Haven Behavioral Hospital of Phoenix

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51960 Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting patient’s rights as evidenced by the following references to standard-level deficiencies: Cross reference A-0116: The hospital failed to ensure that written copies of the patient ’ s rights were provided to patients upon admission. Cross reference A-0131: The hospital failed to ensure a patient or a patient’s representative provided informed consent regarding treatment and psychotropic medication consent. Cross reference A-0144: The hospital failed to ensure a patient received care in a safe setting by close observations not being completed by staff per policy and physician orders. Cross reference A-0160: The hospital failed to record and monitor a chemical restraint as a restraint in reference to: missing restraint documentation and missing physician order for a chemical restraint. Cross reference A-0168: The hospital failed to ensure an order was made before restraint/seclusion was initiated. Cross reference A-0169: The hospital failed to ensure patients receiving a chemical restraint were not administered it on an as needed basis (PRN). Cross reference A-0175: The hospital failed to ensure a patient requiring restraint for a violent episode also received one to one observations during the restraint to ensure safety. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.”

“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: 51960 Based on the review of documents and interviews, it was determined that the hospital failed to meet the requirement of the Conditions of Participation for Nursing Services as evidenced by the following reference to condition-level deficiency: Cross reference A-0395: The Nurse Executive failed to ensure appropriate supervision of non licensed staff providing services related to patient care. The egregious effect of this systemic deficient practice resulted in the facility’s failure to meet the requirement for Condition of Participation for Nursing Services.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 51960 Based on review of policy and procedure, medical records and staff interview, it was determined the hospital failed to ensure that written copies of the patient ’ s rights were provided to patients upon admission. This deficient practice can result in patients not knowing what rights they have regarding their care. Findings include: Policy titled “Patient Rights - Phoenix, Policy #16209798, Last approved 07/2024,” revealed, “...Each patient, and if applicable, the patient ’ s parent, guardian, custodian, designated representative, or agent is entitled to: 1. A written list and verbal explanation of the following patient rights, as deemed by Licensing and Accreditation agencies, for inpatient psychiatric services for adults, youth, and for persons diagnosed with a severe mental illness;...2. The opportunity to acknowledge, in writing, receipt of a written list and verbal explanation of the rights ....” A request was made on May 29, 2025 for a copy of the patient rights that is available for patients to review. None was provided. Evidence that patients #11-15 had the opportunity to review a patient rights document was requested. None was provided. Employee #5 confirmed in an interview on May 29, 2025 that the hospital did not have a copy of patient rights available for review upon admission.”

“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: 51960 Based on review of hospital policy and procedure, medical records and staff interview, it was determined the hospital failed to ensure a patient or a patient’s representative provided informed consent regarding treatment, including being able to accept or refuse treatment, as evidenced by: (1) Failure to obtain informed consent by the patient or the patient’s representative for hospital admission per hospital policy for three (3) of twenty (20) patients (Patients #5, 6, and 8); and (2) Failure to obtain written informed consent for psychotropic medication per hospital policy for ten (10) out of twenty (20) patients (Patients #11, 12, 13, 14, 15, 16, 17, 18, 19, and 20). This deficient practice poses a potential risk to patients that may compromise the quality and safety of patient care through patients making uninformed decisions about the risks and reasons for receiving treatment and for patients receiving psychotropic medications without understanding the risks, benefits, and effects the medications may have. Findings include: (1) Policy titled “Patient Rights,” policy #16209798, approved 07/2024, revealed “...Each patient has the right to ...give general consent and ...informed consent to treatment ....” Policy titled “Consent for Admission - MHPOA, Guardianship, Intent for Guardianship,” policy #16209800, approved 07/2024, revealed “...Social services will document