HospitalInspections.org

Based on observation, interview, and record review, the facility failed to protect the rights of 2 of 2 patients (Patient #1 and Patient #4).

Patient #1.

The facility failed to provide care in a safe setting through the review and analysis of a fall by Patient #1, a 67-year-old involuntary male patient, weighing 97 lbs. and described as "extremely cachectic" and in need of total care. He presented for admission with a history of three cerebrovascular accidents, stroke, traumatic brain injury, and transient ischemic attack. His presentation on admission was of such concern that he was transferred out by 911 for medical clearance (altered mental status, left ear bloody discharge, suspicion of sepsis), and then returned to the facility. On the day of the fall, he had been in the day room in a recliner for twelve hours. He was "found on the floor bleeding." He sustained a laceration over his left eye and skin tear on his left shoulder after he "fell from a recliner" during change of shift report. He was transferred by 911 to an emergency room to evaluate his injuries. He was never returned to the facility. The facility neither investigated the specifics of the fall to determine the presence or extent of any safety issues.

See A0144 - Patient Rights: Care in Safe Setting.


Patient #4.

The facility failed to protect the rights of Patient #4, a 68-year-old involuntary female patient, subject to a court order to administer psychoactive medication, who was "incapable of making rational decisions to maintain safety of herself or others" This negligence was evidenced by the facility's failure to ensure Patient #4 had a written discharge order prior to being released from the facility, as well as discharge arrangements completed by a discharge planner in collaboration with the receiving facility. Additionally, Patient #4, wearing only blue disposable scrubs, was transported to a homeless shelter in the facility's van that was driven by a facility employee. The van driver removed the patient (whom he described as "rambling") from a transportation wheelchair, lowed her onto the sidewalk, handed her a discharge packet, and drove away.

See A0145 - Patient Rights: Free from Abuse/Harassment for details.

Based on observation, record review, and interview, the facility failed to provide care in a safe setting for 1 of 1 patients (Patient #1).
This negligence was evidenced by the facility's failure to ensure a review and analysis was completed of a fall from a recliner by Patient 1 resulting in a 911 transfer to a medical facility to evaluate and treat a head injury sustained during the fall.

Findings were:

Patient #1.
Review of the Face Sheet:
Admission 2/12/2025.
Discharge 2/17/2025.

Intake referral form by Staff DD (RN - Intake Department) dated 2/12/2025 at 8:22 PM showed: Patient depressed, threatening to harm self with a knife, angry, screams all day and night. History of three cerebrovascular accidents - last in December 2024 with major brain bleed, emphysema, transient ischemic accidents, traumatic brain injury in 2019 from motor vehicle accident, hypertension, hyperlipidemia. Small skin tears in various places. Needs assistance with bathroom, shower, dressing. Needs assistance sitting to stand and ambulation. Complete assistance. Bladder and bowel incontinence.
Exclusion Criteria: no items checked.
Administrator Accepted: Staff A (CEO)
Accepting Physician: Staff F (Attending MD)
Involuntary Admit: Emergency Detention Warrant.

Review of legal documents showed:
Application for Emergency Detention, Certificate of Preliminary Medical Examination, Order of Emergency Apprehension and Detention (dated 2/12/2025), and Emergency Apprehension and Detention Warrant executed 2/12/2025 at 10:09 PM. "The patient is depressed, agitated, aggressive towards others, disorganized, refusing care, is likely to cause serious harm self and others."

Review of the Preadmission Evaluation & Medical Clearance Screening by Staff AA (MD - telemedicine) dated 2/12/2025 at 6:09 PM showed: 67-year-old male involuntarily admitted with depression and threats to harm himself with a knife.
Past medical history: chronic obstructive pulmonary disease, emphysema, cerebrovascular accident, stroke, traumatic brain injury, transient ischemic attack.

Review of Physician's Orders by Staff F (Attending MD) dated 2/12/2025 at 9:00 PM showed: Fall Precautions and Bleeding Precautions.

Skin Assessment by dated 2/12/2025 (not timed and author not identified) showed the following conditions were present on admission: "left hip open wound," "upper left arm open skin tears," "left ear skin tear," "right forearm generalized open skin tears and bruises," "old bruises all over his left hand," "right hand old bruises," and "chest old bruises."

