Alaska Psychiatric Institute

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40259 . Based on record review and interviews, the facility failed to meet the Condition of Participation of Patient Right’s according to CFR 482.13. The facility failed to protect and promote each patient’s rights which had the potential to place all patients of the Katmai unit (based on a census of 24) at risk for neglect. Findings: 1. The facility failed to ensure care was received in a safe setting. Specifically, the facility failed to: 1) Accurately perform Close Observation Status Scale (COSS) every 15-minute (Q15min) patient safety checks for patients on the Katmai unit; and 2) Act and render aid for 1 Patient (#5), out of 1 patient reviewed, whose position of sleep placed the patient at increased risk to his/her safety. (Refer to A-0144). 2. The facility failed to ensure 1 Patient (#5), out of 1 patient reviewed, was free from neglect. Specifically, the facility failed to ensure: a) The nightshift Licensed Nurses (LN’s) (#’s 16 and 21) used appropriate medication administration expectations, and reassessment of medication administrations expectations; for 1 patient (#5), out of 1 patient reviewed; b) The nightshift LN’s (#’s 16 and 21) and Psychiatric Nursing Assistants (PNA’s) (#’s 4, 7, 8, 11, and 12) followed the behavior plan for 1 patient (#5), out of 1 patient reviewed; and c) The nightshift LN’s (#’s 16 and 21) and PNA’s (#’s 4, 7, 8, 11, and 12), as well as, the dayshift LN (#30) failed to act and render aid to Patient #5 whose position of sleep placed the patient at increased risk to his/her safety. (Refer to A-0145). 3. The facility failed to ensure chemical restraints were not used for 1 Patient (#5), out of 1 patient reviewed, which restricted the patient’s behavior and freedom of movement within his/her room, which was an approved intervention in a treatment team-approved individualized behavior plan (an individualized behavior plan to address challenging behaviors and interventions staff can use to work through them). (Refer to A-0160). .”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to meet the Condition of Participation of Nursing Services according to CFR 482.23. The facility failed to have an organized nursing service that provided safe and appropriate nursing services. Findings: 1. The facility failed to ensure the nightshift Licensed Nurses (LN #’s 16 and 21) supervised and evaluated the nursing care provided for 1 Patient (#5), out of 1 patient reviewed. Specifically, LN #16 and #21 failed to: a) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications; b) Appropriately assess and offer PRN (as needed) medication to Patient #5 prior to administering court ordered IMBU medication; c) Appropriately re-assess Patient #5, within the facility’s standard timeframe, after each administration of IMBU medication was received; and d) Appropriately completed an evaluation for Patient #5 after reports of concern of possible deterioration of physical status were reported by Psychiatric Nursing Assistants (PNA #’s 7 and 12). (Refer to A-0395). 2. The facility failed to ensure the nightshift Licensed Nurses (LN #s 16 and 21) prepare and administer medications in accordance with the orders of the practitioner and accepted standards of practice for 1 Patient (#5), out of 1 patient reviewed. Specifically, LN #16 and LN #21 failed to: a) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications; b) Appropriately administer PRN (as needed) medications, based on the written parameters within the medication orders; c) Appropriately assess and offer PO PRN medication to Patient #5 prior to administering court ordered IMBU medication; and d) Appropriately re-assess Patient #5, within the facility’s standard timeframe, after each administration of IMBU medication was received. (Refer to A-0405) .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure care was received in a safe setting. Specifically, the facility failed to: 1) Accurately perform Close Observation Status Scale (COSS - the level of observation required for safety) every 15-minute (Q15min) patient safety checks for patients on the Katmai unit; and 2) Act and render aid for 1 Patient (#5), out of 1 patient reviewed, whose position of sleep placed the patient at increased risk to his/her safety. These failed practices: 1) increased the risk to patient safety for all patients of the Katmai unit (based on a census of 24); and 2) placed Patient #5 at risk for a deterioration of his/her physical status. Patient #5 passed away in the facility. Findings: COSS Patient Safety Checks Review of video recordings, dated 3/27-28/25, revealed there were three separate hours on night shift where staff did not perform appropriate Q15min patient safety checks: 1) 3/27/25 from 9:00 PM to 10:00 PM: PNA #4 was assigned Q15min checks for this hour. - At 9:02 PM, it was observed that PNA #4 pulled a chair out of a small group room known as the “fishbowl” and sat next to PNA #8 in the hall by the nurse’s station. PNA #4 had the patient safety checklist clipboard in his/her hand. PNA #4, remained seated by the nursing station for the hour assigned without rising to complete any Q15min check rounds. - At 9:42 PM, PNA #8 completed a safety check for Patient #5 (despite not being assigned). Review of the unit’s Q15min checklist, dated 3/27/25, revealed PNA #4 documented that he/she completed all four Q15min checks from 9:00 PM to 10:00 PM. 2) 3/27/25 from 10:00 PM to 11:00 PM: PNA #11 was assigned Q15min checks for this hour. - There was no observation on the video review that PNA #11 completed any Q15min check rounds. Review of the unit’s Q15min checklist, dated 3/27/25, revealed PNA #11 documented that he/she completed all four Q15min checks from 10:00 PM to 11:00 PM. During an interview on 4/30/25 at 2:47 PM, the Director of Risk Management stated PNA #11 did not perform the Q15min checks on 3/27/25 from 10:00 to 11:00 PM. 3) 3/28/25 from 2:00 AM to 3:00 AM: PNA #4 was assigned Q15min checks for this hour. - At 1:57 AM, it was observed that PNA #4 completed a safety check for Patient #5. - At 2:01 AM, it was observed that PNA #4 sat in the hall by the nurse’s station with the patient safety checklist clipboard in his/her hand. PNA #4 remained seated by the nursing station for the remaining hour assigned without rising to complete any Q15min check rounds. Review of the unit’s Q15min checklist, dated 3/28/25, revealed PNA #4 documented that he/she physically completed all four Q15min checks at 2:15 AM, 2:30 AM, and 2:45 AM. During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that PNA #4’s Q15min deficiencies were noted during the facility’s investigation, video review, and interview. The DON further stated it was determined PNA #4 falsified the Q15min check documentation during the 9:00 PM to 10:00 PM and 2:00 AM to 3:00 AM timeframes. During an interview on 4/30/25 at 11:17 AM, the Director of Quality Assurance and Performance Improvement (QAPI) stated PNA #11 did not perform the Q15min checks from 10:00 PM to 11:00 PM. Act and Render Aid Patient #5 Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5’s court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment. Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension. Review of the most recent “Petition for Court Approval of Administration of Psychotropic Medication,” dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: “. . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . .” Further review revealed that Patient #5 was on 1st Degree COSS, which required Patient #5 to have an every-15-minute observation and engagement for patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety). Patient #5’s Treatment Plan Review of Patient #5’s “Multidisciplinary Master Treatment Plan,” dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: “Disturbance of Thought: “[Patient #5] shows active disturbance of though and oppositional behavior.” Further review revealed identified interventions to address Patient #5’s “disturbance of thought” that included: - “LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level,” initiated on 11/6/23; - “RN will prompt [Patient #5] to comply with safety behavior,” initiated on 1/30/24; - “Psychology will develop behavior plan to guide staff response to challenging behaviors,” initiated on 9/11/24; and - “Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes,” initiated 11/6/24. Patient #5’s Challenging Behaviors During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5’s history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor. The DON further stated that Patient #5’s behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as “normal” for Patient #5. During an interview on 4/30/25 at 10:21 AM, Patient #5’s Provider stated that Patient #5’s behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted. Patient #5’s Provider stated that these behaviors had been present since his/her 2020 admission. Patient #5’s Behavior Plan During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans were initiated when a patient’s behavior became increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times. Review of Patient #5’s behavior plan, last updated 3/25/25, revealed: - “Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an ‘episode.’” - “. . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . .” - “. . . If you notice [Patient #5] is about to have an “episode,” walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball.” - “Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an “episode.” Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5’s] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, “hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn’t flood.” Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress.” During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime. Incident on 3/28/25 During an interview on 4/30/25 at 9:58 AM, the DON and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night. The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient’s status for safety), told another PNA in the hall that Patient #5 was, “laying down on the table.” The “table” was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk. The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side. As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5’s left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair. During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn’t think it was something alarming. An observation on 4/30/25 at 2:38 PM, of Patient #5’s bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5’s upper body to be lower than his/her hips, buttocks, and legs which were still on the desk. Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck. Further observation revealed that when standing in the doorway of Patient #5’s bedroom, a person’s view would have been of Patient #5’s buttocks, legs, and feet only, with a minimal view of Patient #5’s back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5’s face or the rise and fall of Patient #5’s front chest during respirations, which was face down in the chair. During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient. When asked what if the patient resisted, the ADON stated then repeated attempts should have been tried until the patient was positioned for safety. This could have achieved by trying to physically move the patient or communicate with the patient to achieve cooperation to move him/her into a safer position. Review of the facility’s video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 4:29 AM, revealed: - From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5’s bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA’s in the hall, it could be heard on the video that PNA #7 stated, “[he’s/she’s] laying on down on the table.” PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door. - From 2:00 AM to 3:00 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time. - From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5. - At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited. - At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the light and could be heard calling Patient #5’s name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse’s station to get the nurses. PNA #7 could be heard on the video recording saying, “[he’s/she’s] not moving.” At 4:32 AM, PNA #12 told nurses, “[he/she] was breathing earlier” when they met him/her at Patient #5’s doorway. All staff entered Patient #5’s bedroom. Staff could be heard calling Patient #5’s name. PNA #11 said, “let me get a pillow for [his/her] head” and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, “[he/she] was holding onto something.” During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closest to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5’s pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down. The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5’s bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, “no.” Review of Patient #5’s nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: “. . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Further review revealed no documentation of the pulse check, or the rate assessed, that the LNs reported completing at 4:29 AM. No other assessment information was documented, nor was there any other documentation from the LNs on 3/28/25. During an interview on 4/30/25 at 12:39 AM, when asked what the expectation would be for an LN who was asked to come assess a patient for breathing, the Lead Educator stated the expectation would be to complete a head-to-toe assessment and call medical staff if needed. Further review of the facility video recording, dated 3/28/25 from 4:38 AM to 7:14 AM, revealed: - At 4:38 AM, PNA #7 completed a patient safety check for Patient #5 by standing in the doorway. - At 4:45 AM, PNA #12 completed a patient safety check for Patient #5. PNA #12 entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 37 seconds, then exited. - From 4:59 AM to 5:41 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #12 completed the check at 4:59 AM, PNA #8 completed the checks at 5:11 AM, 5:28 AM, and 5:41 AM. - At 5:54 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 1 minute, 50 seconds, then exited. - At 6:01 AM, PNA #7 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. - At 6:11 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and could be heard calling Patient #5’s name. PNA #7 was in the room for 1 minute, then exited. - At 6:29 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 35 seconds, then exited. - At 6:47 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #12 could be heard on the video recording saying, “[Patient #5] is going to be sore in the morning.” - At 6:59 AM, PNA #12 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. Shift change was conducted at 7:00 AM - At 7:10 AM, PNA #7 completed a patient safety check round with dayshift PNA #9 and PNA #10. Both dayshift PNAs laughed at Patient #5’s position on the desk and chair. PNA #10 called out Patient #5’s name. PNA #9 stated, “You don’t see that every day.” PNA #9 asked, “did the nurses know about it?” and left to get the dayshift LN #30 to look at Patient #5. When LN #30 looked into Patient #5’s bedroom from the hall, he/she laughed out loud, shook his/her head, and walked away back towards the nurse’s station. At 7:12 AM, PNA #9 could be heard on the video saying, “This should be a meme.” During an interview on 6/2/25 at 9:51 AM, when asked what state of dress Patient #5 was in, the Risk Manager stated Patient #5’s pants were down past his/her buttocks. - At 7:13 AM, dayshift PNA #13 looked into Patient #5’s room, turned back to the PNAs with a disapproving look, and entered Patient #5’s bedroom. PNA #10 also entered the room and closed the door. PNA #13 left the room to go get LN #30 back into Patient #5’s bedroom and could be heard saying, “you better get a pulse.” - At 7:14 AM, PNA #13 called on the radio to have the front desk announce a Code Blue to Katmai unit. “Code Blue Katmai Unit” could be heard on the overhead page system. Staff immediately brought the crash cart. Other staff members entered the unit to assist, including the Assistant Director of Nursing (ADON). Review of the facility provided “Emergency [and] Disaster Treatment Form” (A code blue documentation sheet), dated 3/28/25, revealed: - 7:17 AM: “Start CPR [cardiopulmonary resuscitation]” - 7:17 AM: “Attaching AED [automated external defibrillator]. No pulse. O2 [Oxygen] pulled. Suction pulled. O2 applied . . . calling 911. Asked for a [second] O2 tank. Not getting air in (“locked up”).” - 7:20 AM: “No shock advised. [Second] O2 tank connected.” - 7:21 AM: “Suction in mouth used. Continuing CPR [and] rescue breaths. Continues to be stiff. Can feel pulse in neck with CPR. Pt cold to the touch.” - 7:24 AM: “No pulse. AED - no shock advised. No pulse. EMS arrived . . .” Further observation of the facility video recording revealed EMS arrived on Katmai unit at 7:25 AM. During an interview on 4/30/25 at 1:12 PM, the Director of QAPI stated that when LN #30 entered the room, he/she and other staff moved Patient #5 off the desk and placed him/her on the floor. The Director of QAPI stated once Patient #5 was on the floor they could see that Patient #5’s face and his/her tongue was hanging out of his/her mouth and his/her jaw was stiff and closed around his/her tongue. Also, Patient #5’s left arm remained tucked close to his/her chest because it was stiff and did not move. The Director of QAPI stated LN #30 initiated CPR and three rounds of CPR were attempted by facility staff, but no shock was advised with the AED that facility staff had placed during CPR. The Director of QAPI further stated that when EMS arrived, they attempted two rounds of CPR and again no shock was advised. EMS determined Patient #5 was deceased and stopped CPR efforts. During an interview on 5/1/25 at 10:45 AM, the ADON stated that when she entered Patient #5’s room, responding to the Code Blue announcement, Patient #5 was on the floor dressed in a T-shirt and boxers. The ADON stated staff said they had to pull the boxers up because Patient #5’s genitals were exposed when they laid him/her on the floor. The ADON stated Patient #5’s tongue was out a little bit, and blood was seen around his/her mouth and a little on his/her nose (which the ADON suspected was probably from his/her mouth, because it was not coming from inside his/her nose). The ADON stated she attempted to use the AMBU bag to help with respirations, while LN #30 was performing CPR, however Patient #5’s neck was stiff, and she was not able to tilt his/her head back or open his/her jaw. The ADON stated Patient #5 was cool and clammy when touched and Patient #5’s t-shirt was wet. The ADON stated she suspected this wetness was urine, because it had an odor, but this was never confirmed. The ADON stated she remembered it being wet because the shirt was cut off when the AED was applied during CPR efforts. Further review of the facility video recording, dated 3/28/25 from 7:56 AM to 10:17 AM, revealed: - At 7:56 AM, Anchorage Police Department arrived on Katmai unit. - At 7:59 AM, EMS left the Katmai unit. - At 9:36 AM, Medical Examiner arrived on Katmai unit. - At 10:17 AM, Medical Examiner departed with Patient #5. Policy Review Review of the facility’s policy “Patient Rights,” effective 1/29/24, revealed: “Procedure: Except as otherwise provided . . . a patient has rights that include the following . . . to be treated with consideration and recognition of the patient’s dignity and individuality. . . to receive care in a safe, respectful, and the least restrictive setting and environment . . .” Review of the facility’s nursing department procedure “PNA Responsibilities,” effective 8/19/24, revealed: “. . . Employees are responsible for knowing and following Hospital Policy [and] Procedures (P&P) and Nursing Department Procedures (NDP) . . . Rounds: Unit round are to be made at the beginning of each shift and no less than every fifteen (15) minutes throughout the remainder of the shift to identify potential risks and to assure that a therapeutic and safe environment is maintained. All patients admitted to API [Alaska Psychiatric Institute] are monitored on Q15 checks (24/7) [24 hours a day, 7 days a week] during their hospitalization including all Close Observation Status Scale Orders (COSS) are monitored Q15 minutes . . . The staff member responsible for making the round is required to take a radio, the Patient Location Checklist, and a pen with them when they do rounds. They are responsible to: Do not just count heads, account for each patient according to their status . . . Staff are required to check on the physical well-being of the patients as well as their physical presence on the Unit. When the patient is in bed, sleeping, observe respirations (chest rising and falling) and listen for the patient’s breathing . . . Patient Care . . . Treat patients with dignity and respect at all times . . . Be alert for signs and/or symptoms that suggest a patient’s physical status may be deteriorating or at risk of evolving into a medical emergency. Notify the Charge Nurse if any concerns . . . Between rounds . . . Maintain and ensure patient safety . . . Document observations and incidents as they occur; describe in detail your observations and patient behavior . . .” Review of the facility’s nursing department procedure “Nurse Responsibilities,” effective 10/12/23, revealed: “. . . Employees are responsible for knowing and following Hospital Policy [and] Procedures (P&Ps) and Nursing Department Procedures (NDPs) . . . Unit Rounds are to be made at the beginning of each shift and each patient will be monitored on Routine Q15 minute checks (24/7) [24 hours a day, 7 days a week] during hospitalization to identify potential risks and to assure that a therapeutic and safe environment is maintained. Rounds are generally done by the PNA staff but may be done by a Nurse. The Nurse is responsible for weeing these are done regularly. The Nurse is responsible to assess every patient assigned to the unit at least once during their shift and not rely solely on the PNA to evaluate a patient’s well-being. The staff member responsible for making the round is required to take a radio, the Patient Location Checklist, and a pen with them when they do rounds . . .Staff is required to check on the physical well being of the patients as well as their physical presence on the Unit. When the patient is in bed, sleeping, observe respirations (chest rising and falling) and listen for the patient’s breathing . . . Patient Care: Treat patients with dignity and respect at all times. Know the location and activity of each patient on [1st degree] COSS at all times . . . Monitor each patient for signs and/or symptoms that suggest their physical status is deteriorating or at risk of evolving into a medical emergency . . . Between rounds . . . The Nurse is responsible for seeing that the PNAs carry out duties appropriately, chart correctly and perform to expectations . . . RN retains accountability for duties delegated to PNA staff . . . Ensure that significant interactions with patients are noted in the patient record and passed along in report. Document observations and incidents as they occur; chart accurately on patient noting incidents and behavior in detail . . .” Review of the facility’s policy “Close Observation Status Scale (COSS),” last reviewed 2/13/23, revealed: “Purpose: To delineate Alaska Psychiatric Institute’s (API) policy for the ordering and performing of close observation for the protection of individual patients and others . . . COSS Observation Requirements: 1st Degree COSS: 15-minute observation and engagement checks, noted on the Patient Location Checklist . . .” Review of the facility’s nursing department procedure “Patient Safety Checklist,” effective 7/1/24, revealed: “. . . All patients will be monitored through Q15 [every 15] minute checks throughout their hospitalization regardless of COSS. Security and Q15min [minutes] checks are completed to identify potential risks and to assure that a therapeutic and safe environment is maintained . . . Patient safety checklists are made by night staff for the next 24-hour period with the first check beginning at 0700 [7:00 AM]. All patients are listed on the patient safety checklist . . . The unit charge nurse or designated staff member will assign a staff member on the unit assignment sheet hourly to complete and record Q15min safety checks. Staff may not be assigned to another task when assigned to Q15min checks. Q15min rounds are completed for all patients regardless of COSS status. The staff member that records the safety check is responsible for physically identifying the patient and verifying the presence and safety of the patient for that round. Completing a round means you have physically checked and are verifying the physical presence and wellbeing of the patient on the unit. When a patient is in bed staff are to verify they witness respirations (chest rise and fall) and can hear breathing . . . Staff are to notify the RN [Registered Nurse] immediately if there are any irregularities in the patient’s breathing or safety concerns . . . Staff assigned to safety checks is expected to be alert for potential safety hazards and take corrective action if needed . . .” Further review of the facility’s policy “Patient Safety Checklist,” effective 7/1/24, revealed: “. . . Safety checks are to be completed at minimum every 15 minutes and recorded in real time. If a round is not documented or has been missed the staff that identifies the deficiency is expected to: complete the next round immediately to ensure the location, safety, and wellbeing of all patients. Notify RN of missed round and current status of patients. Strike through the undocumented or missed round. Record on the back of the safety check list the time of the missed round and why the round was missed of undocumented and sign the note. Make a copy the front and back of the safety check list(s). Attach the copies of the safety check list(s) to a Unusual occurrence Report (UOR). Submit the UOR to the unit manager or NNS [Nursing Shift Supervisor] (in the absence of the unit manager) . . .” Review of the facility’s policy “Deterioration of Physical Status, Medical Emergencies, and Code Blue Response,” effective 8/12/24, revealed: “Purpose: To recognition of a deteriorating physical status is an interdisciplinary response that provides for early intervention and management of patients to decrease the risk for cardiopulmonary arrest and/or other adverse medical events . . . Procedure: Deteriorating Physical Status: Any API staff member, patient, visitor, or family member of patient may notify nursing staff of concern for deterioration in physical status of an API patient. The goal of the initial evaluation for deteriorating physical status is to identify and correct conditions before they progress to medically emergent of life-threatening status. Nursing staff response: If a patient exhibits early warning signs or symptoms, unit nursing staff will initiate an evaluation without delay using established criteria as guidelines (See Attachment: Criteria for Deteriorating Physical Status and Trigger for Response); - If criteria are met: Nursing staff will assess severity of signs or symptoms and will determine if immediate consultation by in-house staff or emergent consultation at outside facility (emergency room) is indicated; - If criteria are not present, but concern expressed by staff, family, etc.: Nursing staff will document concern, evaluation and follow-up using Situation Background Assessment Recommendation/Request (SBAR) [a format for note documentation] method including hand-off communication to on-coming shift. Nursing staff will provide verbal feedback to concerned party of increased vigilance for comprise of physical status . . . If at any time signs/symptoms progress towards meeting criteria, nursing will proceed with protocol for Deteriorating Physical Status . . .” Further review of the policy attachment “Criteria for Deteriorating Physical Status and Trigger for Response,” last updated 8/2022, revealed: Recognition of the following by staff and verification by Nursing staff should initiate contact with the medical Officer staff (MOS) or LIP [Provider] on call . . . Concern: Change in Respiratory Rate . . . Criteria: Respiratory rate is a change from baseline and less than 8 or greater than 28 . . . Response: Assess Vital Signs including Pulse Oximetry [oxygen saturation levels in the blood]; Loof for etiology (pain, infection, wheezing/rhonchi [noisy breath sounds]; Contact LIP/MOS to determine further level of care or work up . . . Concern: Altered Mental Status or Acute Chang in LOC [level of consciousness] or CNS [central nervous system] status . . . Criteria: Patient becomes somnolent, difficult to awaken, confused or obtunded or any other change in mental status or CNS status: ex. Pupil reaction, slurred speech, onset of unilateral limb or facial weakness; Response: Assess Vital Signs including Pulse Oximetry; Look for etiology (medication adverse effects, h/o [history of] stroke or embolism, h/o water intoxication); Contact LIP/MOS to determine further level of care or work up . . .” .