medication event in which Patient #3 received extra doses of lithium. She said that after the Patient filed a grievance related to the event, the Hospital investigated and determined corrective actions to be implemented.

During an interview on 7/31/25 at 4:55 P.M., Nurse Practitioner (NP) #1 said she planned to increase Patient #3 ' s lithium dose due to his/her worsening depression to 1200 mg at bedtime. NP #1 said the lithium 450 mg twice daily should have been discontinued and as a result Patient #3 ended up receiving extra doses for a few days. NP #1 said she missed the error, and the pharmacy review and nurses also missed the error. NP #1 said there were discussions after the event regarding signs and symptoms of lithium toxicity and one of the items discussed was adding a flag alert to the electronic medical record to alert staff to check lithium levels, but she was unsure if this had been implemented.

The Hospital was unable to provide the surveyor with documentation that identified corrective actions were implemented to prevent a like occurrence from happening.

Based on a review of security footage, medical records, Hospital Policies, and staff interviews, the Hospital failed to ensure staff followed established policies and procedures in managing Nurse #1's conduct.

On 1/29/25, multiple staff observed Nurse #1 acting unprofessionally and inappropriately during patient care, including telling Patient #4, "You deserved to be hit in the face [by another patient]," during a restraint application. Despite witnessing Nurse #1's inappropriate behavior, staff failed to document the incident per the incident reporting policy. As a result, the Hospital issued a Final Written Warning to Nurse #1. However, Nurse #1 returned to work before meeting with leadership to review and acknowledge the corrective action, in violation of policy.

On 2/11/25, Nurse #1 was again involved in an incident where staff and patients witnessed him using excessive force and unapproved techniques during a physical altercation with Patient #1. Staff reportedly asked him multiple times to leave the elevator, but he was noncompliant. Nurse #1 was suspended immediately and terminated on 2/17/25, following an internal investigation.

Findings include:

Review of the Hospital's Code of Conduct Policy, dated May 2025, indicated the Hospital was committed to ethical conduct and expects staff to uphold professional behavior. The Policy guides staff to conduct to ensure ethical, professional care.

Review of the Hospital's Incident Report Protocols and Patient Safety Events policy, dated May 2025, indicated staff must document safety incidents via the reporting system and notify their supervisor. The Safety committee would use the details of collected and analyzed incident reports to reduce and prevent unsafe acts, conditions, and practices.

A review of the Hospital's Discipline Policy, dated July 2025, indicated the Hospital promoted a culture where employees and supervisors engage in constructive conversations regarding job performance or work-related conduct with a shared objective of improving unsatisfactory job performance or correcting unacceptable work-related behaviors. Employees would be asked to sign copies of written disciplinary actions and/or coaching forms to attest to their receipt and understanding of the correction action(s) outlines in the documents. If an employee refuses to sign, make a note about their refusal to sign should be made by the supervisor. Human Resource (HR) Leaders would be trained on the Policy and HR leaders would be responsible for training their CEO/leadership teams at Facility leadership team meetings.

A review of the Department of Public Health's Health Care Reporting System (HCFRS) included a complaint alleging that on 2/11/25, Nurse #1 was involved in a physical altercation with Patient #1. Staff repeatedly asked Nurse #1 to exit the elevator, but he refused, and had to be physically removed from the elevator and separated from the patient.

A review of the Hospital's Internal Investigations substantiated that on 2/11/25, multiple staff and patients witnessed Nurse #1 use excessive force and unapproved techniques responding to a physical altercation with Patient #1. Nurse #1 was immediately suspended and terminated on 2/17/25, after the Hospital completed an internal investigation.

A Review of Nurse #1's personnel file included a Final Written Warning as a result of acting in an unprofessional manner and engaging in inappropriate conduct, when on 1/29/25, when several staff members witnessed him tell Patient #4 during a restraint application, "You deserved to be hit in the face [by another patient]."

There was no documentation to support staff followed the Hospital's Incident Report Protocols and Patient Safety Events policy to document multiple staff witnessing Nurse #1 engaging in inappropriate conduct while providing patient care on 1/29/25.

During an interview on 7/24/25 at 2:24 P.M., the Director of Quality/Risk Management said the there was no documentation to support staff completed a safety event/incident report involving Nurse #1 on 1/29/25. The Director said the event type on 1/29/25 would require staff to document the incident via the internal reporting system which is how the Hospital's Safety committee would use the details of collected and analyzed incident reports to reduce and prevent unsafe acts, conditions, and practices.

Review of Nurse #1's Timesheet Report, indicated Nurse #1 returned to work [on 1/31/25] before reviewing the Final Written Warning with Hospital leadership and attest to the receipt and understanding of the corrective action (appropriate conduct with patient at all times) following the 1/29/25 event.

There was no documentation to support staff followed the Hospital's Discipline Policy to have Nurse #1 review and attest to receiving the Final Written disciplinary action and understanding of the correction action(s) related to the 1/29/25 event before returning to work.

During an interview on 7/23/25 at 10:50 A.M., the Chief Nursing Officer (CNO) said she witnessed the event on 1/29/25 and participated in the investigation and development of Nurse #1's Final Written Warning; however, she did not meet with Nurse #1 before his return to work.

During an interview on 7/24/25 at 10:05 A.M., the Director of People Services (Human Resources) said he witnessed the event on 1/29/25 and he participated in the investigation and development of Nurse #1's Final Written Warning; however, Nurse #1 returned to work without meeting with Hospital leadership, in accordance with Policy.