Review of Admit Nursing Assessment by Staff Z (RN) dated 2/13/2025 at 3:56 AM showed, a 67-year-old male, weighing 97 lbs. The following items were checked: unclean, malodorous, oriented to person only, restless, agitated, threatening. Unable to walk. History of pneumonia. Incontinent. Total assist. Needs wheelchair.

Review of the Edmonson Psychiatric Fall Risk Assessment on 2/13/2025 at 2:43 AM by Staff Z (RN) showed an assessment score of 111.
[Edmonson Psychiatric Fall Risk Assessment - a tool used to identify and assess fall risks in psychiatric patients, considering factors like medication use, diagnosis, ambulation, nutrition, and sleep patterns.]

Review of Plan of Care, developed 2/13/2025, showed problem #2 was "a risk for falls related to orthostatic changes, cognitive deficit, motor deficit as evidenced by a fall risk score 111, limited mobility, shuffling gait or unsteady gait, poor balance or motor function." Interventions were: "Keep pathways clear ... assist with ADLs [Activities of Daily Living] ... implement walk program and assess footwear safety."

Review of Face-to-Face Visit e-signed on 2/13/2025 at 3:08 PM by Staff BB (PA-C) and on 2/23/2025 at 10:03 PM by Staff CC (MD) showed: "extremely cachectic [a state of wasting or emaciation]," "cursing and uncooperative," "attempted to hit provider, has skin tears all over forearm, poor hygiene, encrusted bloody drainage from left ear," "refusing to eat since yesterday, scab over skin where PEG tube [percutaneous endoscopic gastrostomy - feeding tube] was removed. Staff extremely concerned about change in mentation. No intake since yesterday." "Patient sent out by 911 for altered mental status, left ear bloody discharge, suspicion of sepsis [a life-threatening medical emergency caused by the body's extreme response to an infection]."

Review of Physician Orders on 2/13/2025 at 10:41 AM showed: "Transfer to Memorial Hermann Hospital for change in mental status."

Review of Face-to-Face Visit e-signed on 2/14/2025 at 7:42 PM by Staff BB (PA-C) and on 2/23/2025 at 10:03 PM by Staff CC (MD) showed: Patient returned from ER [emergency room]. Oral antibiotics for possible urinary tract infection. Uncooperative, combative, refusing to eat.

Review of RN Daily Shift Assessment - 7AM-7PM by Staff G (RN) dated 2/17/2025 at 9:28 AM showed: Patient ambulates with wheelchair. Total care. Requires assistance with feeding. Combative. In dayroom sitting in recliner. Patient is high fall risk.

Review of Skin Assessment by dated 2/17/2025 (not timed and author not identified) showed "left lower extremity open [wound] not present on admission," "left eye laceration [were] not present on admission," and "left shoulder laceration not present on admission."

Review of Progress Note by Staff G (RN) dated 2/17/2025 at 7:48 PM showed: "Around 7:23 PM during nurse's report, Mental Health Technician interrupted report states 'Emergency patient fell from recliner and is bleeding from the head.' Nursing staff find [sic] patient on the floor bleeding, upon assessment staff note[d]: patient has a cut on left eye lid and skin tear on left shoulder. ... 911 called ... patent taken to Memorial Hermann."

Review of the Observation Check Sheet / Graphic Flowsheet with entries by various MHTs for Patient #1 showed he was sitting in the day room in a recliner on 2/17/2025 from 6:45 PM until 7:30 PM, the time the fall occurred. Further analysis of the form showed he was in the dayroom from 7:00 AM until the fall except for being in his room at 1:00 PM and entries for meals. There were no aggressive behaviors documented.

Review of Physician Orders on 2/17/2025 at 7:31 PM showed: "Transfer patient to Memorial Hermann ER for fall. Bleeding from head."

Review of Progress Note by Staff S (RN) dated 2/18/2025 at 3:04 AM showed: Patient at Memorial Hermann Katy - Scan of the head showed brain bleed."

In an interview with Staff B (DON) on 3/19/2025 at 2:15 PM she stated she did not know the final outcome of Patient #1 following the 911 transfer to a medical facility following the fall.


Additional information.

In an interview with Staff A (CEO), Staff B (DON), Staff C (RM), and Staff I (Intake Director) on 03/28/2025 at 10:15 AM, they stated that an investigation into Patient #1's fall was not conducted.