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure 1 Patient (#5), out of 1 patient reviewed, was free from neglect. Specifically, the facility failed to ensure: 1) The nightshift Licensed Nurses (LN’s) (#’s 16 and 21) used appropriate medication administration expectations, and reassessment of medication administrations expectations; for 1 patient (#5), out of 1 patient reviewed; 2) The nightshift LN’s (#’s 16 and 21) and Psychiatric Nursing Assistants (PNA’s) (#’s 4, 7, 8, 11, and 12) followed the behavior plan for 1 patient (#5), out of 1 patient reviewed; and 3) The nightshift LN’s (#’s 16 and 21) and PNA’s (#’s 4, 7, 8, 11, and 12), as well as, the dayshift LN (#30) failed to act and render aid to Patient #5 whose position of sleep placed the patient at increased risk to his/her safety. These failed practices placed Patient #5 at risk for: 1) adverse reactions to medications; 2) escalated behavior that was not addressed with least restrictive measures; and 3) a deterioration of his/her physical status. Patient #5 passed away in the facility. Findings: Patient #5 Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5’s court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment. Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension. Review of the most recent “Petition for Court Approval of Administration of Psychotropic Medication,” dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: “. . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . .” Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety). Patient #5’s Treatment Plan Review of Patient #5’s “Multidisciplinary Master Treatment Plan,” dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: “Disturbance of Thought: “[Patient #5] shows active disturbance of though and oppositional behavior.” Further review revealed identified interventions to address Patient #5’s “disturbance of thought” that included: - “LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level,” initiated on 11/6/23; - “RN will prompt [Patient #5] to comply with safety behavior,” initiated on 1/30/24; - “Psychology will develop behavior plan to guide staff response to challenging behaviors,” initiated on 9/11/24; and - “Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes,” initiated 11/6/24. Patient #5’s Challenging Behaviors During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5’s history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor. The DON further stated that Patient #5’s behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as “normal” for Patient #5. During an interview on 4/30/25 at 10:21 AM, Patient #5’s Provider stated that Patient #5’s behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted. Patient #5’s Provider stated that these behaviors had been present since his/her 2020 admission. Patient #5’s Behavior Plan During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient’s behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times. Review of Patient #5’s behavior plan, last updated 3/25/25, revealed: - “Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an ‘episode.’” - “. . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . .” - “. . . If you notice [Patient #5] is about to have an “episode,” walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball.” - “Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an “episode.” Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5’s] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, “hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn’t flood.” Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress.” During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime. Patient #5’s Medication Regimen Review of Patient #5’s ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a “shot” form of medication if Patient #5 refused to take his/her medications by mouth, called an IMBU (intramuscular, or IM, back up). These were ordered by the courts to aid in Patient #5’s consistent treatment. These medications included: Scheduled Medications 1) “Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia.” This order started on 1/21/25. Further review revealed: “Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU.” 1a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . .” This order started on 12/5/23 and remained in effect. 2) “Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia.” This order was started on 1/21/25. Further review revealed: “Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU.” 3) “Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia.” This order started on 2/25/25. Further review revealed: “Court ordered: If patient refuses, provide IMBU lorazepam.” 2a and 3a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . .” This order started on 9/30/24 and remained in effect. PRN Medications: 4) “Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation.” This order started on 12/20/23. Further review revealed: “Court ordered: If refused give haloperidol IMBU.” 4a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . .” This order started on 12/5/23 and remained in effect. 5) “Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation.” This order started on 2/6/25. Further review revealed: “Court ordered: If refused give Lorazepam IMBU.” 5a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . .” This order started on 9/30/24 and remained in effect. 6) “Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation.” This order started on 12/24/24. Further review revealed: “Court ordered: If refused give chlorpromazine IMBU.” 6a) “Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN.” This order started on 12/24/24 and remained in effect. Medication Administrations #1 for nightshift on 3/27/25 Review of Patient #5’s electronic Medication Administration Record (eMAR), dated 3/27/25, revealed: - At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation. Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order. - At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time). - At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time). - At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication. - At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication. Video Review of Medication Administrations #1 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed: - From 6:00 PM to 6:16 PM, Patient #5 was in the unit’s TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop. - At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom. During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior. - From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5’s bedroom door, which was closed, and looked in the window and listened. - At 7:02 PM, PNA #4 approached Patient #5’s bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse’s station to turn off Patient #5’s water. During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room’s water supplies could be turned off at the nurse’s station. When asked about Patient #5’s behavior plan, and needing to speak to Patient #5 about exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off. - At 7:06 PM, PNA #11 approached Patient #5’s room to complete a safety check. - At 7:10 PM, PNA #11 approached Patient #5’s room to complete a safety check. On the video, Patient #5 could be heard making animal noises from within his/her room area. - At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications. During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth. - From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room. - At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this. Reassessment of Medications Administration #1 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 8:42 PM, LN #21 documented a reassessment for Patient #5’s response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both “Medication effectiveness for clinical indication: effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections. Medication Administrations #2 for Nightshift on 3/27/25 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation. - At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication. Video Review of Medication Administration #2 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of “severe agitation” from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5’s behavior plan were attempted. Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5’s bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA’s #7 and #11, and exited shortly after. During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used. When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse’s discretion to determine what those terms mean. When asked what she thought “severe agitation” meant, the ADON stated it would mean to the point of causing potential harm to self or others. During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling. The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication. During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan. When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed. Reassessment of Medication Administration #2 Further review of Patient #5’s eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5’s response to the IMBU Chlorpromazine (16 minutes after its administration): “Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient. During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5’s room. Review of Patient #5’s nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: “Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] ‘seizure like shaking.’ Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn’t show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Patient #5’s Aggressive Behavior During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025. During an interview on 4/30/25 at 11:00 AM, the Patient #5’s Provider stated consoling and encouraging was the best therapy for Patient #5’s during his/her episodes. During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5’s “severe agitation” would look like, Patient #5’s Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff. When asked if rolling on the floor, tapping, and making animal noises in Patient #5’s bedroom area would be considered “severe agitation” and warrant PRN medication, Patient #5’s Provider stated, “No. The treatment team made the decision to be as least restrictive as possible with [Patient #5].” The Director of QAPI was in the room during this interview and asked Patient #5’s Provider, “What if Patient #5 was rolling on the floor and making animal noises for hours?” Patient #5’s Provider stated, “No, as long as [he/she] was in [his/her] room it would not warrant PRN medication.” An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5’s Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5’s Provider returned to the room and stated Patient #5’s lengthy behavior of rolling around on the floor and making animal noises could be considered agitation. Incident on 3/28/25 During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night. The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient’s status for safety), told another PNA in the hall that Patient #5 was, “laying down on the table.” The “table” was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk. The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side. As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5’s left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair. During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn’t think it was something alarming. An observation on 4/30/25 at 2:38 PM, of Patient #5’s bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5’s upper body to be lower than his/her hips, buttocks, and legs which were still on the desk. Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck. Further observation revealed that when standing in the doorway of Patient #5’s bedroom, a person’s view would have been of Patient #5’s buttocks, legs, and feet only, with a minimal view of Patient #5’s back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5’s face or the rise and fall of Patient #5’s front chest during respirations, which was face down in the chair. During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient. When asked what if the patient resisted, the ADON stated then repeated attempts should be tried until the patient is positioned for safety. This could be trying to physically move the patient or communicate with the patient to achieve cooperation to move into a safer position. Review of the facility’s video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 4:29 AM, revealed: - From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5’s bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA’s in the hall, it could be heard on the video that PNA #7 stated, “[he’s/she’s] laying on down on the table.” PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door. - From 2:15 AM to 2:53 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time. - From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5. - At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited. - At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the light and could be heard calling Patient #5’s name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse’s station to get the nurses. PNA #7 could be heard on the video recording saying, “[he’s/she’s] not moving.” At 4:32 AM, PNA #12 told nurses, “[he/she] was breathing earlier” when they met him/her at Patient #5’s doorway. All staff entered Patient #5’s bedroom. Staff could be heard calling Patient #5’s name. PNA #11 said, “let me get a pillow for [his/her] head” and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, “[he/she] was holding onto something.” During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closet to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5’s pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down. The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5’s bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, “no.” Review of Patient #5’s nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: “. . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Further review revealed no documentation of the pulse check, or the rate assessed, that the LNs reported completing at 4:29 AM. No other assessment information was documented, nor was there any other documentation from the LNs on 3/28/25. During an interview on 4/30/25 at 12:39 AM, when asked what the expectation would be for an LN who was asked to come assess a patient for breathing, the Lead Educator stated the expectation would be to complete a head-to-toe assessment and call medical staff if needed. Review of the facility’s video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 4:38 AM to 7:14 AM, revealed: - At 4:38 AM, PNA #7 completed a patient safety check for Patient #5 by standing in the doorway. - At 4:45 AM, PNA #12 completed a patient safety check for Patient #5. PNA #12 entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 37 seconds, then exited. - From 4:59 AM to 5:41 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #12 completed the check at 4:59 AM, PNA #8 completed the checks at 5:11 AM, 5:28 AM, and 5:41 AM. - At 5:54 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 1 minute, 50 seconds, then exited. - At 6:01 AM, PNA #7 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. - At 6:11 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and could be heard calling Patient #5’s name. PNA #7 was in the room for 1 minute, then exited. - At 6:29 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 35 seconds, then exited. - At 6:47 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #12 could be heard on the video recording saying, “[Patient #5] is going to be sore in the morning.” - At 6:59 AM, PNA #12 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. Shift change was conducted at 7:00 AM - At 7:10 AM, PNA #7 completed a patient safety check round with dayshift PNA #9 and PNA #10. Both dayshift PNAs laughed at Patient #5’s position on the desk and chair. PNA #10 called out Patient #5’s name. PNA #9 stated, “You don’t see that every day.” PNA #9 asked, “did the nurses know about it?” and left to get the dayshift LN #30 to look at Patient #5. When LN #30 looked into Patient #5’s bedroom from the hall, he/she laughed out loud, shook his/her head, and walked away back towards the nurse’s station. At 7:12 AM, PNA #9 could be heard on the video saying, “This should be a meme.” During an interview on 6/2/25 at 9:51 AM, when asked what state of dress Patient #5 was in, the Risk Manager stated Patient #5’s pants were down past his/her buttocks. - At 7:13 AM, dayshift PNA #13 looked into Patient #5’s room, turned back to the PNAs with a disapproving look, and entered Patient #5’s bedroom. PNA #10 also entered the room and closed the door. PNA #13 left the room to go get LN #30 back into Patient #5’s bedroom and could be heard saying, “you better get a pulse.” - At 7:14 AM, PNA #13 called on the radio to have the front desk announce a Code Blue to Katmai unit. “Code Blue Katmai Unit” could be heard on the overhead page system. Staff immediately brought the crash cart. Other staff members entered the unit to assist, including the Assistant Director of Nursing (ADON). Review of the facility provided “Emergency [and] Disaster Treatment Form” (A code blue documentation sheet), dated 3/28/25, revealed: - 7:17 AM: “Start CPR [cardiopulmonary resuscitation]” - 7:17 AM: “Attaching AED [automated external defibrillator]. No pulse. O2 [Oxygen] pulled. Suction pulled. O2 applied . . . calling 911. Asked for a [second] O2 tank. Not getting air in (“locked up”).” - 7:20 AM: “No shock advised. [Second] O2 tank connected.” - 7:21 AM: “Suction in mouth used. Continuing CPR [and] rescue breaths. Continues to be stiff. Can feel pulse in neck with CPR. Pt cold to the touch.” - 7:24 AM: “No pulse. AED - no shock advised. No pulse. EMS arrived . . .” Further observation of the facility video recording revealed EMS arrived on Katmai unit at 7:25 AM. During an interview on 4/30/25 at 1:12 PM, the Director of QAPI stated that when LN #30 entered the room, he/she and other staff moved Patient #5 off the desk and placed him/her on the floor. The Director of QAPI stated once Patient #5 was on the floor they could see that Patient #5’s face and his/her tongue was hanging out of his/her mouth and his/her jaw was stiff and closed around his/her tongue. Also, Patient #5’s left arm remained tucked close to his/her chest because it was stiff and did not move due to being in a rigor mortis state. The Director of QAPI stated LN #30 initiated CPR and three rounds of CPR were attempted by facility staff, but no shock was advised with the AED that facility staff had placed during CPR. The Director of QAPI further stated that when EMS arrived, they attempted two rounds of CPR and again no shock was advised. EMS determined Patient #5 was deceased and stopped CPR efforts. During an interview on 5/1/25 at 10:45 AM, the ADON stated that when she entered Patient #5’s room, responding to the Code Blue announcement, Patient #5 was on the floor dressed in a T-shirt and boxers. The ADON stated staff said they had to pull the boxers up because Patient #5’s genitals were exposed when they laid him/her on the floor. The ADON stated Patient #5’s tongue was out a little bit, and blood was seen around his/her mouth and a little on his/her nose (which the ADON suspected was probably from his/her mouth, because it was not coming from inside his/her nose). The ADON stated she attempted to use the AMBU bag to help with respirations, while LN #30 was performing CPR, however Patient #5’s neck was stiff, and she was not able to tilt his/her head back or open his/her jaw. The ADON stated Patient #5 was cool and clammy when touched and Patient #5’s t-shirt was wet. The ADON stated she suspected this wetness was urine, because it had an odor, but this was never confirmed. The ADON stated she remembered it being wet because the shirt was cut off when the AED was applied during CPR efforts. Review of the facility’s video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 7:56 AM to 10:17 AM, revealed: - At 7:56 AM, Anchorage Police Department arrived on Katmai unit. - At 7:59 AM, EMS left the Katmai unit. - At 9:36 AM, Medical Examiner arrived on Katmai unit. - At 10:17 AM, Medical Examiner departed with Patient #5. During an interview on 5/1/25 at 9:27 AM, when asked why there was no documentation in Patient #5’s medical record about the 3/28/25 incident (other than the cold blue form), the Director of QAPI stated the nurses from nightshift and dayshift were too emotionally unstable to complete any documentation on the day of Patient #5’s death. Then the chart was locked down due to Patient #5’s death. When asked how it was possible an addendum to LN #21’s 3/28/25 nurse’s note was placed, the Director of QAPI stated she allowed LN #21 to make that addendum based on camera review of the time discrepancy. Policy Review Review of the facility’s policy “Abuse [and] Neglect; Conduct Involving Patients,” effective 10/16/24, revealed: “. . . Policy: Patients at API have the right to treatment in a setting that is physically and emotionally safe, and free from inappropriate treatment . . . Definitions: Emotional Abuse: Behavior designed to hurt another person mentally. Includes yelling, threats, shaming, humiliation . . . Neglect: Failure to provide reasonable necessary goods and services to maintain the physical and mental health of any patient. Failure presents imminent danger to a patient or a substantial probability that death or serious physical injury. Neglects includes but is not limited to: Failure to provide adequate supervision or use approved interventions needed to mitigate serious danger . . . Providing Quality Care: Ensuring Therapeutic Relationships: All employees will abide by high standards to patient care . . . Patients must always be treated in a respectful, therapeutic, and culturally sensitive manner . . . Abuse, neglect, and other serious unacceptable behaviors are prohibited . . . Unacceptable behaviors include but are not limited to: gossiping about patients . . . falsifying records . . .” Review of the facility’s policy “Patient Rights,” effective 1/29/24, revealed: “Procedure: Except as otherwise provided . . . a patient has rights that include the following . . . to be treated with consideration and recognition of the patient’s dignity and individuality. . . to receive care in a safe, respectful, and the least restrictive setting and environment . . .” Review of the facility’s nursing department procedure “PNA Responsibilities,” effective 8/19/24, revealed: “. . . Employees are responsible for knowing and following Hospital Policy [and] Procedures (P&P) and Nursing Department Procedures (NDP) . . . Rounds: Unit round are to be made at the beginning of each shift and no less than every fifteen (15) minutes throughout the remainder of the shift to identify potential risks and to assure that a therapeutic and safe environment is maintained. All patients admitted to API [Alaska Psychiatric Institute] are monitored on Q15 checks (24/7) [24 hours a day, 7 days a week] during their hospitalization including all Close Observation Status Scale Orders (COSS) are monitored Q15 minutes . . . The staff member responsible for making the round is required to take a radio, the Patient Location Checklist, and a pen with them when they do rounds. They are responsible to: Do not just count heads, account for each patient according to their status . . . Staff are required to check on the physical well-being of the patients as well as their physical presence on the Unit. When the patient is in bed, sleeping, observe respirations (chest rising and falling) and listen for the patient’s breathing . . . Patient Care . . . Treat patients with dignity and respect at all times . . . Be alert for signs and/or symptoms that suggest a patient’s physical status may be deteriorating or at risk of evolving into a medical emergency. Notify the Charge Nurse if any concerns . . . Between rounds . . . Maintain and ensure patient safety . . . Document observations and incidents as they occur; describe in detail your observations and patient behavior . . .” Review of the facility’s nursing department procedure “Nurse Responsibilities,” effective 10/12/23, revealed: “. . . Employees are responsible for knowing and following Hospital Policy [and] Procedures (P&Ps) and Nursing Department Procedures (NDPs) . . . Unit Rounds are to be made at the beginning of each shift and each patient will be monitored on Routine Q15 minute checks (24/7) [24 hours a day, 7 days a week] during hospitalization to identify potential risks and to assure that a therapeutic and safe environment is maintained. Rounds are generally done by the PNA staff but may be done by a Nurse. The Nurse is responsible for weeing these are done regularly. The Nurse is responsible to assess every patient assigned to the unit at least once during their shift and not rely solely on the PNA to evaluate a patient’s well-being. The staff member responsible for making the round is required to take a radio, the Patient Location Checklist, and a pen with them when they do rounds . . .Staff is required to check on the physical well being of the patients as well as their physical presence on the Unit. When the patient is in bed, sleeping, observe respirations (chest rising and falling) and listen for the patient’s breathing . . . Patient Care: Treat patients with dignity and respect at all times. Know the location and activity of each patient on [1st degree] COSS at all times . . . Monitor each patient for signs and/or symptoms that suggest their physical status is deteriorating or at risk of evolving into a medical emergency . . . Between rounds . . . The Nurse is responsible for seeing that the PNAs carry out duties appropriately, chart correctly and perform to expectations . . . RN retains accountability for duties delegated to PNA staff . . . Ensure that significant interactions with patients are noted in the patient record and passed along in report. Document observations and incidents as they occur; chart accurately on patient noting incidents and behavior in detail . . .” Review of the facility’s policy “Medication Orders, Preparation, and Administration,” effective 5/19/22, revealed: “. . . A complete order indicates the following . . . PRN . . . orders require “clear intent” which implies the inclusion of the indication for use and/or precise instructions for PRN medications: The use of “PRN” with medication orders must be qualified to include the frequency and the specific symptom(s) of therapeutic indication for which the drug is to be used. The PRN therapeutic indication shall be clear and unique (no two medications shall have the same PRN indication) . . . Medication Administration Time Requirements . . . All scheduled medications are administered 90 minutes prior to or 90 minutes after the scheduled time . . . The Patient shall be monitored for their perception of side effects and the effectiveness of the