every action taken ...to work with the legal representative ...If there is no evidence that a guardianship petition has been filed, the patient will be evaluated to determine ...if the patient is willing and has capacity to give informed consent for admission and treatment to the hospital ....” Policy titled “Medical Record Content,” policy #16495984, approved 09/2024, revealed “...The medical record must address ...evidence of informed consent ...Before obtaining patient consent, the risks, benefits, and potential complications are discussed ....” Medical record for patient #5 revealed the following: Patient #5 was admitted to the hospital on April 9, 2025 Patient #5 ’ s “Admission Forms,” dated 04/09/2025, revealed “...Consent for Treatment ...unable to sign ....” A request for documentation regarding attempts to obtain consent for treatment from patient #5 was made on May 29, 2025. None was provided at the time of survey. Medical record for patient #6 revealed the following: Patient #6 was admitted to the hospital on April 25, 2025. Patient #6 ’ s “Admission Forms,” dated 04/25/2025, revealed “...Consent for Treatment ...unable to sign ....” A request for documentation regarding attempts to obtain consent for treatment from patient #6 was made on May 29, 2025. None was provided at the time of survey. Medical record for patient #8 revealed the following: Patient #8 was admitted to the hospital on May 2, 2025. Patient #8 ’ s “Admission Forms,” dated 05/02/2025, revealed “...Consent for Treatment ...unable to sign ....” A request for documentation regarding attempts to obtain consent for treatment from patient #8 was made on May 29, 2025. None was provided at the time of survey. Employee #4 confirmed during an interview conducted on May 29, 2025, that documentation regarding attempts to obtain informed consent for treatment from patient #5, patient #6 and patient #8 could not be provided. (2) Policy titled “Informed Consent - Psychotropic Medication,” policy #17304106, approved 01/2025, revealed, “...PROCEDURE ...1. Nurse, Provider or Pharmacist will discuss prescribed psychotropic medications with the patient or guardian(s) after psychotropic medications are ordered but before first psychotropic medication dose is administered ...a. Discussion will include benefits and risks of the psychotropic medication being ordered ...b. Nurse, Provider or Pharmacist will document Informed Consent in patient medical record before first psychotropic medication dose is administered ...” Policy titled “Medication Administration,” policy #17185152, approved 12/2024, revealed “...PROCEDURE ...Check medical record for presence of medication consent form ...A consent must be present for any medication to be administered except in an emergency situation ....” Medical record for Patient #11 revealed the following: Patient #11 was admitted to the hospital on May 22, 2025. Patient #11 ’ s medication administration record revealed: “...chlorproMAZINE (*Thorazine) 100 mg Oral NOW for Agitation ...Administered ...5/24/2025 02:14 ...” “...cloZAPine (*Clozaril) 100 mg Oral AT BEDTIME for Psychosis ...Administered ...5/28/2025 20:34 ...” A request for medication consents for Thorazine and Clozaril for Patient #11 was made on May 29, 2025 and none were provided at the time of survey. Medical record for Patient #12 revealed the following: Patient #12 was admitted to the hospital on May 13, 2025 to May 19, 2025. Patient #12 ’ s medication administration record revealed: “...QUEtiapine (*SEROquel) 25 mg Oral AT BEDTIME for Mood ...Administered ...5/14/2025 21:12 ...” “...QUEtiapine (*SEROquel) 50 mg Oral AT BEDTIME for Mood ...Administered ...5/15/2025 20:45 ...5/16/2025 20:19 ...5/17/2025 20:40 ...5/18/2025 20:06 ...” A request for medication consent for Seroquel for Patient #12 was made on May 29, 2025 and none was provided at the time of survey. Medical record for Patient #13 revealed the following: Patient #13 was admitted to the hospital on May 14, 2025 to May 19, 2025 Patient #13 ’ s medication administration record revealed: “...propranolol (*Inderal) 10 mg Oral NOW for Anxiety/Tremors ...Administered ...5/16/2025 09:32 ...” A request for medication consent for Inderal for Patient #13 was made on May 29, 2025 and none was provided at the time of survey. Medical record for Patient #14 revealed the following: Patient #14 was admitted to the hospital on May 16, 2025 to May 27, 2025 Patient #14 ’ s medication administration record revealed: “...hydrOXYzine hydrochloride (*Atarax) 50 mg Oral EVERY 4 HOURS PRN for Anxiety ...Administered ...5/18/2025 20:50 ...5/19/2025 20:13 ...5/20/2025 20:15 ...5/21/2025 08:23 ...” “...ARIPiprazole (*Aristada) 882 mg into muscle EVERY 28 DAYS (28 DAYS) for SCHIZOAFFECTIVE DISORDER and BIPOLAR TYPE ...Administered ...5/19/2025 08:52 ...” “...ARIPiprazole (*Abilify) 15 mg Oral AT BEDTIME for Mood ...Administered ...5/19/2025 20:13 ...5/20/2025 20:15 ...5/21/2025 20:10 ...5/22/2025 20:16 ...” “...divalproex sodium ERT (*Depakote ER) 1,500 mg Oral AT BEDTIME To give 1,500 mg use 3 of 500 mg for Mood ...Administered ...5/17/2025 21:00 ...5/18/2025 20:50 ...5/19/2025 20:13 ...5/20/2025 20:15 ...5/21/2025 20:11 ...5/22/2025 20:17 ...” A request for medication consents for Atarax, Aristada and Abilify for Patient #14 was made on May 29, 2025 and none were provided at the time of survey. Medical record for Patient #15 revealed the following: Patient #15 was admitted to the hospital on May 15, 2025 to May 23, 2025. Patient #15 ’ s medication administration record revealed: “...hydrOXYzine hydrochloride (*Atarax) 50 mg Oral EVERY 4 HOURS PRN for Anxiety ...Administered ...5/15/2025 19:21 ...5/16/2025 09:00 ...5/17/2025 19:34 ...5/18/2025 08:40 ...5/19/2025 08:19 ...5/20/2025 08:29 ...5/21/2025 20:47 ...” A request for medication consent for Atarax for Patient #15 was made on May 29, 2025 and none was provided at the time of survey. Medical record for Patient #16 revealed the following: Patient #16 was admitted to the hospital on April 24, 2025 to May 1, 2025. Patient #16 ’ s medication administration record revealed: “...ARIPiprazole (*Abilify) 2 mg Oral ONCE A DAY for Psychosis/Mood ...Administered ...4/25/2025 08:52 ...4/26/2025 08:36 ...” “...ARIPiprazole (Abilify) 5 mg Oral ONCE A DAY for Psychosis/Mood ...Administered ...4/27/2025 09:00 ...4/28/2025 09:00 ...4/29/2025 08:08 ...4/30/2025 11:32 ...” “...LORazepam (*Ativan) 2 mg into muscle NOW for Agitation ...Administered ...4/29/2025 21:35 ...” A request for medication consents for Abilify and Ativan for Patient #16 was made on May 29, 2025 and none were provided at the time of survey. Medical record for Patient #17 revealed the following: Patient #17 was admitted to the hospital on April 7, 2025 to April 17, 2025. Patient #17 ’ s medication administration record revealed: “...hydrOXYzine hydrochloride (*Atarax) 50 mg Oral EVERY 4 HOURS PRN for Anxiety ...Administered ...4/8/2025 20:38 ...4/9/2025 11:57 ...4/10/2025 20:47 ...4/11/2025 00:52 ...4/11/2025 03:23 ...” “...OXcarbazepine (*Trileptal) 150 mg Oral TWICE A DAY for Mood ...Administered ...4/9/2025 20:34 ...4/10/2025 08:01 ...4/11/2025 09:00 ...” A request for medication consents for Atarax and Trileptal for Patient #17 was made on May 29, 2025 and none were provided at the time of survey. Medical record for Patient #18 revealed the following: Patient #18 was admitted to the hospital on March 3, 2025 to March 11, 2025 Patient #18 ’ s medication administration record revealed: “...LORazepam (Ativan) 2 mg into muscle NOW for Axiety ...Administered ...3/7/2025 15:46 ...” A request for medication consent for Ativan for Patient #18 was made on May 29, 2025 and none was provided at the time of survey. Medical record for Patient #19 revealed the following: Patient #19 was admitted to the hospital on March 20, 2025 to April 16, 2025. Patient #19 ’ s medication administration record revealed: “...cloZAPine (Clozaril) 25 mg Oral EVERY MORNING for Psychosis ...Administered ...4/3/2025 08:01 ...4/4/2025 08:13 ...4/5/2025 08:04 ...4/6/2025 08:14 ...4/7/2025 08:41 ...4/8/2025 08:34 ...4/9/2025 08:00 ...” “...cloZAPine (Clozaril) 100 mg Oral EVERY MORNING for Psychosis ...Administered ...4/3/2025 08:01 ...4/4/2025 08:14 ...4/5/2025 08:04 ...4/6/2025 08:14 ...4/7/2025 08:41 ...4/8/2025 08:35 ...4/9/2025 08:00 ...” “...cloZAPine (Clozaril) 300 mg Oral AT BEDTIME for Psychosis ...Administered ...4/3/2025 20:07 ...4/4/2025 20:07 ...4/5/2025 20:04 ...4/6/2025 20:00 ...4/7/2025 20:01 ...4/8/2025 20:01 ...4/9/2025 20:00 ...” “...propranolol (Inderal) 10 mg Oral TWICE A DAY for Anxeity ...Administered ...4/3/2025 08:02 ...4/4/2025 08:14 ...4/5/2025 08:05 ...4/6/2025 08:15 ...4/7/2025 08:41 ...4/8/2025 08:35 ...4/9/2025 08:00 ...” A request for medication consents for Clozaril and Inderal for Patient #19 was made on May 29, 2025 and none were provided at the time of survey. Medical record for Patient #20 revealed the following: Patient #20 was admitted to the hospital on April 18, 2025 to April 24, 2025. Patient #20 ’ s medication administration record revealed: “...buprenorphine (*Subutex) 4 mg Under Tongue THREE TIMES DAILY To give 4 mg use 2 of 2 mg for opiate dependence ...Administered ...4/19/2025 09:34 ...15:07 ...20:15 ...4/20/2025 08:35 ...14:25 ...20:54 ...4/21/2025 08:38 ...14:45 ...20:36 ...4/22/2025 08:03 ...15:22 ...20:23 ...4/23/2025 08:17 ...14:46 ...20:10 ...4/24/2025 08:13 ...” A request for medication consent for Subutex for Patient #20 was made on May 29, 2025 and none was provided at the time of survey. Employee #5 confirmed during an interview conducted on May 29, 2025, that Patients #11-20 had been administered psychotropic medications with no documentation of informed consent in their medical record.”