Based on observation, record review, and interview, the facility failed to provide care for 1 of 1 patients (Patient #4) that was free of abuse.
This negligence was evidenced by the facility's failure to ensure Patient #4,
a) Had a written discharge order prior to being released from the facility;
b) Had prior discharge arrangements completed by the discharge planner in collaboration with the receiving facility;
c) Was clothed in garments other than disposable scrubs when she was transported in the facility's van to a shelter; and
d) Was left in a safe environment when removed from a wheelchair and lowered to a sidewalk outside of a shelter by the van driver, even though she was a significant fall risk.

Findings were:

First admission of Patient #4.

Review of the Face Sheet showed:
Admission 2/19/2025.
Discharge 2/26/2025.

Review of the legal documents showed:
" Emergency Apprehension and Warrant executed 2/19/2025.
" Certificate of Preliminary Medical Examination by Staff M (MD) dated 2/18/2025 showed psychosis, delusions, somatic preoccupation, paranoia, aggression, deterioration of her mental and physical state.
" Order of Protective Custody and Notice of Hearing dated 2/20/2025. Hearing date set for 2/28/2025.

Review of the Preadmission Evaluation & Medical Clearance Screening by Staff O (MD) dated 2/19/2025 at 2:24 AM showed: 68-year-old female with paranoia and delusions ("other people controlling her, trying to kill her, and defecating / urinating through her vagina"). "Unkept, disheveled with dried feces and urine on clothing."

Review of Physician's Preadmission Examination Orders by Staff O (MD) dated 2/19/2025 at 2:24 AM showed violent / homicide precautions, elopement precautions.

Review of Physician Orders by Staff F (Attending MD) dated 2/19/2025 at 11:44 AM showed PRN Haldol, PRN Zydis, Risperdal BID, and Depakote BID. Review of the Medication Administration showed routine and PRN medications were never given.
[Haldol, Zydis, and Risperdal - antipsychotic medications. Depakote - mood stabilizer]

Review of the Admit Nursing Assessment by Staff N (RN) signed 2/19/2025 at 6:15 AM showed: "Agitation, verbal and physical aggression, paranoid, delusional, refusal of medications."

Review of Edmonson Psychiatric Fall Risk Assessment by Staff S (RN) dated 2/19/2025 at 5:44 PM showed a "FALL RISK SCORE of 142. Fall risk = score of 90 or greater. Fall precautions."
[Edmonson Psychiatric Fall Risk Assessment - a tool used to identify and assess fall risks in psychiatric patients, considering factors like medication use, diagnosis, ambulation, nutrition, and sleep patterns.]

Review of six Face-to-Face Visits by Staff Q (NP), co-signed by Staff F (Attending Physician), showed the following information was documented verbatim in each of the six visits dated 2/20, 2/21, 2/22, 2/23, 2/24, and 2/25/2025: "Assessment: Schizoaffective disorder, bipolar type, severe.
Justification for continued stay: Does not appear capable of making rational decisions to maintain safety of self or others. Not at baseline. Inpatient psychiatric level of care medically necessary. Noncompliant with medications."
Further review of the six Face-to-Face Visits dated 2/20, 2/21, 2/22, 2/23, 2/24, and 2/25/2025 showed the following variances in the documentation.
1) 2/20/2025, not timed (e-signed 2/21/2025 at 5:00 PM) - "Agitation, physically and verbally aggressive, loud. Insomnia. Combative with care. Paranoia, delusions (people able to change appearance), psychosis. Poor judgment. Unsteady gait with chronic leg pain."
2) 2/21/2025, not timed (e-signed 2/22/2025 at 5:56 PM) - Paranoid, delusional (people change appearance with cell phones). Verbal and physical aggression, combative with care. Ambulates with wheelchair. Poor judgment.
3) 2/22/2025 at 6:10 PM - "Refusing psychotropic meds."
4) 2/23/2025 at 3:44 PM - "Agitated, paranoid, delusional (being poisoned), loud, yelling profanities, combative with care, not responding to assessment questions. Poor judgment."
5) 2/24/2025 at 5:20 PM - "Refusing psychotropic meds. Angry, demanding, yelling, cursing and foul language toward staff. Delusional (someone stole her purse). Unprovoked physical aggressive. Combative with care. Per nurses: screaming, disruptive to milieu during lunch. Poor judgment." [Documentation of an emergency medication immediately follows.]
6) 2/25/2025, not dated (e-signed 2/27/2025 at 1:02 PM) - "Refusing psychotropic meds. Profane language. Yelling. Delusional. Paranoid. Ambulates with wheelchair. Poor judgment."