medication(s). Necessary assessments and re-assessments shall be completed . . . All medications administered for any type of pain, all PRN medications, all 1st doses and all one time orders . . . require follow up documentation/reassessment: IM Medications - 30 minutes . . .” Review of the facility’s policy “Deterioration of Physical Status, Medical Emergencies, and Code Blue Response,” effective 8/12/24, revealed: “Purpose: To recognition of a deteriorating physical status is an interdisciplinary response that provides for early intervention and management of patients to decrease the risk for cardiopulmonary arrest and/or other adverse medical events . . . Procedure: Deteriorating Physical Status: Any API staff member, patient, visitor, or family member of patient may notify nursing staff of concern for deterioration in physical status of an API patient. The goal of the initial evaluation for deteriorating physical status is to identify and correct conditions before they progress to medically emergent of life-threatening status. Nursing staff response: If a patient exhibits early warning signs or symptoms, unit nursing staff will initiate an evaluation without delay using established criteria as guidelines (See Attachment: Criteria for Deteriorating Physical Status and Trigger for Response); - If criteria are met: Nursing staff will assess severity of signs or symptoms and will determine if immediate consultation by in-house staff or emergent consultation at outside facility (emergency room) is indicated; - If criteria are not present, but concern expressed by staff, family, etc.: Nursing staff will document concern, evaluation and follow-up using Situation Background Assessment Recommendation/Request (SBAR) [a format for note documentation] method including hand-off communication to on-coming shift. Nursing staff will provide verbal feedback to concerned party of increased vigilance for comprise of physical status . . . If at any time signs/symptoms progress towards meeting criteria, nursing will proceed with protocol for Deteriorating Physical Status . . .” Further review of the policy attachment “Criteria for Deteriorating Physical Status and Trigger for Response,” last updated 8/2022, revealed: Recognition of the following by staff and verification by Nursing staff should initiate contact with the medical Officer staff (MOS) or LIP [Provider] on call . . . Concern: Change in Respiratory Rate . . . Criteria: Respiratory rate is a change from baseline and less than 8 or greater than 28 . . . Response: Assess Vital Signs including Pulse Oximetry [oxygen saturation levels in the blood]; Loof for etiology (pain, infection, wheezing/rhonchi [noisy breath sounds]; Contact LIP/MOS to determine further level of care or work up . . . Concern: Altered Mental Status or Acute Chang in LOC [level of consciousness] or CNS [central nervous system] status . . . Criteria: Patient becomes somnolent, difficult to awaken, confused or obtunded or any other change in mental status or CNS status: ex. Pupil reaction, slurred speech, onset of unilateral limb or facial weakness; Response: Assess Vital Signs including Pulse Oximetry; Look for etiology (medication adverse effects, h/o [history of] stroke or embolism, h/o water intoxication); Contact LIP/MOS to determine further level of care or work up . . .” Review of the facility’s policy “Management of Patient Behavior,” effective 7/1/24, revealed: “. . . Policy: API will provide the least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and will ensure the safety and well-being of all patients, staff, and visitors . . . In situations where a patient exhibits behavior that are or have the imminent potential to be harmful to themselves or others, staff will intervene in the least restrictive manner effective to assist the patient to regain emotional control and to mitigate the danger of the situation. The following describes the therapeutic measure that may be used by staff during the escalation of dangerous patient behavior, from least restrictive to most restrictive: Non-verbal interventions; verbal interventions; Physical interventions to guide and direct a patient; and Physical interventions which restrict a patient’s movement . . . Management of Patient Behavior: API’s procedures safely and therapeutically manage and improve that behavior(s) of a patient manifesting from the patient’s emotional or behavioral disorder. These procedures include de-escalation of a patient through the progression of non-verbal, verbal, and physical interventions necessary to manage a patient’s behaviors safely and therapeutically. As a last resort, the interventions may include seclusion, physical holds/restraints, and mechanical restraints . . . Individual Behavior Plans (IBP): Refer to P&P [Policy and Procedure] PC-050-05.05 Treatment Planning . . .” Review of the facility policy “Code of Conduct,” effective 11/14/23, revealed: “. . . Policy: API staff will comply with standards of performance and conduct that have been established and will demonstrate honesty, integrity, respect for all persons, and commitment to professional and ethical service . . . Definitions: Culture of Safety: The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, and organization’s health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventative measures . . . Procedure: Commitment to Safety: API is committed to safety in all our values, beliefs, and activities. The standards of conduct are developed to assure a working environment that is safe for both patients and staff. Dignity and Respect: Employees, patients and their families, staff, students, interns, visitors, and contractors, will be treated respectfully and professionally at all times . . . Relationships with patients . . . All patients are to be treated with respect, dignity, and compassion . . .” .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure chemical restraints were not used for 1 Patient (#5), out of 1 patient reviewed, which restricted the patient’s behavior and freedom of movement within his/her room, which was an approved intervention in a treatment team-approved behavior plan (an individualized behavior plan to address challenging behaviors and interventions staff can use to work through them). This failed practice violated the patient’s right to be free from restraints, of any form. Findings: Patient #5 Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5’s court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment. Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension. Review of the most recent “Petition for Court Approval of Administration of Psychotropic Medication,” dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: “. . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . .” Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety, ranging from 1st degree to 3rd degree. The higher the degree number, the closer the observation interval), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety). Patient #5’s Treatment Plan Review of Patient #5’s “Multidisciplinary Master Treatment Plan,” dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: “Disturbance of Thought: “[Patient #5] shows active disturbance of though and oppositional behavior.” Further review revealed identified interventions to address Patient #5’s “disturbance of thought” that included: - “LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level,” initiated on 11/6/23; - “RN will prompt [Patient #5] to comply with safety behavior,” initiated on 1/30/24; - “Psychology will develop behavior plan to guide staff response to challenging behaviors,” initiated on 9/11/24; and - “Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes,” initiated 11/6/24. Patient #5’s Challenging Behaviors During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5’s history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor. The DON further stated that Patient #5’s behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as “normal” for Patient #5. During an interview on 4/30/25 at 10:21 AM, Patient #5’s Provider stated that Patient #5’s behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted. Patient #5’s Provider stated that these behaviors had been present since his/her 2020 admission. Patient #5’s Behavior Plan During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient’s behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times. Review of Patient #5’s behavior plan, last updated 3/25/25, revealed: - “Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an ‘episode.’” - “. . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . .” - “. . . If you notice [Patient #5] is about to have an “episode,” walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball.” - “Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an “episode.” Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5’s] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, “hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn’t flood.” Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress.” During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime. Patient #5’s Medication Regimen Review of Patient #5’s ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a “shot” form of medication if Patient #5 refused to take his/her medications by mouth. These were ordered by the courts to aid in Patient #5’s consistent treatment. These medications included: Scheduled Medications: 1) “Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia.” This order started on 1/21/25. Further review revealed: “Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU [IM, or shot, back up].” 1a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . .” This order started on 12/5/23 and remained in effect. 2) “Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia.” This order was started on 1/21/25. Further review revealed: “Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU.” 3) “Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia.” This order started on 2/25/25. Further review revealed: “Court ordered: If patient refuses, provide IMBU lorazepam.” 2a and 3a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . .” This order started on 9/30/24 and remained in effect. PRN Medications: 4) “Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation.” This order started on 12/20/23. Further review revealed: “Court ordered: If refused give haloperidol IMBU.” 4a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . .” This order started on 12/5/23 and remained in effect. 5) “Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation.” This order started on 2/6/25. Further review revealed: “Court ordered: If refused give Lorazepam IMBU.” 5a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . .” This order started on 9/30/24 and remained in effect. 6) “Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation.” This order started on 12/24/24. Further review revealed: “Court ordered: If refused give chlorpromazine IMBU.” 6a) “Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN.” This order started on 12/24/24 and remained in effect. Medication Administrations #1 for nightshift on 3/27/25 Review of Patient #5’s electronic Medication Administration Record (eMAR), dated 3/27/25, revealed: - At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation. Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order. - At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time). - At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time). - At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication. - At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication. Video Review of Medication Administrations #1 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed: - From 6:00 PM to 6:16 PM, Patient #5 was in the unit’s TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop. - At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom. During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior. - From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5’s bedroom door, which was closed, and looked in the window and listened. - At 7:02 PM, PNA #4 approached Patient #5’s bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse’s station to turn off Patient #5’s water. During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room’s water supplies could be turned off at the nurse’s station. When asked about Patient #5’s behavior plan, and needing to speak to Patient #5 about him/her exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off. - At 7:06 PM, PNA #11 approached Patient #5’s room to complete a safety check. - At 7:10 PM, PNA #11 approached Patient #5’s room to complete a safety check . On the video, Patient #5 could be heard making animal noises from within his/her room area. - At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications. During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth. - From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room. - At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this. Reassessment of Medications Administration #1 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 8:42 PM, LN #21 documented a reassessment for Patient #5’s response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both “Medication effectiveness for clinical indication: effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections. Medication Administrations #2 for Nightshift on 3/27/25 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation. - At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication. Video Review of Medication Administration #2 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of “severe agitation” from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5’s behavior plan were attempted. Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5’s bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA’s #7 and #11, and exited shortly after. During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used. When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse’s discretion to determine what those terms mean. When asked what she thought “severe agitation” meant, the ADON stated it would mean to the point of causing potential harm to self or others. During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling. The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication. During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan. When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed. Reassessment of Medication Administration #2 Further review of Patient #5’s eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5’s response to the IMBU Chlorpromazine (16 minutes after its administration): “Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient. During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5’s room. Review of Patient #5’s nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: “Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] ‘seizure like shaking.’ Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn’t show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Patient #5’s Aggressive Behavior During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025. During an interview on 4/30/25 at 11:00 AM, the Patient #5’s Provider stated consoling and encouraging was the best therapy for Patient #5’s during his/her episodes. During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5’s “severe agitation” would look like, Patient #5’s Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff. When asked if rolling on the floor, tapping, and making animal noises in Patient #5’s bedroom area would be considered “severe agitation” and warrant PRN medication, Patient #5’s Provider stated, “No. The treatment team made the decision to be as least restrictive as possible with [Patient #5].” The Director of QAPI was in the room during this interview and asked Patient #5’s Provider, “What if Patient #5 was rolling on the floor and making animal noises for hours?” Patient #5’s Provider stated, “No, as long as [he/she] was in [his/her] room it would not warrant PRN medication.” An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5’s Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5’s Provider returned to the room and stated Patient #5’s lengthy behavior of rolling around on the floor and making animal noises could be considered agitation. During an interview on 6/2/25 at 1:16 PM, the Education Coordinator stated the definition of a chemical restraint was to cause sedation to limit or stop a behavior. When asked about the facility’s policy on chemical restraint, the Education Coordinator stated the facility did not use chemical restraints, and was considered prohibited, and this was trained to all staff. Review of the facility’s policy “Patient Rights,” effective 1/29/24, revealed: “Procedure: Except as otherwise provided . . . a patient has rights that include the following . . . to be free from physical or chemical restraints . . . to be treated with consideration and recognition of the patient’s dignity and individuality . . . to be free from unnecessary or excessive medications . . . to receive care in a safe, respectful, and the least restrictive setting and environment . . .” Review of the facility’s policy “Medication Orders, Preparation, and Administration,” effective 5/19/22, revealed: “. . . A complete order indicates the following . . . PRN . . . orders require “clear intent” which implies the inclusion of the indication for use and/or precise instructions for PRN medications: The use of “PRN” with medication orders must be qualified to include the frequency and the specific symptom(s) of therapeutic indication for which the drug is to be used. The PRN therapeutic indication shall be clear and unique (no two medications shall have the same PRN indication) . . . Medication Administration Time Requirements . . . All scheduled medications are administered 90 minutes prior to or 90 minutes after the scheduled time . . . The Patient shall be monitored for their perception of side effects and the effectiveness of the medication(s). Necessary assessments and re-assessments shall be completed . . . All medications administered for any type of pain, all PRN medications, all 1st doses and all one time orders . . . require follow up documentation/reassessment: IM Medications - 30 minutes . . .” Review of the facility’s policy “Management of Patient Behavior,” effective 7/1/24, revealed: “. . . Policy: API will provide the least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and will ensure the safety and well-being of all patients, staff, and visitors . . . In situations where a patient exhibits behavior that are or have the imminent potential to be harmful to themselves or others, staff will intervene in the least restrictive manner effective to assist the patient to regain emotional control and to mitigate the danger of the situation. The following describes the therapeutic measure that may be used by staff during the escalation of dangerous patient behavior, from least restrictive to most restrictive: Non-verbal interventions; verbal interventions; Physical interventions to guide and direct a patient; and Physical interventions which restrict a patient’s movement . . . Management of Patient Behavior: API’s procedures safely and therapeutically manage and improve that behavior(s) of a patient manifesting from the patient’s emotional or behavioral disorder. These procedures include de-escalation of a patient through the progression of non-verbal, verbal, and physical interventions necessary to manage a patient’s behaviors safely and therapeutically. As a last resort, the interventions may include seclusion, physical holds/restraints, and mechanical restraints . . . Individual Behavior Plans (IBP): Refer to P&P [Policy and Procedure] PC-050-05.05 Treatment Planning . . .” Review of the facility policy “Treatment Planning,” effective 1/22/25, revealed: “. . . Individual Behavioral Plans: If the patient demonstrates unsafe behaviors that do not respond to other intervention on the Treatment Plan, the Treatment Team may recommend the patient receive an assessment and an Individualized Behavioral Plan (IBP) . . . The IBP will specifically target maladaptive behaviors and document adaptive/replacement behaviors and interventions . . . The Clinical Services MHC [Mental Health Clinician] will educate team members on the implementation of the IBP and specific behavioral strategies . . . The IBP will be attached to the Daily Nursing Communication Report for each patient, every day, to be reviewed by staff as they receive report and arrive on the unit . . .” .”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure the nightshift Licensed Nurses (LN #’s 16 and 21) supervised and evaluated the nursing care provided for 1 Patient (#5), out of 1 patient reviewed. Specifically, LN #16 and #21 failed to: 1) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications; 2) Appropriately assess and offer PRN (as needed) medication to Patient #5 prior to administering court ordered IMBU medication; 3) Appropriately re-assess Patient #5, within the facility’s standard timeframe, after each administration of IMBU medication was received; and 4) Appropriately completed an evaluation for Patient #5 after reports of concern of possible deterioration of physical status were reported by Psychiatric Nursing Assistants (PNA #’s 7 and 12). These failed practices, to not appropriately assess the patient’s care needs, health status/condition, and response to interventions, placed Patient #5 at risk for a compromised airway and deterioration of physical status, which had the potential to increase the risk of respiratory distress, and harm, up to and including death. Findings: Patient #5 Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5’s court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment. Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension. Review of the most recent “Petition for Court Approval of Administration of Psychotropic Medication,” dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: “. . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . .” Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety, ranging from 1st degree to 3rd degree. The higher the degree number, the closer the observation interval), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety). Patient #5’s Treatment Plan Review of Patient #5’s “Multidisciplinary Master Treatment Plan,” dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: “Disturbance of Thought: “[Patient #5] shows active disturbance of though and oppositional behavior.” Further review revealed identified interventions to address Patient #5’s “disturbance of thought” that included: - “LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level,” initiated on 11/6/23; - “RN will prompt [Patient #5] to comply with safety behavior,” initiated on 1/30/24; - “Psychology will develop behavior plan to guide staff response to challenging behaviors,” initiated on 9/11/24; and - “Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes,” initiated 11/6/24. Patient #5’s Challenging Behaviors During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5’s history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor. The DON further stated that Patient #5’s behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as “normal” for Patient #5. During an interview on 4/30/25 at 10:21 AM, Patient #5’s Provider stated that Patient #5’s behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted. Patient #5’s Provider stated that these behaviors had been present since his/her 2020 admission. Patient #5’s Behavior Plan During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient’s behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times. Review of Patient #5’s behavior plan, last updated 3/25/25, revealed: - “Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an ‘episode.’” - “. . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . .” - “. . . If you notice [Patient #5] is about to have an “episode,” walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball.” - “Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an “episode.” Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5’s] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, “hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn’t flood.” Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress.” During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime. Patient #5’s Medication Regimen Review of Patient #5’s ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a “shot” form of medication if Patient #5 refused to take his/her medications by mouth. These were ordered by the courts to aid in Patient #5’s consistent treatment. These medications included: Scheduled Medications: 1) “Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia.” This order started on 1/21/25. Further review revealed: “Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU [IM, or shot, back up].” 1a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . .” This order started on 12/5/23 and remained in effect. 2) “Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia.” This order was started on 1/21/25. Further review revealed: “Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU.” 3) “Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia.” This order started on 2/25/25. Further review revealed: “Court ordered: If patient refuses, provide IMBU lorazepam.” 2a and 3a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . .” This order started on 9/30/24 and remained in effect. PRN Medications: 4) “Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation.” This order started on 12/20/23. Further review revealed: “Court ordered: If refused give haloperidol IMBU.” 4a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . .” This order started on 12/5/23 and remained in effect. 5) “Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation.” This order started on 2/6/25. Further review revealed: “Court ordered: If refused give Lorazepam IMBU.” 5a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . .” This order started on 9/30/24 and remained in effect. 6) “Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation.” This order started on 12/24/24. Further review revealed: “Court ordered: If refused give chlorpromazine IMBU.” 6a) “Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN.” This order started on 12/24/24 and remained in effect. Medication Administrations #1 for nightshift on 3/27/25 Review of Patient #5’s electronic Medication Administration Record (eMAR), dated 3/27/25, revealed: - At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation. Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order. - At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time). - At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time). - At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication. - At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication. Video Review of Medication Administrations #1 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed: - From 6:00 PM to 6:16 PM, Patient #5 was in the unit’s TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop. - At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom. During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior. - From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5’s bedroom door, which was closed, and looked in the window and listened. - At 7:02 PM, PNA #4 approached Patient #5’s bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse’s station to turn off Patient #5’s water. During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room’s water supplies could be turned off at the nurse’s station. When asked about Patient #5’s behavior plan, and needing to speak to Patient #5 about him/her exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off. - At 7:06 PM, PNA #11 approached Patient #5’s room to complete a safety check. - At 7:10 PM, PNA #11 approached Patient #5’s room to complete a safety check. On the video, Patient #5 could be heard making animal noises from within his/her room area. - At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications. During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth. - From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room. - At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this. Reassessment of Medications Administration #1 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 8:42 PM, LN #21 documented a reassessment for Patient #5’s response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both “Medication effectiveness for clinical indication: effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections. Medication Administrations #2 for Nightshift on 3/27/25 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation. - At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication. Video Review of Medication Administration #2 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of “severe agitation” from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5’s behavior plan were attempted. Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5’s bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA’s #7 and #11, and exited shortly after. During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used. When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse’s discretion to determine what those terms mean. When asked what she thought “severe agitation” meant, the ADON stated it would mean to the point of causing potential harm to self or others. During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling. The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication. During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan. When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed. Reassessment of Medication Administration #2 Further review of Patient #5’s eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5’s response to the IMBU Chlorpromazine (16 minutes after its administration): “Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient. During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5’s room. Review of Patient #5’s nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: “Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] ‘seizure like shaking.’ Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn’t show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Patient #5’s Aggressive Behavior During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025. During an interview on 4/30/25 at 11:00 AM, the Patient #5’s Provider stated consoling and encouraging was the best therapy for Patient #5’s during his/her episodes. During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5’s “severe agitation” would look like, Patient #5’s Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff. When asked if rolling on the floor, tapping, and making animal noises in Patient #5’s bedroom area be considered “severe agitation” and warrant PRN medication, Patient #5’s Provider stated, “No. The treatment team made the decision to be as least restrictive as possible with [Patient #5].” The Director of QAPI was in the room during this interview and asked Patient #5’s Provider, “What if Patient #5 was rolling on the floor and making animal noises for hours?” Patient #5’s Provider stated, “No, as long as [he/she] was in [his/her] room it would not warrant PRN medication.” An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5’s Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5’s Provider returned to the room and stated Patient #5’s lengthy behavior of rolling around on the floor and making animal noises could be considered agitation. Incident on 3/28/25 During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night. The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient’s status for safety), told another PNA in the hall that Patient #5 was, “laying down on the table.” The “table” was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk. The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side. As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5’s left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair. During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn’t think it was something alarming. An observation on 4/30/25 at 2:38 PM, of Patient #5’s bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5’s upper body to be lower than his/her hips, buttocks, and legs which were still on the desk. Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck. Further observation revealed that when standing in the doorway of Patient #5’s bedroom, a person’s view would have been of Patient #5’s buttocks, legs, and feet only, with a minimal view of Patient #5’s back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5’s face or the rise and fall of Patient #5’s front chest during respirations, which was face down in the chair. During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient. When asked what if the patient resisted, the ADON stated then repeated attempts should be tried until the patient is positioned for safety. This could be trying to physically move the patient or communicate with the patient to achieve cooperation to move into a safer position. Review of the facility’s video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 7:15 AM, revealed: - From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5’s bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA’s in the hall, it could be heard on the video that PNA #7 stated, “[he’s/she’s] laying on down on the table.” PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door. - From 2:15 AM to 2:53 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time. - From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5. - At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited. - At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the light and could be heard calling Patient #5’s name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse’s station to get the nurses. PNA #7 could be heard on the video recording saying, “[he’s/she’s] not moving.” At 4:32 AM, PNA #12 told nurses, “[he/she] was breathing earlier” when they met him/her at Patient #5’s doorway. All staff entered Patient #5’s bedroom. Staff could be heard calling Patient #5’s name. PNA #11 said, “let me get a pillow for [his/her] head” and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, “[he/she] was holding onto something.” During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closest to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5’s pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down. The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5’s bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, “no.” Review of Patient #5’s nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: “. . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Further review revealed no documentation of the pulse check, or the rate assessed, that the LNs reported completing at 4:29 AM. No other assessment information was documented, nor was there any documentation that the LNs reported this incident/concern to their supervisor. During an interview on 4/30/25 at 12:39 AM, when asked what the expectation would be for an LN who was asked to come assess a patient for breathing, the Lead Educator stated the expectation would be to complete a head-to-toe assessment and call medical staff if needed. Further review of the facility video recording, dated 3/28/25, revealed: - At 4:38 AM, PNA #7 completed a patient safety check for Patient #5 by standing in the doorway. - At 4:45 AM, PNA #12 completed a patient safety check for Patient #5. PNA #12 entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 37 seconds, then exited. - From 4:59 AM to 5:41 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #12 completed the check at 4:59 AM, PNA #8 completed the checks at 5:11 AM, 5:28 AM, and 5:41 AM. - At 5:54 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 1 minute, 50 seconds, then exited. - At 6:01 AM, PNA #7 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. - At 6:11 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and could be heard calling Patient #5’s name. PNA #7 was in the room for 1 minute, then exited. - At 6:29 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 35 seconds, then exited. - At 6:47 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #12 could be heard on the video recording saying, “[Patient #5] is going to be sore in the morning.” - At 6:59 AM, PNA #12 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. Shift change was conducted at 7:00 AM - At 7:10 AM, PNA #7 completed a patient safety check round with dayshift PNA #9 and PNA #10. Both dayshift PNAs laughed at Patient #5’s position on the desk and chair. PNA #10 called out Patient #5’s name. PNA #9 stated, “You don’t see that every day.” PNA #9 asked, “did the nurses know about it?” and left to get the dayshift LN #30 to look at Patient #5. When LN #30 looked into Patient #5’s bedroom from the hall, he/she laughed out loud, shook his/her head, and walked away back towards the nurse’s station. At 7:12 AM, PNA #9 could be heard on the video saying, “This should be a meme.” During an interview on 6/2/25 at 9:51 AM, when asked what state of dress Patient #5 was in, the Risk Manager stated Patient #5’s underwear was down past his/her buttocks. - At 7:13 AM, dayshift PNA #13 looked into Patient #5’s room, turned back to the PNAs with a disapproving look, and entered Patient #5’s bedroom. PNA #10 also entered the room and closed the door. PNA #13 left the room to go get LN #30 back into Patient #5’s bedroom and could be heard saying, “you better get a pulse.” - At 7:14 AM, PNA #13 called on the radio to have the front desk announce a Code Blue to Katmai unit. “Code Blue Katmai Unit” could be heard on the overhead page system. Staff immediately brought the crash cart. Other staff members entered the unit to assist, including the Assistant Director of Nursing (ADON). Review of the facility provided “Emergency [and] Disaster Treatment Form” (A code blue documentation sheet), dated 3/28/25, revealed: - 7:17 AM: “Start CPR [cardiopulmonary resuscitation]” - 7:17 AM: “Attaching AED [automated external defibrillator]. No pulse. O2 [Oxygen] pulled. Suction pulled. O2 applied . . . calling 911. Asked for a [second] O2 tank. Not getting air in (“locked up”).” - 7:20 AM: “No shock advised. [Second] O2 tank connected.” - 7:21 AM: “Suction in mouth used. Continuing CPR [and] rescue breaths. Continues to be stiff. Can feel pulse in neck with CPR. Pt cold to the touch.” - 7:24 AM: “No pulse. AED - no shock advised. No pulse. EMS arrived . . .” Further observation of the facility video recording revealed EMS arrived on Katmai unit at 7:25 AM. During an interview on 4/30/25 at 1:12 PM, the Director of QAPI stated that when LN #30 entered the room, staff moved Patient #5 off the desk and placed him/her on the floor. The Director of QAPI stated once Patient #5 was on the floor they could see that Patient #5’s face and his/her tongue was hanging out of his/her mouth and his/her jaw was stiff and closed around his/her tongue. Also, Patient #5’s left arm remained tucked close to his/her chest because it was stiff and did not move due to being in a rigor mortis state. The Director of QAPI stated LN #30 initiated CPR and three rounds of CPR were attempted by facility staff, but no shock was advised with the AED that facility staff had placed during CPR. The Director of QAPI further stated that when EMS arrived, they attempted two rounds of CPR and again no shock was advised. EMS determined Patient #5 was deceased and stopped CPR efforts. During an interview on 5/1/25 at 10:45 AM, the ADON stated that when she entered Patient #5’s room, responding to the Code Blue announcement, Patient #5 was on the floor dressed in a T-shirt and boxers. The ADON stated staff said they had to pull the boxers up because Patient #5’s genitals were exposed when they laid him/her on the floor. The ADON stated Patient #5’s tongue was out a little bit, and blood was seen around his/her mouth and a little on his/her nose (which the ADON suspected was probably from his/her mouth, because it was not coming from inside his/her nose). The ADON stated she attempted to use the AMBU bag to help with respirations, while LN #30 was performing CPR, however Patient #5’s neck was stiff, and she was not able to tilt his/her head back or open his/her jaw. The ADON stated Patient #5 was cool and clammy when touched and Patient #5’s t-shirt was wet. The ADON stated she suspected this wetness was urine, because it had an odor, but this was never confirmed. The ADON stated she remembered it being wet because the shirt was cut off when the AED was applied during CPR efforts. - At 7:56 AM, Anchorage Police Department arrived on Katmai unit. - At 7:59 AM, EMS left the Katmai unit. - At 9:36 AM, Medical Examiner arrived on Katmai unit. - At 10:17 AM, Medical Examiner departed with Patient #5. During an interview on 5/1/25 at 9:27 AM, when asked why there was no documentation in Patient #5’s medical record about the 3/28/25 incident (other than the cold blue form), the Director of QAPI stated the nurses from nightshift and dayshift were too emotionally unstable to complete any documentation on the day of Patient #5’s death. Then the chart was locked down due to Patient #5’s death. When asked how it was possible an addendum to LN #21’s 3/28/25 nurse’s note was placed, the Director of QAPI stated she allowed LN #21 to make that addendum based on camera review of the time discrepancy. Review of the facility’s policy “Medication Orders, Preparation, and Administration,” effective 5/19/22, revealed: “. . . A complete order indicates the following . . . PRN . . . orders require “clear intent” which implies the inclusion of the indication for use and/or precise instructions for PRN medications: The use of “PRN” with medication orders must be qualified to include the frequency and the specific symptom(s) of therapeutic indication for which the drug is to be used. The PRN therapeutic indication shall be clear and unique (no two medications shall have the same PRN indication) . . . Medication Administration Time Requirements . . . All scheduled medications are administered 90 minutes prior to or 90 minutes after the scheduled time . . . The Patient shall be monitored for their perception of side effects and the effectiveness of the medication(s). Necessary assessments and re-assessments shall be completed . . . All medications administered for any type of pain, all PRN medications, all 1st doses and all one time orders . . . require follow up documentation/reassessment: IM Medications - 30 minutes . . .” Review of the facility’s policy “Deterioration of Physical Status, Medical Emergencies, and Code Blue Response,” effective 8/12/24, revealed: “Purpose: To recognition of a deteriorating physical status is an interdisciplinary response that provides for early intervention and management of patients to decrease the risk for cardiopulmonary arrest and/or other adverse medical events . . . Procedure: Deteriorating Physical Status: Any API staff member, patient, visitor, or family member of patient may notify nursing staff of concern for deterioration in physical status of an API patient. The goal of the initial evaluation for deteriorating physical status is to identify and correct conditions before they progress to medically emergent of life-threatening status. Nursing staff response: If a patient exhibits early warning signs or symptoms, unit nursing staff will initiate an evaluation without delay using established criteria as guidelines (See Attachment: Criteria for Deteriorating Physical Status and Trigger for Response); - If criteria are met: Nursing staff will assess severity of signs or symptoms and will determine if immediate consultation by in-house staff or emergent consultation at outside facility (emergency room) is indicated; - If criteria are not present, but concern expressed by staff, family, etc.: Nursing staff will document concern, evaluation and follow-up using Situation Background Assessment Recommendation/Request (SBAR) [a format for note documentation] method including hand-off communication to on-coming shift. Nursing staff will provide verbal feedback to concerned party of increased vigilance for comprise of physical status . . . If at any time signs/symptoms progress towards meeting criteria, nursing will proceed with protocol for Deteriorating Physical Status . . .” Further review of the policy attachment “Criteria for Deteriorating Physical Status and Trigger for Response,” last updated 8/2022, revealed: Recognition of the following by staff and verification by Nursing staff should initiate contact with the medical Officer staff (MOS) or LIP [Provider] on call . . . Concern: Change in Respiratory Rate . . . Criteria: Respiratory rate is a change from baseline and less than 8 or greater than 28 . . . Response: Assess Vital Signs including Pulse Oximetry [oxygen saturation levels in the blood]; Loof for etiology (pain, infection, wheezing/rhonchi [noisy breath sounds]; Contact LIP/MOS to determine further level of care or work up . . . Concern: Altered Mental Status or Acute Chang in LOC [level of consciousness] or CNS [central nervous system] status . . . Criteria: Patient becomes somnolent, difficult to awaken, confused or obtunded or any other change in mental status or CNS status: ex. Pupil reaction, slurred speech, onset of unilateral limb or facial weakness; Response: Assess Vital Signs including Pulse Oximetry; Look for etiology (medication adverse effects, h/o [history of] stroke or embolism, h/o water intoxication); Contact LIP/MOS to determine further level of care or work up . . .” .”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure the nightshift Licensed Nurses (LN #s 16 and 21) prepare and administer medications in accordance with the orders of the practitioner and accepted standards of practice for 1 Patient (#5), out of 1 patient reviewed. Specifically, LN #16 and LN #21 failed to: 1) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications; 2) Appropriately administer PRN (as needed) medications, based on the written parameters within the medication orders; 3) Appropriately assess and offer PO PRN medication to Patient #5 prior to administering court ordered IMBU medication; and 4) Appropriately re-assess Patient #5, within the facility’s standard timeframe, after each administration of IMBU medication was received. This failed practice violated the court-approved petition for court ordered medications, denied Patient #5 the choice of potentially accepting PO medications, and placed the patient at risk for adverse drug reactions. Findings: Patient #5 Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5’s court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment. Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension. Review of the most recent “Petition for Court Approval of Administration of Psychotropic Medication,” dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: “. . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . .” Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety, ranging from 1st degree to 3rd degree. The higher the degree number, the closer the observation interval), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety). Patient #5’s Treatment Plan Review of Patient #5’s “Multidisciplinary Master Treatment Plan,” dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: “Disturbance of Thought: “[Patient #5] shows active disturbance of though and oppositional behavior.” Further review revealed identified interventions to address Patient #5’s “disturbance of thought” that included: - “LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level,” initiated on 11/6/23; - “RN will prompt [Patient #5] to comply with safety behavior,” initiated on 1/30/24; - “Psychology will develop behavior plan to guide staff response to challenging behaviors,” initiated on 9/11/24; and - “Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes,” initiated 11/6/24. Patient #5’s Challenging Behaviors During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5’s history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor. The DON further stated that Patient #5’s behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as “normal” for Patient #5. During an interview on 4/30/25 at 10:21 AM, Patient #5’s Provider stated that Patient #5’s behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted. Patient #5’s Provider stated that these behaviors had been present since his/her 2020 admission. Patient #5’s Behavior Plan During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient’s behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times. Review of Patient #5’s behavior plan, last updated 3/25/25, revealed: - “Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an ‘episode.’” - “. . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . .” - “. . . If you notice [Patient #5] is about to have an “episode,” walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball.” - “Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an “episode.” Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5’s] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, “hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn’t flood.” Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress.” During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime. Patient #5’s Medication Regimen Review of Patient #5’s ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a “shot” form of medication if Patient #5 refused to take his/her medications by mouth. These were ordered by the courts to aid in Patient #5’s consistent treatment. These medications included: Scheduled Medications: 1) “Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia.” This order started on 1/21/25. Further review revealed: “Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU [IM, or shot, back up].” 1a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . .” This order started on 12/5/23 and remained in effect. 2) “Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia.” This order was started on 1/21/25. Further review revealed: “Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU.” 3) “Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia.” This order started on 2/25/25. Further review revealed: “Court ordered: If patient refuses, provide IMBU lorazepam.” 2a and 3a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . .” This order started on 9/30/24 and remained in effect. PRN Medications: 4) “Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation.” This order started on 12/20/23. Further review revealed: “Court ordered: If refused give haloperidol IMBU.” 4a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . .” This order started on 12/5/23 and remained in effect. 5) “Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation.” This order started on 2/6/25. Further review revealed: “Court ordered: If refused give Lorazepam IMBU.” 5a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . .” This order started on 9/30/24 and remained in effect. 6) “Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation.” This order started on 12/24/24. Further review revealed: “Court ordered: If refused give chlorpromazine IMBU.” 6a) “Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN.” This order started on 12/24/24 and remained in effect. Medication Administrations #1 for nightshift on 3/27/25 Review of Patient #5’s electronic Medication Administration Record (eMAR), dated 3/27/25, revealed: - At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation. Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order. - At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time). - At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time). - At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication. - At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication. Video Review of Medication Administrations #1 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed: - From 6:00 PM to 6:16 PM, Patient #5 was in the unit’s TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop. - At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom. During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior. - From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5’s bedroom door, which was closed, and looked in the window and listened. - At 7:02 PM, PNA #4 approached Patient #5’s bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse’s station to turn off Patient #5’s water. During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room’s water supplies could be turned off at the nurse’s station. When asked about Patient #5’s behavior plan, and needing to speak to Patient #5 about exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off. - At 7:06 PM, PNA #11 approached Patient #5’s room to complete a safety check. - At 7:10 PM, PNA #11 approached Patient #5’s room to complete a safety check . On the video, Patient #5 could be heard making animal noises from within his/her room area. - At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications. During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth. - From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room. - At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this. Reassessment of Medications Administration #1 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 8:42 PM, LN #21 documented a reassessment for Patient #5’s response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both “Medication effectiveness for clinical indication: effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections. Medication Administrations #2 for Nightshift on 3/27/25 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation. - At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication. Video Review of Medication Administration #2 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of “severe agitation” from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5’s behavior plan were attempted. Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5’s bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA’s #7 and #11, and exited shortly after. During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used. When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse’s discretion to determine what those terms mean. When asked what she thought “severe agitation” meant, the ADON stated it would mean to the point of causing potential harm to self or others. During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling. The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication. During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan. When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed. Reassessment of Medication Administration #2 Further review of Patient #5’s eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5’s response to the IMBU Chlorpromazine (16 minutes after its administration): “Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient. During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5’s room. Review of Patient #5’s nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: “Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] ‘seizure like shaking.’ Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn’t show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Patient #5’s Aggressive Behavior During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025. During an interview on 4/30/25 at 11:00 AM, the Patient #5’s Provider stated consoling and encouraging was the best therapy for Patient #5’s during his/her episodes. During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5’s “severe agitation” would look like, Patient #5’s Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff. When asked if rolling on the floor, tapping, and making animal noises in Patient #5’s bedroom area be considered “severe agitation” and warrant PRN medication, Patient #5’s Provider stated, “No. The treatment team made the decision to be as least restrictive as possible with [Patient #5].” The Director of QAPI was in the room during this interview and asked Patient #5’s Provider, “What if Patient #5 was rolling on the floor and making animal noises for hours?” Patient #5’s Provider stated, “No, as long as [he/she] was in [his/her] room it would not warrant PRN medication.” An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5’s Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5’s Provider returned to the room and stated Patient #5’s lengthy behavior of rolling around on the floor and making animal noises could be considered agitation. Review of the facility’s policy “Medication Orders, Preparation, and Administration,” effective 5/19/22, revealed: “. . . A complete order indicates the following . . . PRN . . . orders require “clear intent” which implies the inclusion of the indication for use and/or precise instructions for PRN medications: The use of “PRN” with medication orders must be qualified to include the frequency and the specific symptom(s) of therapeutic indication for which the drug is to be used. The PRN therapeutic indication shall be clear and unique (no two medications shall have the same PRN indication) . . . Medication Administration Time Requirements . . . All scheduled medications are administered 90 minutes prior to or 90 minutes after the scheduled time . . . The Patient shall be monitored for their perception of side effects and the effectiveness of the medication(s). Necessary assessments and re-assessments shall be completed . . . All medications administered for any type of pain, all PRN medications, all 1st doses and all one time orders . . . require follow up documentation/reassessment: IM Medications - 30 minutes . . .” Review of the facility’s policy “Deterioration of Physical Status, Medical Emergencies, and Code Blue Response,” effective 8/12/24, revealed: “Purpose: To recognition of a deteriorating physical status is an interdisciplinary response that provides for early intervention and management of patients to decrease the risk for cardiopulmonary arrest and/or other adverse medical events . . . Procedure: Deteriorating Physical Status: Any API staff member, patient, visitor, or family member of patient may notify nursing staff of concern for deterioration in physical status of an API patient. The goal of the initial evaluation for deteriorating physical status is to identify and correct conditions before they progress to medically emergent of life-threatening status. Nursing staff response: If a patient exhibits early warning signs or symptoms, unit nursing staff will initiate an evaluation without delay using established criteria as guidelines (See Attachment: Criteria for Deteriorating Physical Status and Trigger for Response); - If criteria are met: Nursing staff will assess severity of signs or symptoms and will determine if immediate consultation by in-house staff or emergent consultation at outside facility (emergency room) is indicated; - If criteria are not present, but concern expressed by staff, family, etc.: Nursing staff will document concern, evaluation and follow-up using Situation Background Assessment Recommendation/Request (SBAR) [a format for note documentation] method including hand-off communication to on-coming shift. Nursing staff will provide verbal feedback to concerned party of increased vigilance for comprise of physical status . . . If at any time signs/symptoms progress towards meeting criteria, nursing will proceed with protocol for Deteriorating Physical Status . . .” Further review of the policy attachment “Criteria for Deteriorating Physical Status and Trigger for Response,” last updated 8/2022, revealed: Recognition of the following by staff and verification by Nursing staff should initiate contact with the medical Officer staff (MOS) or LIP [Provider] on call . . . Concern: Change in Respiratory Rate . . . Criteria: Respiratory rate is a change from baseline and less than 8 or greater than 28 . . . Response: Assess Vital Signs including Pulse Oximetry [oxygen saturation levels in the blood]; Loof for etiology (pain, infection, wheezing/rhonchi [noisy breath sounds]; Contact LIP/MOS to determine further level of care or work up . . . Concern: Altered Mental Status or Acute Chang in LOC [level of consciousness] or CNS [central nervous system] status . . . Criteria: Patient becomes somnolent, difficult to awaken, confused or obtunded or any other change in mental status or CNS status: ex. Pupil reaction, slurred speech, onset of unilateral limb or facial weakness; Response: Assess Vital Signs including Pulse Oximetry; Look for etiology (medication adverse effects, h/o [history of] stroke or embolism, h/o water intoxication); Contact LIP/MOS to determine further level of care or work up . . .” .”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure medical records were complete and accurate that described the patient’s progress and response to medications and services, for 1 Patient (#5), out of 15 sampled patients. Specifically, the facility failed to: 1) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications; 2) Appropriately assess and offer PRN (as needed) medication to Patient #5 prior to administering court ordered IMBU medication; 3) Appropriately re-assess Patient #5, within the facility’s standard timeframe, after each administration of IMBU medication was received; and 4) Appropriately completed an evaluation for Patient #5 after reports of concern of possible deterioration of physical status were reported by Psychiatric Nursing Assistants (PNA #’s 7 and 12). This failed practice placed the patient at risk for incomplete medical records and caused an incomplete accounting of all interventions, care, and treatment provided, and responses from these medications and services. Patient #5 passed away in the facility. Findings: Patient #5 Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5’s court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment. Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension. Review of the most recent “Petition for Court Approval of Administration of Psychotropic Medication,” dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: “. . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . .” Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety, ranging from 1st degree to 3rd degree. The higher the degree number, the closer the observation interval), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety). Patient #5’s Treatment Plan Review of Patient #5’s “Multidisciplinary Master Treatment Plan,” dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: “Disturbance of Thought: “[Patient #5] shows active disturbance of though and oppositional behavior.” Further review revealed identified interventions to address Patient #5’s “disturbance of thought” that included: - “LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level,” initiated on 11/6/23; - “RN will prompt [Patient #5] to comply with safety behavior,” initiated on 1/30/24; - “Psychology will develop behavior plan to guide staff response to challenging behaviors,” initiated on 9/11/24; and - “Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes,” initiated 11/6/24. Patient #5’s Challenging Behaviors During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5’s history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor. The DON further stated that Patient #5’s behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as “normal” for Patient #5. During an interview on 4/30/25 at 10:21 AM, Patient #5’s Provider stated that Patient #5’s behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted. Patient #5’s Provider stated that these behaviors had been present since his/her 2020 admission. Patient #5’s Behavior Plan During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient’s behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times. Review of Patient #5’s behavior plan, last updated 3/25/25, revealed: - “Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an ‘episode.’” - “. . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . .” - “. . . If you notice [Patient #5] is about to have an “episode,” walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball.” - “Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an “episode.” Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5’s] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, “hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn’t flood.” Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress.” During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime. Patient #5’s Medication Regimen Review of Patient #5’s ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a “shot” form of medication if Patient #5 refused to take his/her medications by mouth. These were ordered by the courts to aid in Patient #5’s consistent treatment. These medications included: Scheduled Medications: 1) “Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia.” This order started on 1/21/25. Further review revealed: “Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU [IM, or shot, back up].” 1a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . .” This order started on 12/5/23 and remained in effect. 2) “Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia.” This order was started on 1/21/25. Further review revealed: “Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU.” 3) “Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia.” This order started on 2/25/25. Further review revealed: “Court ordered: If patient refuses, provide IMBU lorazepam.” 2a and 3a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . .” This order started on 9/30/24 and remained in effect. PRN Medications: 4) “Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation.” This order started on 12/20/23. Further review revealed: “Court ordered: If refused give haloperidol IMBU.” 4a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . .” This order started on 12/5/23 and remained in effect. 5) “Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation.” This order started on 2/6/25. Further review revealed: “Court ordered: If refused give Lorazepam IMBU.” 5a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . .” This order started on 9/30/24 and remained in effect. 6) “Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation.” This order started on 12/24/24. Further review revealed: “Court ordered: If refused give chlorpromazine IMBU.” 6a) “Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN.” This order started on 12/24/24 and remained in effect. Medication Administrations #1 for nightshift on 3/27/25 Review of Patient #5’s electronic Medication Administration Record (eMAR), dated 3/27/25, revealed: - At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation. Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order. - At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time). - At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time). - At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication. - At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication. Video Review of Medication Administrations #1 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed: - From 6:00 PM to 6:16 PM, Patient #5 was in the unit’s TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop. - At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom. During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior. - From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5’s bedroom door, which was closed, and looked in the window and listened. - At 7:02 PM, PNA #4 approached Patient #5’s bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse’s station to turn off Patient #5’s water. During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room’s water supplies could be turned off at the nurse’s station. When asked about Patient #5’s behavior plan, and needing to speak to Patient #5 about him/her exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off. - At 7:06 PM, PNA #11 approached Patient #5’s room to complete a safety check. - At 7:10 PM, PNA #11 approached Patient #5’s room to complete a safety check. On the video, Patient #5 could be heard making animal noises from within his/her room area. - At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications. During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth. - From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room. - At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this. Reassessment of Medications Administration #1 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 8:42 PM, LN #21 documented a reassessment for Patient #5’s response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both “Medication effectiveness for clinical indication: effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections. Medication Administrations #2 for Nightshift on 3/27/25 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation. - At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication. Video Review of Medication Administration #2 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of “severe agitation” from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5’s behavior plan were attempted. Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5’s bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA’s #7 and #11, and exited shortly after. During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used. When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse’s discretion to determine what those terms mean. When asked what she thought “severe agitation” meant, the ADON stated it would mean to the point of causing potential harm to self or others. During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling. The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication. During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan. When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed. Reassessment of Medication Administration #2 Further review of Patient #5’s eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5’s response to the IMBU Chlorpromazine (16 minutes after its administration): “Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient. During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5’s room. Review of Patient #5’s nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: “Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] ‘seizure like shaking.’ Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn’t show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Patient #5’s Aggressive Behavior During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025. During an interview on 4/30/25 at 11:00 AM, the Patient #5’s Provider stated consoling and encouraging was the best therapy for Patient #5’s during his/her episodes. During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5’s “severe agitation” would look like, Patient #5’s Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff. When asked if rolling on the floor, tapping, and making animal noises in Patient #5’s bedroom area be considered “severe agitation” and warrant PRN medication, Patient #5’s Provider stated, “No. The treatment team made the decision to be as least restrictive as possible with [Patient #5].” The Director of QAPI was in the room during this interview and asked Patient #5’s Provider, “What if Patient #5 was rolling on the floor and making animal noises for hours?” Patient #5’s Provider stated, “No, as long as [he/she] was in [his/her] room it would not warrant PRN medication.” An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5’s Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5’s Provider returned to the room and stated Patient #5’s lengthy behavior of rolling around on the floor and making animal noises could be considered agitation. Incident on 3/28/25 During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night. The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient’s status for safety), told another PNA in the hall that Patient #5 was, “laying down on the table.” The “table” was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk. The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side. As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5’s left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair. During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn’t think it was something alarming. An observation on 4/30/25 at 2:38 PM, of Patient #5’s bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5’s upper body to be lower than his/her hips, buttocks, and legs which were still on the desk. Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck. Further observation revealed that when standing in the doorway of Patient #5’s bedroom, a person’s view would have been of Patient #5’s buttocks, legs, and feet only, with a minimal view of Patient #5’s back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5’s face or the rise and fall of Patient #5’s front chest during respirations, which was face down in the chair. During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient. When asked what if the patient resisted, the ADON stated then repeated attempts should be tried until the patient is positioned for safety. This could be trying to physically move the patient or communicate with the patient to achieve cooperation to move into a safer position. Review of the facility’s video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 7:15 AM, revealed: - From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5’s bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA’s in the hall, it could be heard on the video that PNA #7 stated, “[he’s/she’s] laying on down on the table.” PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door. - From 2:15 AM to 2:53 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time. - From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5. - At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited. - At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the light and could be heard calling Patient #5’s name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse’s station to get the nurses. PNA #7 could be heard on the video recording saying, “[he’s/she’s] not moving.” At 4:32 AM, PNA #12 told nurses, “[he/she] was breathing earlier” when they met him/her at Patient #5’s doorway. All staff entered Patient #5’s bedroom. Staff could be heard calling Patient #5’s name. PNA #11 said, “let me get a pillow for [his/her] head” and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, “[he/she] was holding onto something.” During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closest to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5’s pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down. The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5’s bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, “no.” Review of Patient #5’s nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: “. . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Further review revealed no documentation of the pulse check, or the rate assessed, that the LNs reported completing at 4:29 AM. No other assessment information was documented, nor was there any documentation that the LNs reported this incident/concern to their supervisor. During an interview on 4/30/25 at 12:39 AM, when asked what the expectation would be for an LN who was asked to come assess a patient for breathing, the Lead Educator stated the expectation would be to complete a head-to-toe assessment and call medical staff if needed. Further review of the facility video recording, dated 3/28/25, revealed: - At 4:38 AM, PNA #7 completed a patient safety check for Patient #5 by standing in the doorway. - At 4:45 AM, PNA #12 completed a patient safety check for Patient #5. PNA #12 entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 37 seconds, then exited. - From 4:59 AM to 5:41 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #12 completed the check at 4:59 AM, PNA #8 completed the checks at 5:11 AM, 5:28 AM, and 5:41 AM. - At 5:54 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 1 minute, 50 seconds, then exited. - At 6:01 AM, PNA #7 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. - At 6:11 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and could be heard calling Patient #5’s name. PNA #7 was in the room for 1 minute, then exited. - At 6:29 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 35 seconds, then exited. - At 6:47 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #12 could be heard on the video recording saying, “[Patient #5] is going to be sore in the morning.” - At 6:59 AM, PNA #12 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. Shift change was conducted at 7:00 AM - At 7:10 AM, PNA #7 completed a patient safety check round with dayshift PNA #9 and PNA #10. Both dayshift PNAs laughed at Patient #5’s position on the desk and chair. PNA #10 called out Patient #5’s name. PNA #9 stated, “You don’t see that every day.” PNA #9 asked, “did the nurses know about it?” and left to get the dayshift LN #30 to look at Patient #5. When LN #30 looked into Patient #5’s bedroom from the hall, he/she laughed out loud, shook his/her head, and walked away back towards the nurse’s station. At 7:12 AM, PNA #9 could be heard on the video saying, “This should be a meme.” During an interview on 6/2/25 at 9:51 AM, when asked what state of dress Patient #5 was in, the Risk Manager stated Patient #5’s underwear was down past his/her buttocks. - At 7:13 AM, dayshift PNA #13 looked into Patient #5’s room, turned back to the PNAs with a disapproving look, and entered Patient #5’s bedroom. PNA #10 also entered the room and closed the door. PNA #13 left the room to go get LN #30 back into Patient #5’s bedroom and could be heard saying, “you better get a pulse.” - At 7:14 AM, PNA #13 called on the radio to have the front desk announce a Code Blue to Katmai unit. “Code Blue Katmai Unit” could be heard on the overhead page system. Staff immediately brought the crash cart. Other staff members entered the unit to assist, including the Assistant Director of Nursing (ADON). Review of the facility provided “Emergency [and] Disaster Treatment Form” (A code blue documentation sheet), dated 3/28/25, revealed: - 7:17 AM: “Start CPR [cardiopulmonary resuscitation]” - 7:17 AM: “Attaching AED [automated external defibrillator]. No pulse. O2 [Oxygen] pulled. Suction pulled. O2 applied . . . calling 911. Asked for a [second] O2 tank. Not getting air in (“locked up”).” - 7:20 AM: “No shock advised. [Second] O2 tank connected.” - 7:21 AM: “Suction in mouth used. Continuing CPR [and] rescue breaths. Continues to be stiff. Can feel pulse in neck with CPR. Pt cold to the touch.” - 7:24 AM: “No pulse. AED - no shock advised. No pulse. EMS arrived . . .” Further observation of the facility video recording revealed EMS arrived on Katmai unit at 7:25 AM. During an interview on 4/30/25 at 1:12 PM, the Director of QAPI stated that when LN #30 entered the room, staff moved Patient #5 off the desk and placed him/her on the floor. The Director of QAPI stated once Patient #5 was on the floor they could see that Patient #5’s face and his/her tongue was hanging out of his/her mouth and his/her jaw was stiff and closed around his/her tongue. Also, Patient #5’s left arm remained tucked close to his/her chest because it was stiff and did not move due to being in a rigor mortis state. The Director of QAPI stated LN #30 initiated CPR and three rounds of CPR were attempted by facility staff, but no shock was advised with the AED that facility staff had placed during CPR. The Director of QAPI further stated that when EMS arrived, they attempted two rounds of CPR and again no shock was advised. EMS determined Patient #5 was deceased and stopped CPR efforts. During an interview on 5/1/25 at 10:45 AM, the ADON stated that when she entered Patient #5’s room, responding to the Code Blue announcement, Patient #5 was on the floor dressed in a T-shirt and boxers. The ADON stated staff said they had to pull the boxers up because Patient #5’s genitals were exposed when they laid him/her on the floor. The ADON stated Patient #5’s tongue was out a little bit, and blood was seen around his/her mouth and a little on his/her nose (which the ADON suspected was probably from his/her mouth, because it was not coming from inside his/her nose). The ADON stated she attempted to use the AMBU bag to help with respirations, while LN #30 was performing CPR, however Patient #5’s neck was stiff, and she was not able to tilt his/her head back or open his/her jaw. The ADON stated Patient #5 was cool and clammy when touched and Patient #5’s t-shirt was wet. The ADON stated she suspected this wetness was urine, because it had an odor, but this was never confirmed. The ADON stated she remembered it being wet because the shirt was cut off when the AED was applied during CPR efforts. - At 7:56 AM, Anchorage Police Department arrived on Katmai unit. - At 7:59 AM, EMS left the Katmai unit. - At 9:36 AM, Medical Examiner arrived on Katmai unit. - At 10:17 AM, Medical Examiner departed with Patient #5. During an interview on 5/1/25 at 9:27 AM, when asked why there was no documentation in Patient #5’s medical record about the 3/28/25 incident (other than the cold blue form), the Director of QAPI stated the nurses from nightshift and dayshift were too emotionally unstable to complete any documentation on the day of Patient #5’s death. Then the chart was locked down due to Patient #5’s death. When asked how it was possible an addendum to LN #21’s 3/28/25 nurse’s note was placed, the Director of QAPI stated she allowed LN #21 to make that addendum based on camera review of the time discrepancy. Review of the facility’s policy “Medication Orders, Preparation, and Administration,” effective 5/19/22, revealed: “. . . A complete order indicates the following . . . PRN . . . orders require “clear intent” which implies the inclusion of the indication for use and/or precise instructions for PRN medications: The use of “PRN” with medication orders must be qualified to include the frequency and the specific symptom(s) of therapeutic indication for which the drug is to be used. The PRN therapeutic indication shall be clear and unique (no two medications shall have the same PRN indication) . . . Medication Administration Time Requirements . . . All scheduled medications are administered 90 minutes prior to or 90 minutes after the scheduled time . . . The Patient shall be monitored for their perception of side effects and the effectiveness of the medication(s). Necessary assessments and re-assessments shall be completed . . . All medications administered for any type of pain, all PRN medications, all 1st doses and all one time orders . . . require follow up documentation/reassessment: IM Medications - 30 minutes . . .” Review of the facility’s policy “Deterioration of Physical Status, Medical Emergencies, and Code Blue Response,” effective 8/12/24, revealed: “Purpose: To recognition of a deteriorating physical status is an interdisciplinary response that provides for early intervention and management of patients to decrease the risk for cardiopulmonary arrest and/or other adverse medical events . . . Procedure: Deteriorating Physical Status: Any API staff member, patient, visitor, or family member of patient may notify nursing staff of concern for deterioration in physical status of an API patient. The goal of the initial evaluation for deteriorating physical status is to identify and correct conditions before they progress to medically emergent of life-threatening status. Nursing staff response: If a patient exhibits early warning signs or symptoms, unit nursing staff will initiate an evaluation without delay using established criteria as guidelines (See Attachment: Criteria for Deteriorating Physical Status and Trigger for Response); - If criteria are met: Nursing staff will assess severity of signs or symptoms and will determine if immediate consultation by in-house staff or emergent consultation at outside facility (emergency room) is indicated; - If criteria are not present, but concern expressed by staff, family, etc.: Nursing staff will document concern, evaluation and follow-up using Situation Background Assessment Recommendation/Request (SBAR) [a format for note documentation] method including hand-off communication to on-coming shift. Nursing staff will provide verbal feedback to concerned party of increased vigilance for comprise of physical status . . . If at any time signs/symptoms progress towards meeting criteria, nursing will proceed with protocol for Deteriorating Physical Status . . .” Further review of the policy attachment “Criteria for Deteriorating Physical Status and Trigger for Response,” last updated 8/2022, revealed: Recognition of the following by staff and verification by Nursing staff should initiate contact with the medical Officer staff (MOS) or LIP [Provider] on call . . . Concern: Change in Respiratory Rate . . . Criteria: Respiratory rate is a change from baseline and less than 8 or greater than 28 . . . Response: Assess Vital Signs including Pulse Oximetry [oxygen saturation levels in the blood]; Loof for etiology (pain, infection, wheezing/rhonchi [noisy breath sounds]; Contact LIP/MOS to determine further level of care or work up . . . Concern: Altered Mental Status or Acute Chang in LOC [level of consciousness] or CNS [central nervous system] status . . . Criteria: Patient becomes somnolent, difficult to awaken, confused or obtunded or any other change in mental status or CNS status: ex. Pupil reaction, slurred speech, onset of unilateral limb or facial weakness; Response: Assess Vital Signs including Pulse Oximetry; Look for etiology (medication adverse effects, h/o [history of] stroke or embolism, h/o water intoxication); Contact LIP/MOS to determine further level of care or work up . . .” .”