Emergency medication documentation by Staff U (RN) dated 2/24/2025 at 1:23 PM - 2:12 PM showed: Patient screaming, disrupting milieu, disrupting milieu, "got everyone riled up," attempted to throw food at staff, noncompliant with medications. Haldol 5mg, Benadryl 50mg, and Ativan 2mg given intramuscularly. (This was also documented in the Physician Orders and the Medication Administration Record.)
[Haldol - antipsychotic. Benadryl - antihistamine given to prevent side effects of the antipsychotic. Ativan - anti-anxiety medication. These three medications are often given in combination.]

Record review of Petition for Order to Administer Psychoactive Medication signed by Staff F (Attending Physician) dated 2/24/2025 showed: "Patient is subject to an order dated 2/28/2025 for court-ordered in-patient mental health services. Diagnosis: Schizoaffective disorder, bipolar type, severe. Patient is paranoid suspicious, guarded, saying people are trying to poison her. Yells, screams, curses at staff and peers irritable, anxious, refuses mediation."

In an interview with Staff E (Court Liaison) on 3/13/2025 at 5:02 PM, she stated there was no force medication hearing for Patient #4, adding that the patient was discharged before this hearing could be completed.

Review of Edmonson Psychiatric Fall Risk Assessment by Staff T (RN) dated 2/25/2025 at 6:12 PM showed a fall risk score of 94. Fall risk = score of 90 or greater.
[Edmonson Psychiatric Fall Risk Assessment - a tool used to identify and assess fall risks in psychiatric patients, considering factors like medication use, diagnosis, ambulation, nutrition, and sleep patterns.]

Review of Physician Orders by Staff F (Attending MD) signed 2/27/2025 at 7:50 AM showed: "Discharge patient, routine, fair condition, with a guarded prognosis to Star of Hope Shelter."
[Star of Hope Mission - homeless shelter for men, women, and children.]

Review of Discharge Summary by Staff F (Attending MD) on 2/27/2025 at 11:16 PM showed a discharge date of 2/26/2025.
"Discharge diagnosis: Schizoaffective disorder, bipolar type, severe.
Refused all psychiatric medications during her stay.
Disheveled / soiled clothes.
Uncooperative, agitated, refused to answer questions.
Verbally aggressive. Loud.
Disorganized thoughts. Irrational / intrusive thoughts.
Insight / judgment fair. Motor activity slowed, unsteady / abnormal gait, needs assistive device."
Discharge Criteria [that was met]: "Improved social functioning; medication compliance; decreased depression, mania, anxiety, and psychosis. Improved mood and affect. Improved motivation for treatment. Improved coping skills.
Patient will discharge to shelter. Patient would like to schedule her own aftercare appoints. Patient was discharged as she has been refusing her psychiatric medications during stay."
[Schizoaffective disorder, bipolar type - a mental health condition characterized by symptoms of both schizophrenia and bipolar disorder, specifically involving periods of mania or hypomania alongside depressive episodes, along with psychotic symptoms like hallucinations and delusions.]

In an interview with Staff F (Attending MD) on 3/14/2025 at 11:00 AM concerning Patient #4,
1) He stated the patient would "scream and yell at me," never took oral medications, ambulated in a wheelchair because of her risk of fall, and was still on an involuntary status when discharged.
2) He said he filed for court-ordered medications, but the patient was discharged before this was completed. He reviewed the discharge criteria he had checked in the Discharge Summary. He then said that two of the checked criteria were wrong: "medication compliance" and "improved motivation for treatment," adding, "What does it matter?"
The documentation in the Face-to-Face Visit from the previous day (2/25/2025) was reviewed with Staff F. Items of particular interest included: "Does not appear capable of making rational decisions to maintain safety of self or others. Not at baseline. Inpatient psychiatric level of care medically necessary. Noncompliant with medications."
After reviewing these items, he stated, "She was not a danger to herself or others. She was disturbing the milieu. I let her go."

Review of Physician Orders by Staff F (Attending MD) signed 2/27/2025 at 7:50 AM showed: "Discharge patient, routine, fair condition, with a guarded prognosis to Star of Hope Shelter."

Review of Transition Plan and Continuity of Care Documentation by Staff D (Discharge Planner) on 2/25/2025 at 4:24 PM showed:
"Method of Transmittal: Hard copy to transport personnel.
Enclosed: transition record, discharge medication, crisis safety plan.
Discharge date: 2/26/2025 at 10:00 AM.
Scheduled discharge. Discharge to shelter.
Mode of transportation at discharge: Facility transportation."

In an interview with Staff G (RN) on 3/13/2025 at 1:12 PM, she stated the patient was discharged to The Star of Hope, adding that the patient left the unit between 7:30 and 8:00 AM.

In an interview with Staff K (RN Supervisor) on 3/13/2025 at 1:12 PM, she stated she took the Verbal Order from Staff F (Attending MD) for discharge of Patient #4 on 2/26/2025 at 11:37 AM, adding she called the physician for a discharge order because the patient had left the hospital and "There was no order for discharge in the chart."

Review of the Transition Plan and Continuity of Care Documentation by Staff D (Discharge Planner) on 2/25/2025 (not timed) showed that a hard copy was provided to Transport Personnel. Patient #4 was discharged to Star of Hope Shelter with three documents: Transition Record, Discharge Medication, and Crisis Safety Plan. The patient was to follow up with Staff W (MD) for medications. No appointment had been made for follow-up with that physician. Further review of the document showed that Staff D (Discharge Planner) witnessed the patient's signature of the Transition Plan and Continuity of Care form and e-signed the form on 2/25/2025 at 4:24 PM.

In an interview with Staff L (Transportation Driver) on 3/13/2025 at 3:09 PM, he stated that when Patient #4 was discharged on 2/26/2025 to the Star of Hope, she was in blue hospital scrubs. He stated he was given a "transportation sheet" that identified the destination of the patient. The patient was "rambling, talking, but not really saying anything. Cursing and used 'the N-word.'" Staff L was observed to be an African American male. He also stated he removed the patient from the wheelchair, lowered her to a "raised curb near grass," and left her there, adding he did not speak to any staff member inside the Star of Hope. He did speak to a security officer that drove by while he was unloading the patient. He concluded by saying the patient was "rambling" and refused to sign the transportation paperwork.

In an interview with staff at The Star of Hope (Staff P) on 3/17/2025 at 1:55 PM, she stated:
1) The doors open for women at 7:00 AM and men at 7:30 AM.
2) Admission is dependent on availability.
3) Individuals must be able to do everything for themselves.
4) Facilities need to get clearance with The Star of Hope before a patient is sent to them.
5) The driver of the transport van got Patient #4 out of the van in a wheelchair and placed her on the ground in front of the building.
6) She ran outside and told the driver of the van, "You cannot do that."
7) The driver of the van drove away with the patient sitting on the sidewalk in blue scrubs.

In an interview with Staff B (DON) on 3/14/2025 at 10:10 AM, she stated patients may be issued blue disposable scrubs. Observation of the scrubs showed Fluid-Resistant Multilayer Spun-bond Disposable Scrubs, blue.

In an interview with Staff A (CEO) on 3/13/2025 at 5:18 PM, he stated a patient should not be discharged in disposable scrubs. He also stated the facility has donated clothes available for patients.

In an interview with Staff C (RM) on 3/14/2025 at 9:00 AM, she stated that they have a "boutique" that has clothing available to patients in need, adding that the facility can purchase items if needed. The "boutique" was observed on 3/19/2025 at 2:00 PM. Numerous items of clothing were hanging on racks - both male and female - and a shelf housed dozens of shoes.

In an interview with Staff C (RM) on 3/13/2025 at 3:56 PM, she stated that during the morning huddle on 2/27, the team questioned why Patient #4 had been discharged on 2/26/2025 only to be readmitted back into the hospital.


Readmission of Patient #4 on 2/26/2025.

In an interview with Staff I (Intake Director) on 3/13/2025 at 12:20 PM, she stated Patient #4 was dropped off at the hospital by a taxi on 2/26/2025 at 2:25 PM. She also stated she saw the patient sitting outside in blue hospital scrubs, having been deposited by a taxi driver who offered no information to hospital staff.

In an interview with Staff V (RN) on 3/13/2025 at 3:15 PM, she stated the patient was readmitted into the hospital on 2/26/2025 wearing the same blue disposal scrubs that she had been discharged in just hours earlier. She also stated she did not believe the patient should have been discharged.

Review of Pre-Admission Patient Screening showed Patient #4 was admitted into Ocean's Hospital of Katy on 2/26/2025. (Time not documented.) The referring facility was identified as Oceans Katy.