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure medical records contained nursing notes, reports of treatments, vital signs, and other information necessary to monitor the patient’s condition for 1 Patient (#5), out of 15 sampled residents. This failed practice placed the patient at risk for incomplete medical records and an incomplete accounting of all interventions, care, and treatment provided, including responses to these services. Patient #5 passed away in the facility. Findings: Patient #5 Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5’s court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment. Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension. Review of the most recent “Petition for Court Approval of Administration of Psychotropic Medication,” dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: “. . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . .” Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety). Patient #5’s Treatment Plan Review of Patient #5’s “Multidisciplinary Master Treatment Plan,” dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: “Disturbance of Thought: “[Patient #5] shows active disturbance of though and oppositional behavior.” Further review revealed identified interventions to address Patient #5’s “disturbance of thought” that included: - “LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level,” initiated on 11/6/23; - “RN will prompt [Patient #5] to comply with safety behavior,” initiated on 1/30/24; - “Psychology will develop behavior plan to guide staff response to challenging behaviors,” initiated on 9/11/24; and - “Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes,” initiated 11/6/24. Patient #5’s Challenging Behaviors During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5’s history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor. The DON further stated that Patient #5’s behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as “normal” for Patient #5. During an interview on 4/30/25 at 10:21 AM, Patient #5’s Provider stated that Patient #5’s behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted. Patient #5’s Provider stated that these behaviors had been present since his/her 2020 admission. Patient #5’s Behavior Plan During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient’s behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times. Review of Patient #5’s behavior plan, last updated 3/25/25, revealed: - “Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an ‘episode.’” - “. . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . .” - “. . . If you notice [Patient #5] is about to have an “episode,” walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball.” - “Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an “episode.” Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5’s] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, “hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn’t flood.” Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress.” During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime. Patient #5’s Medication Regimen Review of Patient #5’s ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a “shot” form of medication if Patient #5 refused to take his/her medications by mouth, called an IMBU (intramuscular, or IM, back up). These were ordered by the courts to aid in Patient #5’s consistent treatment. These medications included: Scheduled Medications 1) “Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia.” This order started on 1/21/25. Further review revealed: “Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU.” 1a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . .” This order started on 12/5/23 and remained in effect. 2) “Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia.” This order was started on 1/21/25. Further review revealed: “Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU.” 3) “Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia.” This order started on 2/25/25. Further review revealed: “Court ordered: If patient refuses, provide IMBU lorazepam.” 2a and 3a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . .” This order started on 9/30/24 and remained in effect. PRN Medications: 4) “Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation.” This order started on 12/20/23. Further review revealed: “Court ordered: If refused give haloperidol IMBU.” 4a) “Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . .” This order started on 12/5/23 and remained in effect. 5) “Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation.” This order started on 2/6/25. Further review revealed: “Court ordered: If refused give Lorazepam IMBU.” 5a) “Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . .” This order started on 9/30/24 and remained in effect. 6) “Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation.” This order started on 12/24/24. Further review revealed: “Court ordered: If refused give chlorpromazine IMBU.” 6a) “Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN.” This order started on 12/24/24 and remained in effect. Medication Administrations #1 for nightshift on 3/27/25 Review of Patient #5’s electronic Medication Administration Record (eMAR), dated 3/27/25, revealed: - At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation. Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order. - At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time). - At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time). - At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication. - At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication. Video Review of Medication Administrations #1 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed: - From 6:00 PM to 6:16 PM, Patient #5 was in the unit’s TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop. - At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom. During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior. - From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5’s bedroom door, which was closed, and looked in the window and listened. - At 7:02 PM, PNA #4 approached Patient #5’s bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse’s station to turn off Patient #5’s water. During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room’s water supplies could be turned off at the nurse’s station. When asked about Patient #5’s behavior plan, and needing to speak to Patient #5 about exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off. - At 7:06 PM, PNA #11 approached Patient #5’s room to complete a safety check. - At 7:10 PM, PNA #11 approached Patient #5’s room to complete a safety check. On the video, Patient #5 could be heard making animal noises from within his/her room area. - At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications. During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth. - From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room. - At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5’s room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this. Reassessment of Medications Administration #1 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 8:42 PM, LN #21 documented a reassessment for Patient #5’s response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both “Medication effectiveness for clinical indication: effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections. Medication Administrations #2 for Nightshift on 3/27/25 Review of Patient #5’s eMAR, dated 3/27/25, revealed: - At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation. - At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication. Video Review of Medication Administration #2 Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of “severe agitation” from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5’s behavior plan were attempted. Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5’s bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA’s #7 and #11, and exited shortly after. During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used. When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse’s discretion to determine what those terms mean. When asked what she thought “severe agitation” meant, the ADON stated it would mean to the point of causing potential harm to self or others. During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling. The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication. During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan. When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed. Reassessment of Medication Administration #2 Further review of Patient #5’s eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5’s response to the IMBU Chlorpromazine (16 minutes after its administration): “Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective.” Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment. During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient. During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5’s room. Review of Patient #5’s nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: “Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] ‘seizure like shaking.’ Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn’t show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Patient #5’s Aggressive Behavior During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025. During an interview on 4/30/25 at 11:00 AM, the Patient #5’s Provider stated consoling and encouraging was the best therapy for Patient #5’s during his/her episodes. During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5’s “severe agitation” would look like, Patient #5’s Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff. When asked if rolling on the floor, tapping, and making animal noises in Patient #5’s bedroom area would be considered “severe agitation” and warrant PRN medication, Patient #5’s Provider stated, “No. The treatment team made the decision to be as least restrictive as possible with [Patient #5].” The Director of QAPI was in the room during this interview and asked Patient #5’s Provider, “What if Patient #5 was rolling on the floor and making animal noises for hours?” Patient #5’s Provider stated, “No, as long as [he/she] was in [his/her] room it would not warrant PRN medication.” An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5’s Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5’s Provider returned to the room and stated Patient #5’s lengthy behavior of rolling around on the floor and making animal noises could be considered agitation. Incident on 3/28/25 During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night. The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient’s status for safety), told another PNA in the hall that Patient #5 was, “laying down on the table.” The “table” was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk. The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side. As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5’s left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair. During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn’t think it was something alarming. An observation on 4/30/25 at 2:38 PM, of Patient #5’s bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5’s upper body to be lower than his/her hips, buttocks, and legs which were still on the desk. Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck. Further observation revealed that when standing in the doorway of Patient #5’s bedroom, a person’s view would have been of Patient #5’s buttocks, legs, and feet only, with a minimal view of Patient #5’s back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5’s face or the rise and fall of Patient #5’s front chest during respirations, which was face down in the chair. During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient. When asked what if the patient resisted, the ADON stated then repeated attempts should be tried until the patient is positioned for safety. This could be trying to physically move the patient or communicate with the patient to achieve cooperation to move into a safer position. Review of the facility’s video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 4:29 AM, revealed: - From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5’s bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA’s in the hall, it could be heard on the video that PNA #7 stated, “[he’s/she’s] laying on down on the table.” PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door. - From 2:15 AM to 2:53 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time. - From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5. - At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited. - At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5’s bedroom. PNA #12 turned on the light and could be heard calling Patient #5’s name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse’s station to get the nurses. PNA #7 could be heard on the video recording saying, “[he’s/she’s] not moving.” At 4:32 AM, PNA #12 told nurses, “[he/she] was breathing earlier” when they met him/her at Patient #5’s doorway. All staff entered Patient #5’s bedroom. Staff could be heard calling Patient #5’s name. PNA #11 said, “let me get a pillow for [his/her] head” and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, “[he/she] was holding onto something.” During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closet to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5’s pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down. The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5’s bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, “no.” Review of Patient #5’s nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: “. . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . .” Further review revealed no documentation of the pulse check, or the rate assessed, that the LNs reported completing at 4:29 AM. No other assessment information was documented, nor was there any other documentation from the LNs on 3/28/25. During an interview on 4/30/25 at 12:39 AM, when asked what the expectation would be for an LN who was asked to come assess a patient for breathing, the Lead Educator stated the expectation would be to complete a head-to-toe assessment and call medical staff if needed. Review of the facility’s video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 4:38 AM to 7:14 AM, revealed: - At 4:38 AM, PNA #7 completed a patient safety check for Patient #5 by standing in the doorway. - At 4:45 AM, PNA #12 completed a patient safety check for Patient #5. PNA #12 entering Patient #5’s bedroom. PNA #12 turned on the bedroom light and was in the room for 37 seconds, then exited. - From 4:59 AM to 5:41 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #12 completed the check at 4:59 AM, PNA #8 completed the checks at 5:11 AM, 5:28 AM, and 5:41 AM. - At 5:54 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 1 minute, 50 seconds, then exited. - At 6:01 AM, PNA #7 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. - At 6:11 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and could be heard calling Patient #5’s name. PNA #7 was in the room for 1 minute, then exited. - At 6:29 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 35 seconds, then exited. - At 6:47 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #12 could be heard on the video recording saying, “[Patient #5] is going to be sore in the morning.” - At 6:59 AM, PNA #12 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door. Shift change was conducted at 7:00 AM - At 7:10 AM, PNA #7 completed a patient safety check round with dayshift PNA #9 and PNA #10. Both dayshift PNAs laughed at Patient #5’s position on the desk and chair. PNA #10 called out Patient #5’s name. PNA #9 stated, “You don’t see that every day.” PNA #9 asked, “did the nurses know about it?” and left to get the dayshift LN #30 to look at Patient #5. When LN #30 looked into Patient #5’s bedroom from the hall, he/she laughed out loud, shook his/her head, and walked away back towards the nurse’s station. At 7:12 AM, PNA #9 could be heard on the video saying, “This should be a meme.” During an interview on 6/2/25 at 9:51 AM, when asked what state of dress Patient #5 was in, the Risk Manager stated Patient #5’s pants were down past his/her buttocks. - At 7:13 AM, dayshift PNA #13 looked into Patient #5’s room, turned back to the PNAs with a disapproving look, and entered Patient #5’s bedroom. PNA #10 also entered the room and closed the door. PNA #13 left the room to go get LN #30 back into Patient #5’s bedroom and could be heard saying, “you better get a pulse.” - At 7:14 AM, PNA #13 called on the radio to have the front desk announce a Code Blue to Katmai unit. “Code Blue Katmai Unit” could be heard on the overhead page system. Staff immediately brought the crash cart. Other staff members entered the unit to assist, including the Assistant Director of Nursing (ADON). Review of the facility provided “Emergency [and] Disaster Treatment Form” (A code blue documentation sheet), dated 3/28/25, revealed: - 7:17 AM: “Start CPR [cardiopulmonary resuscitation]” - 7:17 AM: “Attaching AED [automated external defibrillator]. No pulse. O2 [Oxygen] pulled. Suction pulled. O2 applied . . . calling 911. Asked for a [second] O2 tank. Not getting air in (“locked up”).” - 7:20 AM: “No shock advised. [Second] O2 tank connected.” - 7:21 AM: “Suction in mouth used. Continuing CPR [and] rescue breaths. Continues to be stiff. Can feel pulse in neck with CPR. Pt cold to the touch.” - 7:24 AM: “No pulse. AED - no shock advised. No pulse. EMS arrived . . .” Further observation of the facility video recording revealed EMS arrived on Katmai unit at 7:25 AM. During an interview on 4/30/25 at 1:12 PM, the Director of QAPI stated that when LN #30 entered the room, he/she and other staff moved Patient #5 off the desk and placed him/her on the floor. The Director of QAPI stated once Patient #5 was on the floor they could see that Patient #5’s face and his/her tongue was hanging out of his/her mouth and his/her jaw was stiff and closed around his/her tongue. Also, Patient #5’s left arm remained tucked close to his/her chest because it was stiff and did not move due to being in a rigor mortis state. The Director of QAPI stated LN #30 initiated CPR and three rounds of CPR were attempted by facility staff, but no shock was advised with the AED that facility staff had placed during CPR. The Director of QAPI further stated that when EMS arrived, they attempted two rounds of CPR and again no shock was advised. EMS determined Patient #5 was deceased and stopped CPR efforts. During an interview on 5/1/25 at 10:45 AM, the ADON stated that when she entered Patient #5’s room, responding to the Code Blue announcement, Patient #5 was on the floor dressed in a T-shirt and boxers. The ADON stated staff said they had to pull the boxers up because Patient #5’s genitals were exposed when they laid him/her on the floor. The ADON stated Patient #5’s tongue was out a little bit, and blood was seen around his/her mouth and a little on his/her nose (which the ADON suspected was probably from his/her mouth, because it was not coming from inside his/her nose). The ADON stated she attempted to use the AMBU bag to help with respirations, while LN #30 was performing CPR, however Patient #5’s neck was stiff, and she was not able to tilt his/her head back or open his/her jaw. The ADON stated Patient #5 was cool and clammy when touched and Patient #5’s t-shirt was wet. The ADON stated she suspected this wetness was urine, because it had an odor, but this was never confirmed. The ADON stated she remembered it being wet because the shirt was cut off when the AED was applied during CPR efforts. Review of the facility’s video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 7:56 AM to 10:17 AM, revealed: - At 7:56 AM, Anchorage Police Department arrived on Katmai unit. - At 7:59 AM, EMS left the Katmai unit. - At 9:36 AM, Medical Examiner arrived on Katmai unit. - At 10:17 AM, Medical Examiner departed with Patient #5. During an interview on 5/1/25 at 9:27 AM, when asked why there was no documentation in Patient #5’s medical record about the 3/28/25 incident (other than the cold blue form), the Director of QAPI stated the nurses from nightshift and dayshift were too emotionally unstable to complete any documentation on the day of Patient #5’s death. Then the chart was locked down due to Patient #5’s death. When asked how it was possible an addendum to LN #21’s 3/28/25 nurse’s note was placed, the Director of QAPI stated she allowed LN #21 to make that addendum based on camera review of the time discrepancy. Policy Review Review of the facility’s policy “Abuse [and] Neglect; Conduct Involving Patients,” effective 10/16/24, revealed: “. . . Policy: Patients at API have the right to treatment in a setting that is physically and emotionally safe, and free from inappropriate treatment . . . Definitions: Emotional Abuse: Behavior designed to hurt another person mentally. Includes yelling, threats, shaming, humiliation . . . Neglect: Failure to provide reasonable necessary goods and services to maintain the physical and mental health of any patient. Failure presents imminent danger to a patient or a substantial probability that death or serious physical injury. Neglects includes but is not limited to: Failure to provide adequate supervision or use approved interventions needed to mitigate serious danger . . . Providing Quality Care: Ensuring Therapeutic Relationships: All employees will abide by high standards to patient care . . . Patients must always be treated in a respectful, therapeutic, and culturally sensitive manner . . . Abuse, neglect, and other serious unacceptable behaviors are prohibited . . . Unacceptable behaviors include but are not limited to: gossiping about patients . . . falsifying records . . .” Review of the facility’s policy “Patient Rights,” effective 1/29/24, revealed: “Procedure: Except as otherwise provided . . . a patient has rights that include the following . . . to be treated with consideration and recognition of the patient’s dignity and individuality. . . to receive care in a safe, respectful, and the least restrictive setting and environment . . .” Review of the facility’s nursing department procedure “PNA Responsibilities,” effective 8/19/24, revealed: “. . . Employees are responsible for knowing and following Hospital Policy [and] Procedures (P&P) and Nursing Department Procedures (NDP) . . . Rounds: Unit round are to be made at the beginning of each shift and no less than every fifteen (15) minutes throughout the remainder of the shift to identify potential risks and to assure that a therapeutic and safe environment is maintained. All patients admitted to API [Alaska Psychiatric Institute] are monitored on Q15 checks (24/7) [24 hours a day, 7 days a week] during their hospitalization including all Close Observation Status Scale Orders (COSS) are monitored Q15 minutes . . . The staff member responsible for making the round is required to take a radio, the Patient Location Checklist, and a pen with them when they do rounds. They are responsible to: Do not just count heads, account for each patient according to their status . . . Staff are required to check on the physical well-being of the patients as well as their physical presence on the Unit. When the patient is in bed, sleeping, observe respirations (chest rising and falling) and listen for the patient’s breathing . . . Patient Care . . . Treat patients with dignity and respect at all times . . . Be alert for signs and/or symptoms that suggest a patient’s physical status may be deteriorating or at risk of evolving into a medical emergency. Notify the Charge Nurse if any concerns . . . Between rounds . . . Maintain and ensure patient safety . . . Document observations and incidents as they occur; describe in detail your observations and patient behavior . . .” Review of the facility’s nursing department procedure “Nurse Responsibilities,” effective 10/12/23, revealed: “. . . Employees are responsible for knowing and following Hospital Policy [and] Procedures (P&Ps) and Nursing Department Procedures (NDPs) . . . Unit Rounds are to be made at the beginning of each shift and each patient will be monitored on Routine Q15 minute checks (24/7) [24 hours a day, 7 days a week] during hospitalization to identify potential risks and to assure that a therapeutic and safe environment is maintained. Rounds are generally done by the PNA staff but may be done by a Nurse. The Nurse is responsible for weeing these are done regularly. The Nurse is responsible to assess every patient assigned to the unit at least once during their shift and not rely solely on the PNA to evaluate a patient’s well-being. The staff member responsible for making the round is required to take a radio, the Patient Location Checklist, and a pen with them when they do rounds . . .Staff is required to check on the physical well being of the patients as well as their physical presence on the Unit. When the patient is in bed, sleeping, observe respirations (chest rising and falling) and listen for the patient’s breathing . . . Patient Care: Treat patients with dignity and respect at all times. Know the location and activity of each patient on [1st degree] COSS at all times . . . Monitor each patient for signs and/or symptoms that suggest their physical status is deteriorating or at risk of evolving into a medical emergency . . . Between rounds . . . The Nurse is responsible for seeing that the PNAs carry out duties appropriately, chart correctly and perform to expectations . . . RN retains accountability for duties delegated to PNA staff . . . Ensure that significant interactions with patients are noted in the patient record and passed along in report. Document observations and incidents as they occur; chart accurately on patient noting incidents and behavior in detail . . .” Review of the facility’s policy “Medication Orders, Preparation, and Administration,” effective 5/19/22, revealed: “. . . A complete order indicates the following . . . PRN . . . orders require “clear intent” which implies the inclusion of the indication for use and/or precise instructions for PRN medications: The use of “PRN” with medication orders must be qualified to include the frequency and the specific symptom(s) of therapeutic indication for which the drug is to be used. The PRN therapeutic indication shall be clear and unique (no two medications shall have the same PRN indication) . . . Medication Administration Time Requirements . . . All scheduled medications are administered 90 minutes prior to or 90 minutes after the scheduled time . . . The Patient shall be monitored for their perception of side effects and the effectiveness of the medication(s). Necessary assessments and re-assessments shall be completed . . . All medications administered for any type of pain, all PRN medications, all 1st doses and all one time orders . . . require follow up documentation/reassessment: IM Medications - 30 minutes . . .” Review of the facility’s policy “Deterioration of Physical Status, Medical Emergencies, and Code Blue Response,” effective 8/12/24, revealed: “Purpose: To recognition of a deteriorating physical status is an interdisciplinary response that provides for early intervention and management of patients to decrease the risk for cardiopulmonary arrest and/or other adverse medical events . . . Procedure: Deteriorating Physical Status: Any API staff member, patient, visitor, or family member of patient may notify nursing staff of concern for deterioration in physical status of an API patient. The goal of the initial evaluation for deteriorating physical status is to identify and correct conditions before they progress to medically emergent of life-threatening status. Nursing staff response: If a patient exhibits early warning signs or symptoms, unit nursing staff will initiate an evaluation without delay using established criteria as guidelines (See Attachment: Criteria for Deteriorating Physical Status and Trigger for Response); - If criteria are met: Nursing staff will assess severity of signs or symptoms and will determine if immediate consultation by in-house staff or emergent consultation at outside facility (emergency room) is indicated; - If criteria are not present, but concern expressed by staff, family, etc.: Nursing staff will document concern, evaluation and follow-up using Situation Background Assessment Recommendation/Request (SBAR) [a format for note documentation] method including hand-off communication to on-coming shift. Nursing staff will provide verbal feedback to concerned party of increased vigilance for comprise of physical status . . . If at any time signs/symptoms progress towards meeting criteria, nursing will proceed with protocol for Deteriorating Physical Status . . .” Further review of the policy attachment “Criteria for Deteriorating Physical Status and Trigger for Response,” last updated 8/2022, revealed: Recognition of the following by staff and verification by Nursing staff should initiate contact with the medical Officer staff (MOS) or LIP [Provider] on call . . . Concern: Change in Respiratory Rate . . . Criteria: Respiratory rate is a change from baseline and less than 8 or greater than 28 . . . Response: Assess Vital Signs including Pulse Oximetry [oxygen saturation levels in the blood]; Loof for etiology (pain, infection, wheezing/rhonchi [noisy breath sounds]; Contact LIP/MOS to determine further level of care or work up . . . Concern: Altered Mental Status or Acute Chang in LOC [level of consciousness] or CNS [central nervous system] status . . . Criteria: Patient becomes somnolent, difficult to awaken, confused or obtunded or any other change in mental status or CNS status: ex. Pupil reaction, slurred speech, onset of unilateral limb or facial weakness; Response: Assess Vital Signs including Pulse Oximetry; Look for etiology (medication adverse effects, h/o [history of] stroke or embolism, h/o water intoxication); Contact LIP/MOS to determine further level of care or work up . . .” Review of the facility’s policy “Management of Patient Behavior,” effective 7/1/24, revealed: “. . . Policy: API will provide the least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and will ensure the safety and well-being of all patients, staff, and visitors . . . In situations where a patient exhibits behavior that are or have the imminent potential to be harmful to themselves or others, staff will intervene in the least restrictive manner effective to assist the patient to regain emotional control and to mitigate the danger of the situation. The following describes the therapeutic measure that may be used by staff during the escalation of dangerous patient behavior, from least restrictive to most restrictive: Non-verbal interventions; verbal interventions; Physical interventions to guide and direct a patient; and Physical interventions which restrict a patient’s movement . . . Management of Patient Behavior: API’s procedures safely and therapeutically manage and improve that behavior(s) of a patient manifesting from the patient’s emotional or behavioral disorder. These procedures include de-escalation of a patient through the progression of non-verbal, verbal, and physical interventions necessary to manage a patient’s behaviors safely and therapeutically. As a last resort, the interventions may include seclusion, physical holds/restraints, and mechanical restraints . . . Individual Behavior Plans (IBP): Refer to P&P [Policy and Procedure] PC-050-05.05 Treatment Planning . . .” Review of the facility policy “Code of Conduct,” effective 11/14/23, revealed: “. . . Policy: API staff will comply with standards of performance and conduct that have been established and will demonstrate honesty, integrity, respect for all persons, and commitment to professional and ethical service . . . Definitions: Culture of Safety: The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, and organization’s health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventative measures . . . Procedure: Commitment to Safety: API is committed to safety in all our values, beliefs, and activities. The standards of conduct are developed to assure a working environment that is safe for both patients and staff. Dignity and Respect: Employees, patients and their families, staff, students, interns, visitors, and contractors, will be treated respectfully and professionally at all times . . . Relationships with patients . . . All patients are to be treated with respect, dignity, and compassion . . .” .”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 33393 . Based on record review and interview the facility failed to ensure informed consent processes for the use of psychotropic medications were executed in accordance with State law for one patient (#5) out of 11 sample patients. This failed practice placed the patient at risk for receiving medication against his or her will. Findings: Based on record review from 2/11-12/25 of Patient #5’s medical record review, dated 11/18/24 to 2/10/25, the patient had diagnoses that included: -traumatic brain injury (TBI- a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain); -schizoaffective disorder (a disorder in which the individual suffers from both symptoms that qualify as schizophrenia and symptoms that qualify as a mood disorder such depression or bipolar disorder, for a substantial portion of the active period of the illness, as well as episodes of delusions or hallucinations in the absence of prominent mood symptoms); -catatonia (a disorder that disrupts a person’s awareness); -borderline intellectual function with a full-scale IQ (FSIQ) below 70 (Suggests significantly below-average intellectual functioning. Often associated with cognitive impairments or developmental delays. Comprehensive support and interventions are typically required.); -neurocognitive disorder (a medical condition characterized by a decline in cognitive abilities such as memory, thinking, problem-solving, and language skills.); and -developmental disability (conditions due to an impairment in physical, learning, language, or behavior areas that may impact day to day functioning). Behavior Plan Review: Record review from 2/11-12/25 of Patient #5’s “Individualized Behavior Plan ...”, dated 12/17/24 revealed “ ...experiences a severe mental illness and traumatic brain injury - this affects [his/her] memory and attentions span ...[Patient #5] underwent psychological testing for [his/her cognitive function ...[he/she] has difficulties habituating basic skills ...show novel learning...inattention, impulsivity, and distractibility ...[Patient #5] exhibited difficulties habituating more complex skills based on repetition and difficult blending new information ...will need prompting and repetition of simple, single step instructions in order to complete task ...” Court Document Review: Record review of Patient #5’s medical record revealed the following court documents: August 2024: A petition for 90-day commitment, dated 8/20/24, revealed the petitioner alleged that Patient #5 continued to be gravely disabled, and there was reason to believe that the patient’s mental condition could be improved by continued course of treatment and was likely to cause serious harm to others. The document further stated that Patient #5 had severe deterioration over the past week secondary to noncompliance with scheduled medications and required previous crisis periods that were attributed to psychosis. An order for 90-day commitment, dated 8/23/24 was granted with an expiration date of 11/18/24. A petition for 90-day court approval of administration of psychotropic medications, dated 8/21/24, revealed the Patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and did not have the capacity to participate in treatment decisions by means of a rational thought process. The document further stated that Patient #5 had severe deterioration over the past week secondary to noncompliance with scheduled medications and required previous crisis periods that were attributed to psychosis. An order granting administration of psychotropic medication in non-crisis situations for court approval of administration of psychotropic medications, dated 8/23/24 was granted and filed on 8/21/24 with an expiration date of 11/19/24. November 2024: A petition for 180-day commitment, dated and filed on 11/18/24, revealed the petitioner alleged that Patient #5 continued to be gravely disabled, and there was reason to believe that the patient’s mental condition could be improved by continued course of treatment and remained highly assaultive and unpredictable. The document further stated that when unmedicated, Patient #5 decompensated very rapidly. A stipulation order for 180-day commitment, dated 12/9/24 was granted. A petition for approval of administration of psychotropic medications, dated and filed on 11/18/24, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and did not have the capacity to participate in treatment decisions by means of a rational thought process. No court order or stipulation order was granted for this petition. December 2024: A petition for 180-day court approval of administration of psychotropic medications, dated and filed on 12/9/24, revealed the Patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and did not have the capacity to participate in treatment decisions by means of a rational thought process. Record review of a facility provided email from Legal Staff #1 to Provider #1 and facility leadership and legal counsel, dated 12/9/24, revealed the facility withdrew the medication petition because Attorney #2 stated “ ...case ...resolved ...Client will stipulate to 180-day commitment and Provider #1 ...says client is being compliant with [his/her] medications so no hearing on the medication petition is needed today.” Further review of the same email revealed “Provider #1has informed [Legal Staff #1] that he/she wants to file [medication] again and go forward with [medication] hearing ...petition ready to be filed ...” Record review of a facility provided email from Provider #1 to Legal Staff #1 and facility legal counsel, dated 12/16/24, revealed “[Patient #5] will continue to be compliance but [his/her] public defender does not believe [he/she] has informed consent to agree to [his/her] current medication petition. The medication petition is being requested as the patient has previously been noncompliant during prior ...commitment and as a result had substantial deterioration ...” During an interview on 2/11/25 at 3:00 PM, Provider #1 stated Attorney #2 did not want to stipulate to medication administration, and he was under the assumption that medication stipulation would be revisited but did not occur. Provider #1 further stated that Attorney #2 filed only for commitment and not psychotropic medications. When asked if Patient #5 was competent to make informed decisions, he stated that Patient #5 didn’t understand why he/she was taking medication but will take them. In addition, he stated the Patient had a history of medication noncompliance. Record review on 2/12/25 of the facility’s “Unusual Occurrence Report (UOR)”, dated 1/30/25, revealed incident type was a medication issue. Further review revealed “[Provider #2] notified [registered nurse] and unit manager that [Patient #5] doesn’t have court order medication despite having a ‘court ordered’ labeled medication in the [Medication Administration Record MAR] for months...” January 2025: A petition for 180-day court approval of administration of psychotropic medications, dated and filed on 1/29/25, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process. During an interview on 2/11/25 at 2:33 PM, Provider #2 stated Patient #5 had a history of not taking medications necessary for the safety and well-being of himself/herself or others. Provider #2 further stated that Patient #5 did not have the cognitive capacity to make informed decisions and often confused. February 2025: An amended petition for 180-day court approval of administration of psychotropic medications, dated and filed on 1/29/25, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process. The amended petition was granted on 2/6/25. During an interview with the facility’s attorney on 2/11/25 at 2:14 PM, Attorney #1 stated that if a patient did not have capacity for informed consent, then a petition would be filed for commitment and psychotropic medication if treatment was deemed required. Medication Administration Review: Record review from 2/11-12/25 of Patient #5’s medical record, dated 12/5/24 to 2/5/25 (63 days) revealed the Patient was prescribed the follow psychotropic medications (medications that affect the mind, emotions, and behavior): -chlorpromazine (an antipsychotic agent to treat psychotic disorders) as needed for agitation, administered 34 of the 63 days; -hydroxyzine (a sedative used to treat anxiety) for anxiety, administered 46 of the 63 days; -lorazepam (a benzodiazepine used to treat anxiety) daily for anxiety, as well as lorazepam as need by mouth, if refused administer intramuscularly (IM) for anxiety, administered oral doses 63 of the 63 days. Record review from 2/11-12/25 of Patient #5’s medication record, dated 12/5/24 to 2/5/25 revealed the Patient refused medication attempts 61 times. Psychiatric Progress Note Review: Record review of “ ...Psychiatric Progress Note ...”, dated 11/18/24, revealed Patient #5 is missing morning medications due to sleeping in. Record review of “ ...Psychiatric Progress Note ...”, dated 12/10/24, revealed “needs [medication] court hearing.” Record review of “ ...Psychiatric Progress Note ...”, dated 1/2/25, revealed Patient #5 pretends to sleep and medication injection was administered. Record review of “ ...Psychiatric Progress Note ...”, dated 1/8/24, revealed Patient #5 continues to sleep in during the mornings and made statements about wanting to be compliant with medication all the time. Record review of “ ...Psychiatric Progress Note ...”, dated 1/14/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 1/17/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 1/23/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 1/29/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 1/30/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 2/5/25, revealed events of medication refusal since last encounter. State Law Review: During an interview on 2/11/24, the Chief Clinical Officer stated it was the responsibility of the providers to ensure a valid consent was active before ordering the administration of psychotropic medications. Review of the facility’s policy “MS-030-16 Psychotropic Medications and Informed Consent,” dated 10/16/24, revealed “ ...Alaska Psychiatric Institute (API) will follow Alaska Statutes (AS) 47.30.836 - 47.30.839 in the administration of psychotropic medication ...court ordered medications will be ordered and administered in accordance with state statute.” Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed “Sec. 47.30.836. Psychotropic medication in non-crisis situation. (a) An evaluation facility or designated treatment facility may not administer psychotropic medication to a patient in a situation that does not involve a crisis under AS 47.30.838(a)(1) unless the patient (1) has the capacity to give informed consent to the medication, as described in AS 47.30.837, and gives that consent; the facility shall document the consent in the patient’s medical chart; or ... (3) is determined by a court to lack the capacity to give informed consent to the medication and the court approves use of the medication under AS 47.30.839.” Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed “Sec. 47.30.837. Informed consent. ...(c) If an evaluation facility or designated treatment facility has provided to the patient the information necessary for the patient’s consent to be informed and the patient voluntarily consents, the facility may administer psychotropic medication to the patient unless the facility has reason to believe that the patient is not competent to make medical or mental health treatment decisions. If the facility has reason to believe that the patient is not competent to make medical or mental health treatment decisions and the facility wishes to administer psychotropic medication to the patient, the facility shall follow the procedures of AS 47.30.839. Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed Sec. 47.30.839. Court-ordered administration of medication. (a) An evaluation facility or designated treatment facility may use the procedures described in this section to obtain court approval of administration of psychotropic medication if (1) there have been, or it appears that there will be, repeated crisis situations as described in AS 47.30.838(a)(1) and the facility wishes to use psychotropic medication in future crisis situations; or (2) the facility wishes to use psychotropic medication in a noncrisis situation and has reason to believe the patient is incapable of giving informed consent ...” Record review on 2/12/25 of the facility provided training entitled “Informed Consent of Psychotropic Medications”, last updated 2024, revealed “Psychiatric [Licensed Provider] may seek court approval for administration of psychotropic medication ...Hearing on capacity to give informed consent and best interest of patient.” Review of the facility’s policy “PRE-030-02 Patient Rights,” dated 1/29/24, revealed “Psychotropic Medications and Informed Consent,” dated 10/16/24, revealed “To ensure that the civil and legal rights of patients are not restricted during their stay at the Alaska Psychiatric Institute (API).” .”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 33393 . Based on record review and interview the facility failed to ensure the medical record contained informed consent and/or court order for the use of psychotropic medications under State law for one patient (#5) out of 11 sampled patients. This failed practice placed the patient at risk for receiving medication against his or her will. Findings: Review of the facility’s policy “IM-050-05.04 Documentation Standards,” dated 1/20/22, revealed “The health record reflects patient care and is used: ...As a means of communication among physicians and professional groups; As a means of communication between clinical staff; To reflect and document the quality of care rendered the patient; ...Documentation of the following must be reflected in the applicable EHR template by responsible staff: ...Change in legal status” Based on record review from 2/11-12/25 of Patient #5’s medical record review, dated 11/18/24 to 2/10/25, the patient had diagnoses that included: -traumatic brain injury (TBI- a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain); -schizoaffective disorder (a disorder in which the individual suffers from both symptoms that qualify as schizophrenia and symptoms that qualify as a mood disorder such depression or bipolar disorder, for a substantial portion of the active period of the illness, as well as episodes of delusions or hallucinations in the absence of prominent mood symptoms); -catatonia (a disorder that disrupts a person’s awareness); -borderline intellectual function with a full-scale IQ (FSIQ) below 70 (Suggests significantly below-average intellectual functioning. Often associated with cognitive impairments or developmental delays. Comprehensive support and interventions are typically required.); -neurocognitive disorder (a medical condition characterized by a decline in cognitive abilities such as memory, thinking, problem-solving, and language skills.); and -developmental disability (conditions due to an impairment in physical, learning, language, or behavior areas that may impact day to day functioning). Behavior Plan Review: Record review from 2/11-12/25 of Patient #5’s “Individualized Behavior Plan ...”, dated 12/17/24, revealed “ ...experiences a severe mental illness and traumatic brain injury - this affects [his/her] memory and attentions span ...[Patient #5] underwent psychological testing for [his/her cognitive function ...[he/she] has difficulties habituating basic skills ...show novel learning...inattention, impulsivity, and distractibility ...[Patient #5] exhibited difficulties habituating more complex skills based on repetition and difficult blending new information ...will need prompting and repetition of simple, single step instructions in order to complete task ...” Court Document Review: Record review of Patient #5’s medical record revealed the following court documents: November 2024: A petition for approval of administration of psychotropic medications, dated and filed on 11/18/24, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and did not have the capacity to participate in treatment decisions by means of a rational thought process. No court order or stipulation order was granted for this petition. December 2024: A petition for 180-day court approval of administration of psychotropic medications, dated and filed on 12/9/24, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process. Record review of a facility provided email from Legal Staff #1 to Provider #1 and facility leadership and legal counsel, dated 12/9/24, revealed the facility withdrew the medication petition because Attorney #2 stated “ ...case ...resolved ...Client will stipulate to 180-day commitment and Provider #1 ...says client is being compliant with [his/her] medications so no hearing on the medication petition is needed today.” Further review of the same email revealed “Provider #1 has informed [Legal Staff #1] that he/she wants to file [medication] again and go forward with [medication] hearing ...petition ready to be filed ...” Record review of a facility provided email from Provider #1 to Legal Staff #1 and facility legal counsel, dated 12/16/24, revealed “[Patient #5] will continue to be compliance but [his/her] public defender does not believe [he/she] has informed consent to agree to [his/her] current medication petition. The medication petition is being requested as the patient has previously been noncompliant during prior ...commitment and as a result had substantial deterioration ...” During an interview on 2/11/25 at 3:00 PM, Provider #1 stated the patient’s public defender and public advocate did not want to stipulate to medication administration and he was under the assumption that medication stipulation would be revisited but did not occur. Provider #1 further stated that the public defender filed only for commitment and not psychotropic medications. When asked if Patient #5 was competent to make informed decisions, he stated that Patient #5 didn’t understand why he/she was taking medication but will take them. In addition, he stated the Patient had a history of medication noncompliance. Record review on 2/12/25 of the facility’s “Unusual Occurrence Report (UOR)”, dated 1/30/25, revealed incident type was a medication issue. Further review revealed “[Provider #2] notified [registered nurse] and unit manager that [Patient #5] doesn’t have court order medication despite having a ‘court ordered’ labeled medication in the [Medication Administration Record MAR] for months...” January 2025: A petition for 180-day court approval of administration of psychotropic medications, dated and filed on 1/29/25, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process. During an interview on 2/11/25 at 2:33 PM, Provider #2 stated Patient #5 had a history of not taking medications necessary for the safety and well-being of himself/herself or others. Provider #2 further stated that Patient #5 did not have the cognitive capacity to make informed decisions and often confused. February 2025: An amended petition for 180-day court approval of administration of psychotropic medications, dated and filed on 1/29/25, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process. A court order, dated 2/6/25, was granted. During an interview with the facility’s attorney on 2/11/25 at 2:14 PM, Attorney #1 stated that if a patient did not have capacity for informed consent, then a petition would be filed for commitment and psychotropic medication if treatment was deemed required. As a result, Patient #5 did not have informed consent and/or court ordered for the administration of psychotropic medications from 12/5/24 to 2/5/25 for a total of 63 days. Medication Administration Review: Record review from 2/11-12/25 of Patient #5’s medical record, dated 12/5/24 to 2/5/25 (63 days) revealed the patient was prescribed the follow psychotropic medications (medications that affect the mind, emotions, and behavior): -chlorpromazine (an antipsychotic agent to treat psychotic disorders) as needed for agitation, administered 34 of the 63 days; -hydroxyzine (a sedative used to treat anxiety) for anxiety, administered 46 of the 63 days; -lorazepam (a benzodiazepine used to treat anxiety) daily for anxiety, as well as lorazepam as need by mouth, if refused administer intramuscularly (IM) for anxiety, administered oral doses 63 of the 63 days. Psychiatric Progress Note Review: Record review of “ ...Psychiatric Progress Note ...”, dated 11/18/24, revealed Patient #5 is missing morning medications due to sleeping in. Record review of “ ...Psychiatric Progress Note ...”, dated 12/10/24, revealed “needs [medication] court hearing.” Record review of “ ...Psychiatric Progress Note ...”, dated 1/2/25, revealed Patient #5 pretends to sleep and medication injection was administered. Record review of “ ...Psychiatric Progress Note ...”, dated 1/8/24, revealed Patient #5 continues to sleep in during the mornings and made statements about wanting to be compliant with medication all the time. Record review of “ ...Psychiatric Progress Note ...”, dated 1/14/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 1/17/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 1/23/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 1/29/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 1/30/25, revealed events of medication refusal since last encounter. Record review of “ ...Psychiatric Progress Note ...”, dated 2/5/25, revealed events of medication refusal since last encounter. State Law Review: During an interview on 2/11/24, the Chief Clinical Officer stated it was the responsibility of the providers to ensure a valid consent was active before ordering the administration of psychotropic medications. Review of the facility’s policy “MS-030-16 Psychotropic Medications and Informed Consent,” dated 10/16/24, revealed “ ...Alaska Psychiatric Institute (API) will follow Alaska Statutes (AS) 47.30.836 - 47.30.839 in the administration of psychotropic medication ...court ordered medications will be ordered and administered in accordance with state statute.” Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed “Sec. 47.30.836. Psychotropic medication in non-crisis situation. (a) An evaluation facility or designated treatment facility may not administer psychotropic medication to a patient in a situation that does not involve a crisis under AS 47.30.838(a)(1) unless the patient (1) has the capacity to give informed consent to the medication, as described in AS 47.30.837, and gives that consent; the facility shall document the consent in the patient’s medical chart; or ... (3) is determined by a court to lack the capacity to give informed consent to the medication and the court approves use of the medication under AS 47.30.839.” Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed “Sec. 47.30.837. Informed consent. ...(c) If an evaluation facility or designated treatment facility has provided to the patient the information necessary for the patient’s consent to be informed and the patient voluntarily consents, the facility may administer psychotropic medication to the patient unless the facility has reason to believe that the patient is not competent to make medical or mental health treatment decisions. If the facility has reason to believe that the patient is not competent to make medical or mental health treatment decisions and the facility wishes to administer psychotropic medication to the patient, the facility shall follow the procedures of AS 47.30.839. Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed Sec. 47.30.839. Court-ordered administration of medication. (a) An evaluation facility or designated treatment facility may use the procedures described in this section to obtain court approval of administration of psychotropic medication if (1) there have been, or it appears that there will be, repeated crisis situations as described in AS 47.30.838(a)(1) and the facility wishes to use psychotropic medication in future crisis situations; or (2) the facility wishes to use psychotropic medication in a noncrisis situation and has reason to believe the patient is incapable of giving informed consent ...” Record review on 2/12/25 of the facility provided training entitled “Informed Consent of Psychotropic Medications”, last updated 2024, revealed “Psychiatric [Licensed Provider] may seek court approval for administration of psychotropic medication ...Hearing on capacity to give informed consent and best interest of patient.” .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to meet the Condition of Participation of Patient Right’s according to CFR 482.13. The facility failed to protect and promote each patient’s rights which had the potential to place all patients (based on a census of 72) at risk for exposure to verbal and physical abuse and prohibited physical hold techniques used during escalated emergencies. Findings: 1. The facility failed to ensure a patient’s right to receive care in a safe setting was maintained for 3 patients (#’s 1, 15, and 32), out of 7 patients reviewed. Specifically, the facility failed to: 1) Re-educated one Psychiatric Nursing Assistant (PNA) (#6) who was identified to use incorrect physical hold techniques during an incident on 12/4/23 when physically restraining an escalated patient (#1); 2) Identify, correct, and/or report PNA #6’s use of incorrect physical hold techniques during an incident on 12/11/23 when physically restraining an escalated patient (#15); and 3) Protect other patients after the 12/11/23 incident, which resulted in PNA #6’s continued use of incorrect physical hold techniques during an incident on 12/13/23 when physically restraining an escalated patient (#32). (Refer to A-144). 2. The facility failed to ensure a patient’s right to be free from all forms of abuse or harassment were upheld for 1 patient (#15), out of 7 patients reviewed. This failed practice exposed this patient to verbal and physical abuse, intimidation, and retaliation which instigated an escalation and a crisis event which resulted in physical restraint. (Refer to A-145). .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure a patient’s right to receive care in a safe setting was maintained for 3 patients (#’s 1, 15, and 32), out of 7 patients reviewed. Specifically, the facility failed to: 1) Re-educated one Psychiatric Nursing Assistant (PNA) (#6) who was identified to use incorrect physical hold techniques during an incident on 12/4/23 when physically restraining an escalated patient (#1); 2) Identify, correct, and/or report PNA #6’s use of incorrect physical hold techniques during an incident on 12/11/23 when physically restraining an escalated patient (#15); and 3) Protect other patients after the 12/11/23 incident, which resulted in PNA #6’s continued use of incorrect physical hold techniques during an incident on 12/13/23 when physically restraining an escalated patient (#32). These failed practices resulted in these patients having prohibited hold techniques inflicted on them during emergency brief manual holds (physical restraint used to control a patient’s arms and movements for safety) when escalated, which increased the risk of asphyxiation, and had the potential to place all patients (based on a census of 72) at risk for inappropriate hold techniques during an escalated incident. Findings: Incident on 12/4/23 Patient #1 Record review on 12/29/23 and 1/3/24 revealed Patient #1 was admitted to the facility with diagnoses that included Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and Reactive Attachment Disorder (RAD - a condition where a child doesn’t form health emotional bonds and has trouble managing their emotions). Further review revealed Patient #1 had a history of self-harm behavior. Review of the facility’s video recording on 1/3/24 at 9:29 AM, of an incident that occurred on 12/4/23, revealed Patient #1 was escalated and had attempted to use a cinder block from the greenhouse to hit himself/herself on the forehead repeatedly. A brief manual hold was initiated by Therapist #9. Further review revealed PNA #6 entered the greenhouse to assist Therapist #9 and took over the hold. PNA #6 was observed to place his/her arms over and around Patient #1’s upper arms from behind. Patient #1 slipped out of the hold, sat on the ground and attempted to hit the staff. PNA #6 was observed to kneel directly behind and slightly above Patient #1 and placed his/her arms around Patient #1 in the same fashion as before. PNA #6 applied pressure with his/her chest to the back of Patient #1’s upper shoulder/neck area, and pushed forward and down from above, forcing Patient #1’s head down towards his/her chest. PNA #6 held this position, which had the potential to restrict Patient #1’s airway and limit his/her ability to take a full breath, which increased the risk of asphyxia, until more help arrived to assist. Review of the facility’s “Camera Review Tool” (a form used by the facility to review video recordings of incidents), dated 12/7/23, and competed by Advanced Mandt Instructor #3, revealed: “ ... The patient [#1] is being restrained in a seated position with staff [PNA #6] [on top]/behind [him/her] from [3:35 PM] to [3:37 PM] ...” In the “Areas for Improvement, Education Identified and/or Positive Feedback” section of the tool, it was documented: “Unsafe dangers/risk of positional asphyxiation.” During an interview on 1/3/24 at 9:45 AM, Advanced Mandt Instructor #4 stated the over arm technique used by PNA #6 during the 12/4/23 incident was not an approved Mandt technique and that the exertion of Patient #1’s head in a downward, forward position increased the risk of asphyxia. During an interview on 1/3/24 at 9:52 AM, Advanced Mandt Instructor #3 stated PNA #6 had not been re-educated on the use of prohibited practices used during the 12/4/23 incident. Incident on 12/11/23 Patient #15 Record review on 12/29/23 and 1/3/24 revealed Patient #15 was admitted to the facility with diagnoses that included autism spectrum disorder and attention deficit hyperactivity disorder (ADHD). Further review revealed Patient #15 was also diagnosed with Smith-Magenis syndrome (a developmental disorder that affects behavior, emotion, and learning processes. Major features of this condition include behavioral problems, mild to moderate intellectual disability and delayed speech and language skills). Review of the facility’s video recording on 1/3/24 at 9:29 AM, of an incident on 12/11/23, revealed Patient #15 was escalated and placed in a brief manual hold by PNA #6. It was observed that Patient #15 had dropped his/her weight while in the hold to sit and then lay down on his/her back on the ground. PNA #6 was observed to position Patient #15 onto his/her right side, placed Patient #15’s left arm across his/her chest, and positioned himself/herself over Patient #15’s body. While PNA #6’s chest area was positioned over and very close to Patient #15’s left shoulder, he/she placed his/her right forearm across Patient #15’s left jaw line/upper neck area and applied pressure to keep Patient #15’s head down on the floor. Once he/she removed his/her forearm, PNA #6 was further observed to place his/her hand on Patient #15’s forehead to keep Patient #15’s head on the floor. Further review of the video recording revealed three other staff members were present during this incident, PNA #16, PNA #53, and Licensed Nurse (LN) #2. No one corrected, or later reported, PNA #6’s use of this prohibited technique during the restraint episode. During an interview on 12/29/23 at 10:18 AM, the Quality Director stated PNA #6’s use of his/her forearm and hand to hold down Patient #15’s head was not an approved Mandt techniques and was a danger to the patient’s safety. When asked how the facility ensured brief manual holds, and any other more restrictive intervention (like a mechanical restraint or seclusion), were conducted safely, the Quality Director stated that when an incident occurred an Unusual Occurrence Report (UOR) was submitted the same day. The Nursing Shift Supervisor (NSS) would have briefly reviewed the video recording of the incident to ensure correct action from the staff was taken, which included Mandt techniques. The next day, or later in the week, Risk Management would have conducted a more in-depth camera review, using the “Camera Review Tool” form, to look at the incident from interactions just prior to and then through the closure of the incident. When asked about the 12/11/23 incident’s UOR review by the NSS on the same day, the Quality Director stated NSS #72 had not completed the UOR review, to include the video review, prior to leaving for the day on 12/11/23. The Quality Director further stated the UOR remained on the NSS’s desk, through the NSS’s weekend, until 12/14/23 when Risk Management received it and completed their camera review. The Quality Director further stated that if a NSS had observed anything concerning from their initial camera reviews, on any UOR incident, they would have alerted leadership of the concern. If there was a safety concern, the staff involved would have been placed on administrative leave until the investigation was completed. Because the 12/11/23 camera review was not completed until 12/14/23 (three days later), and because PNA #6’s behavior wasn’t reported, PNA #6’s verbal and physical abuse was discovered late. PNA #6 was placed on administrative leave on 12/14/23 until the investigation was completed, and when concerns were substantiated, PNA #6 was terminated on 12/14/23. Review of the facility’s “Camera Review Tool,” dated 12/14/23, and competed by Advanced Mandt Instructor #3, revealed: “ ... During this brief manual restraint, [PNA #6] is observed to use a prohibited practice restraint by placing [his/her] forearm/elbow forcibly on patient [#15’s] left jaw/neck area at [1:34 PM] and restraining [him/her] in this manner for 27 seconds until [1:36 PM]. [PNA #6] also presses [patient #15’s] head to the floor by placing [his/her] hand on [his/her] forehead for 30 seconds ...” During an interview on 12/29/23 at 3:20 PM, the Quality Director, the Assistant Director of Nursing, and Advanced Mandt Instructor #5 all agreed that none of the staff present corrected, or later reported, PNA #6’s inappropriate hold technique during the 12/11/23 brief manual hold. Incident on 12/13/23 (one day before PNA #6 was placed on administrative leave) Patient #32 Record review on 12/29/23 and 1/3/24 revealed Patient #32 was admitted to the facility with a diagnosis of autism spectrum disorder. Further review revealed Patient #32’s level of observation, for safety, revealed he/she was on close observation, 2nd degree (one patient has one staff member assigned to continuously observe them at all times). He/she had a history of being dangerous to others and exhibiting unpredictable behaviors. Review of the facility’s video recording on 12/29/23 at 3:30 PM, of an incident on 12/13/23, revealed Patient #32 was quickly pacing up and down the unit hallway and flapping his/her hands constantly (this was a form of stimming, self-stimulation, behavior that could be triggered by excitement, nervousness, or fidgeting). Patient #32 was observed to impulsively strike out at staff when medications were offered to help calm him/her. Further observation revealed a two-person escort was attempted by PNA #6, who restrained the left arm, and PNA #41, who restrained the right arm. Patient #32 was observed to drop his/her weight and sit on the floor. Both PNA’s knelt and PNA #6 positioned himself/herself behind and over Patient #32, while PNA #41 remained on Patient #32’s right side, all the while both continuing to restrain Patient #32’s arms. PNA #6, while still restraining Patient #32’s left arm with his/her left hand, brought his/her right arm up and over Patient #32’s right shoulder close to the neck, and then down in front of Patient #32’s chest area. With his/her chest, PNA #6 exerted pressure to the back of Patient #32’s upper shoulder/neck area and pushed forward and down over Patient #32, forcing his/her head down towards his/her chest. PNA #6 held this position, which had the potential to restrict Patient #32’s airway and limit his/her ability to take a full breath, increasing the risk of asphyxia. As this incident had occurred, two other PNAs (#21 and #80) stood by to assist if needed. Further observation revealed none of the other PNAs present corrected, or later reported, PNA #6’s inappropriate hold technique. During an interview on 12/29/23 at 3:32 PM, Advanced Mandt Instructor #5 stated an arm around or near a patient’s neck, in any fashion, was a prohibited technique. He/she also stated that putting weight on and then leaning a patient forward was prohibited as well because it increased the risk of asphyxia. Review of the facility’s Mandt Instructor manual “The Mandt System Instructor Manual Building Healthy Relationships since 1975 Curriculum 2.0,” dated 1975 - 2022, revealed: “ ... Prohibited Practices ... The Mandt System prohibits these practices ... Pressure or weight on chest, lungs, sternum, diaphragm, back, or upper abdomen ... can results in immediate asphyxiation and death ...Any manual restraint that maintains a person on the floor in any position (prone, supine, side-lying) ... the risks of using such restraints are outweighed by any benefits at this level of training ... Any technique that involves substantial risk of injury. If a practice is not on this list, and you believe it could result in harm or injury, don’t do it!..” Review of the facility’s “Patient Rights from The Joint Commission and The Center for Medicare and Medicaid Services,” dated 11/1/21, revealed: “Psychiatric hospital by the Joint commission will honor and promote the following patient rights and standards ... Patients will be treated in a dignified and respectful manner that supports his or her dignity ... As a Participant of the Medicaid and Medicare, the facility agrees to protect and promote each of the rights listed below ... to receive care in a safe setting ... to safe implementation of restraint or seclusion by trained staff ...” .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure a patient’s right to be free from all forms of abuse or harassment were upheld for 1 patient (#15), out of 7 patients reviewed. This failed practice exposed this patient to verbal and physical abuse, intimidation, and retaliation which instigated an escalation and a crisis event which resulted in physical restraint. Findings: Patient #15 Record review on 12/29/23 and 1/3/24 revealed Patient #15 was admitted to the facility with diagnoses that included autism spectrum disorder and attention deficit hyperactivity disorder (ADHD). Further review revealed Patient #15 was also diagnosed with Smith-Magenis syndrome (a developmental disorder that affects behavior, emotion, and learning processes. Major features of this condition include behavioral problems, mild to moderate intellectual disability and delayed speech and language skills). Review of Patient #15’s behavior plan “Working with [Patient #15],” undated, revealed: “Things to remember: [Patient #15] has a genetic disorder that affects many aspects of [his/her] cognitive and physical functioning. [His/her] functioning level is comparable to that of a 2-year-old. [Patient #15] shifts from calm and happy to elevated and aggressive rapidly. [He/she] also lacks the skills and ability to self-regulate [calm self down]. [Patient #15] values [his/her] space and privacy ... Tips for staff: Remind yourself “[Patient #15] can’t” don’t get stuck thinking “[Patient #15] won’t.” Be calm in times of stress with [Patient #15] even when you need to be firm ... Use a neutral/positive tone of voice. Focus on what [Patient #15] CAN do. Reduce stimulation (light, people, and noise) when [Patient #15] is escalating ...” Review of Patient #15’s level of observation, for safety, revealed he/she was on close observation, 3rd degree in the milieu (one patient has two staff members assigned to continuously observe them at all times) and 2nd degree in the bed area (one patient has one staff member assigned to continuously observe them at all times). Further observation revealed: “staff to disengage when pt [patient] becomes elevated (may monitor outside of room from window).” Incident on 12/11/23 Review of the facility’s video recording on 12/29/23 at 10:18 AM, of an incident involving Patient #15, on 12/11/23, revealed: - 1:19 PM - Patient #15 was in the facility’s gym with two Psychiatric Nursing Assistants (PNAs) #6 and #8. There were no other patients in the gym. - 1:29 PM - Patient #15 was observed to attempt to go pick up a ball, PNA #6 was observed to kick the ball away from Patient #15’s reach. Patient #15 chased after the ball saying, “give it to me.” Patient #15 started to escalate and said “fuck you sissy” to PNA #8 who was not engaged with Patient #15 at the time. PNA #6 immediately said, “Let’s go - oak room [this is a seclusion room]. Now, oak room. Let’s go, you ain’t going to be no bully around me.” Patient #15 walked away from PNA #6 and went to the other side of the gym. Patient #15, continued to focus on PNA #8 and told PNA #8 to leave the gym. PNA #6 stated, “[he’s/she’s] not going nowhere you’re just going to the oak room.” Patient #15 was observed to chant for PNA #8 to leave the gym, while still being on the other side the gym. PNA #6 tossed a ball away that he/she had been bouncing, advanced towards Patient #15 and stated: “Yeah, come on that’s it I’m taking you straight to the oak room.” As PNA #6 continued to advance towards Patient #15, he/she stated: “Let’s go, we’ll go straight to the oak room. Can’t wait.” PNA #6 observed to say “you’re a bully” twice. - 1:30 PM: Patient #15 started to pace in the gym, still focused on PNA #8. PNA #6 started to confront Patient #15, “Let’s go bully, you don’t bully [him/her].” PNA #6 confronted Patient #15 “pick me” and attempted to escort Patient #15 from the gym to the unit. Patient #15 dropped to the floor to sit and PNA #6 stated, “Oh no, I’m gonna fight with you, let’s go to oak room.” Patient #15 started crawling on the floor, PNA #6 was observed to be following him/her as he/she crawled and stood over Patient #15 challenging him/her saying, “Me and you, I’ll put you in a hold let’s go to the oak room, what’s up?” PNA #6 was observed to attempt to pick Patient #15 up off the floor several times by grasping Patient #15’s underarms, to attempt to escort him/her out of the gym, Patient #15 continued to drop or reposition himself/herself on the floor. PNA #6 observed to say, “Let’s go, stand up.” With a raised voice, PNA #6 stated, “Stand up I’ll fight you! Pick me! I’m just going to put you in a hold. You’re rude!” - 1:31 PM: Patient #15 was observed to escalate from this interaction. Patient #15 started to spit on the gym floor, screaming, and banging her head/face on the gym floor. Patient #15 started to crawl toward PNA #8, who was not engaged with Patient #15 at all. PNA #6 was observed to continue to mirror Patient #15’s movement, turn patient physically to divert him/her away from PNA #8, and all the while continuing to verbally abuse Patient #15, “I’m not playing with you;” “you’re being a bully;” “let’s go, get up;” “let’s go bully;” and “come on bully get up, let’s go.” - 1:32 PM: Patient #15 continuing to escalate from PNA #6’s behavior and attempted to kick PNA #6. PNA #6 picked Patient #15 up off the floor by his/her underarms saying, “we are going to the oak room, I promise you.” Further observation revealed PNA #6 escorted Patient #15 back to the unit, at which time Patient #15 refused to walk to the oak room and dropped to the floor. This resulted in a brief manual hold initiated by PNA #6. PNA #6 was observed to position Patient #15 onto his/her right side, placed Patient #15’s left arm across his/her chest, and positioned himself/herself over Patient #15’s body. While PNA #6’s chest area was positioned over and very close to Patient #15’s left shoulder, he/she placed his/her right forearm across Patient #15’s left jaw line/upper neck area and applied pressure to keep Patient #15’s head down on the floor. Once he/she removed his/her forearm, PNA #6 is further observed to place his/her hand on Patient #15’s forehead to keep Patient #15’s head on the floor. From here, Patient #15 was placed on a gurney, taken to the oak room, and placed in mechanical 5-point restraints (mechanical restraints placed on both wrists, both ankles, and a strap across the chest area). Review of the facility’s “Camera Review Tool,” dated 12/27/23, and completed by Advanced Mandt Instructor #3, revealed: “ ... Video review shows multiple instances of verbal and physical abuse directed toward patient [#15] from [PNA #6] ... [PNA #6] is antagonistic and verbally abusive towards the patient as evidenced by [his/her] body language and positioning, the tone and volume of [his/her] voice, and the actual words directed towards the patient. [PNA #6] is heard on the video to make comments such as “Do you need the oak room?” when no observable danger to self or others behavior is displayed by [Patient #15] ...” Further review of the “Camera Review Tool” identified the inappropriate hold techniques used by PNA #6 during the brief manual hold: “ ... During this brief manual restraint, [PNA #6] is observed to use a prohibited practice restraint by placing [his/her] forearm/elbow forcibly on patient [#15’s] left jaw/neck area at [1:34 PM] and restraining [him/her] in this manner for 27 seconds until [1:36 PM]. [PNA #6] also presses [patient #15’s] head to the floor by placing [his/her] hand on [his/her] forehead for 30 seconds ...” During an interview on 12/29/23 at 10:18 AM, the Assistant Director of Nursing (ADON) and Quality Director stated both PNA #6 and #8 had radios and could have called for assistance but did not. The ADON and Quality Director stated that they determined, based on their independent review of the 12/11/23 incident, that PNA #6 had not used approved de-escalation techniques and was verbally and physically abusive towards Patient #15. The Quality Director further stated that Patient #15’s behavior plan was not followed and PNA #6’s behavior escalated Patient #15 to the point of requiring physical intervention. The ADON and Quality Director agreed that PNA #8 had not attempted to disengage PNA #6 from this inappropriate behavior, nor did PNA #8 report PNA #6’s inappropriate behavior to leadership. When asked how the facility ensured brief manual holds, and any other more restrictive intervention (like a mechanical restraint or seclusion), were conducted safely, the Quality Director stated that when an incident occurred an Unusual Occurrence Report (UOR) was submitted the same day. The Nursing Shift Supervisor (NSS) would have briefly reviewed the video recording of the incident to ensure correct action from the staff was taken, which included Mandt techniques. The next day, or later in the week, Risk Management would have conducted a more in-depth camera review, using the “Camera Review Tool” form, to look at the incident from interactions just prior to and then through the closure of the incident. When asked about the 12/11/23 incident’s UOR review by the NSS on the same day, the Quality Director stated NSS #72 had not completed the UOR review, to include the video review, prior to leaving for the day on 12/11/23. The Quality Director further stated the UOR remained on the NSS’s desk, through the NSS’s weekend, until 12/14/23 when Risk Management received it and completed their camera review. The Quality Director further stated that if a NSS had observed anything concerning from their initial camera reviews, on any UOR incident, they would have alerted leadership of the concern. If there was a safety concern, the staff involved would have been placed on administrative leave until the investigation was completed. Because the 12/11/23 camera review was not completed until 12/14/23 (three days later), and because PNA #6’s behavior wasn’t reported, PNA #6’s verbal and physical abuse was discovered late. PNA #6 was placed on administrative leave on 12/14/23 until the investigation was completed, and when concerns were substantiated, PNA #6 was terminated on 12/14/23. Review of the facility’s Mandt Instructor manual “The Mandt System Instructor Manual Building Healthy Relationships since 1975 Curriculum 2.0,” dated 1975 - 2022, revealed: “ ... Staff have a tremendous power to affect the behavior of the people with and for whom they work. It is the staff’s personal approach that creates the climate where they work. The staff’s emotions and attitudes are in the words they say, the way they say them ... Staff may have situations where it was their overreaction that caused a situation to escalate into a crisis event ...” Review of the facility’s Mandt Instructor manual “The Mandt System Instructor Manual Building Healthy Relationships since 1975 Curriculum 2.0,” dated 1975 - 2022, revealed: “ ... Prohibited Practices ... The Mandt System prohibits these practices ... Pressure or weight on chest, lungs, sternum, diaphragm, back, or upper abdomen ... can results in immediate asphyxiation and death ...Any manual restraint that maintains a person on the floor in any position (prone, supine, side-lying) ... the risks of using such restraints are outweighed by any benefits at this level of training ... Any technique that involves substantial risk of injury. If a practice is not on this list, and you believe it could result in harm or injury, don’t do it!..” Review of the facility’s “Patient Rights from The Joint Commission and The Center for Medicare and Medicaid Services,” dated 11/1/21, revealed: “Psychiatric hospital by the Joint commission will honor and promote the following patient rights and standards ... Patients will be treated in a dignified and respectful manner that supports his or her dignity ... Patients have the right to be free from neglect, exploitation, and verbal, mental[,] physical, and sexual abuse ... As a Participant of the Medicaid and Medicare, the facility agrees to protect and promote each of the rights listed below ... to receive care in a safe setting ... to be free from harassment, physical or mental abuse, or corporal punishment ... to be free from restraints or seclusion of any form imposed as a means of coercion discipline, convenience, or retaliation by staff ... to safe implementation of restraint or seclusion by trained staff ...” .”