Review of the admission screening by Staff X (Admission Screener) on 2/26/2025 at 2:25 PM showed: Patient #4 was a homeless female that arrived from a shelter to the hospital with increased agitation and verbal/physical aggression toward staff. She was "talking to a person not there ... responding to internal stimuli, increased mood swings. Going from labile to verbally/physically aggressive in a matter of a few minutes ... aggressive to staff." History of traumatic brain injury. Staff X also documented:
a) "Patient not able to do activities of daily living without assistance. Has physical disability - uses a walker."
b) Patient needed "assistance with ambulation and bed mobility."
c) "Bladder and bowel incontinence."
d) "Patient gravely disabled requiring intensive, comprehensive, multi-modalities of treatment to include 24-hour a day medical supervision and coordination because of mental and emotional decompensation."
e) "Chronic and continuous self-destructive behaviors."
f) "Command hallucinations directing to harm self or others with a risk of acting on this."
g) "Cognitive impairment."
h) "Hallucinations, delusions, mania."
i) "Dementing disorder that requires evaluation and treatment of a psychiatric co-morbidity."
j) "Emergency detention warrant was filed."

Review of the Inpatient Psychiatric Evaluation by Staff F (Attending Physician) dated 2/27/2025, e-signed at 1:03 PM showed a "68-year-old female with a history of schizoaffective disorder, bipolar type. "Upon evaluation on 2/27/2025, patient ... lying in bed ... yelling and screaming ... uses wheelchair to ambulate ... uncooperative ... Patient presents with paranoid delusions and psychosis. Patient was discharged to a shelter on 2/26/2025 and brought back due to continued psychosis ... continues to refuse psychiatric medications." Disorganized thoughts. Irrational / intrusive thoughts. Delusions. Insight and judgment poor. Unsteady / abnormal gait.
Does not appear capable of making rational decisions to maintain safety or safety of others."

Record review of Seclusion & Restraint Packet by Staff Y (RN) dated 3/5/2025 at 8:28 AM showed: Patient #4 "out of control, attempting to attack staff ... spit in [nurses] face ... profanities ... physical hold for about 3 minutes." Thorazine 50mg, Benadryl 50mg, and Ativan 2mg given intramuscularly.
[Thorazine - antipsychotic. Benadryl - antihistamine given to prevent side effects of the antipsychotic. Ativan - anti-anxiety medication. These three medications are often given in combination.]

Review of Court-Ordered Mental Health Services signed on 3/10/2025 at 8:57 AM by the Judge, showed Patient #4 was likely to cause serious harm to self or others and was suffering from severe and abnormal mental, emotional, or physical distress with inability to make rational and informed decisions about treatment.

Review of Petition for Order to Administer Psychoactive Medication dated 3/10/2025 for court-ordered in-patient mental health services to include antidepressants, antipsychotics, anxiolytics/sedatives/hypnotics, and mood stabilizers. Staff F (Attending Physician) wrote, "The patient is is paranoid, suspicious, guarded, saying people are trying to poison her. She yells, creams, curses at staff and peers. She is irritable, anxious refusing medication ... The patient will continue to be psychotic, violent if she does not receive psychotherapeutics to help her with her psychosis. This impedes her ability to be independent and affects her quality of life."

Review of Psychiatric Progress Note by Staff F (Attending Physician) dated 2/28/2025 e-signed at 4:28 PM showed: "In a wheelchair ... signs of psychosis ... appears to be responding to internal stimuli ... non adherent with all psychiatric medications ... Delusional ... Inpatient psychiatric level of care prescribed is medically necessary."

Review of Psychiatric Progress Note by Staff F (Attending Physician) dated 3/13/2025 e-signed 2:45 PM showed Patient #4 "easily agitated ... continues to exhibit signs of psychosis and delusions ... continues to refuse oral medication and is receiving injection as per medication commitment."


Additional Information.
In an interview with Staff C (RM) on 3/19/2025 at 3:25 PM, she stated investigations, such as root cause analyses, are initiated by the Risk Manager. She also stated that there had not been an investigation into the discharge of Patient #4 though there had been a discussion on the afternoon of 3/14/2025 about conducting an RCA [Root Cause Analysis].

In an interview with Staff A (CEO), Staff B (DON), Staff C (RM), and Staff I (Intake Director) on 03/28/2025, they stated they did not have any additional verbal information or supporting documentation concerning Patient #4. They said they did not.