“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: 51960 Based on facility policy review, medical record review and staff interview, it was determined that the hospital failed to ensure that staff implemented close observations as per policy. This deficient practice poses the potential risk of patients not being monitored appropriately, which could result in harm to the health and safety of patients. Findings include: Policy titled “Observation and Special Precautions,” policy #17304080, last approved 02/2025, revealed “...PROCEDURE ...LEVEL OF OBSERVATION ...NOTE: All patients will automatically receive Q15 minute observations for the duration of their hospital stay ...LEVELS OF OBSERVATION ... Q 15 MINUTE CHECKS ...This is the minimum level of observation for any patient admitted ...Staff will observe the patient and document on the Patient Observation Record Q15 minutes....” Patient #15 ’ s medical record revealed the following: Hospital document titled “Patient Observations” dated 5/22/2025 revealed missing codes to describe the patient ’ s location, activity and behavior as well as missing staff initials at observation time 13:45. Patient #17 ’ s medical record revealed the following: Hospital document titled “Patient Observations” dated 4/11/2025 revealed missing staff initials at observation time 10:15. Hospital document titled “Patient Observations” dated 4/15/2025 revealed missing codes to describe the patient ’ s location, activity and behavior as well as missing staff initials at observation time 13:45. Patient #19 ’ s medical record revealed the following: Hospital document titled “Patient Observations” dated 3/30/2025 revealed missing codes to describe the patient ’ s location, activity and behavior as well as missing staff initials at observation time 11:45. Patient #20 ’ s medical record revealed the following: Hospital document titled “Patient Observations” dated 4/18/2025 revealed missing staff initials at observation time 17:00. Hospital document titled “Patient Observations” dated 4/23/2025 revealed missing staff initials at observation time 19:00. Employee #4 and employee #5 confirmed in interviews conducted on May 29, 2025, and May 30, 2025, that there was no additional documentation in the medical record to account for missing observation checks or missing staff initials on any of the “Patient Observations” forms for Patients #15, 17, 19 and 20.”

“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: 51960 Based upon hospital policy and procedure review, scholarly journal review, hospital documentation review, medical records review and request, and employee interview, it was determined the hospital failed to record and monitor as a restraint, the use of 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 as evidenced by: (1) Failure to have an order for a chemical restraint by a provider. (2) Failure to document a chemical restraint as a restraint. This deficient practice poses a risk to patient health and safety including possible death if a patient is administered a chemical restraint when not warranted and not being properly monitored after a chemical restraint. The National Institute of Health, National Library of Medicine, Journal of Education & Teaching in Emergency Medicine, October 15, 2020 article “Agitated Psychiatric Patient” revealed: “ ...The main classes of medications utilized for chemical restraint include first-generation antipsychotics (eg, haloperidol and droperidol), second-generation antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone), benzodiazepines (eg, lorazepam and midazolam), and N-methyl-D-aspartic acid (NMDA) receptor antagonists (eg, ketamine) ....” The Journal of Clinical Psychiatry, May, 2021 article titled “Intramuscular B52” revealed “ ...a patient ’ s aggression is so severe that it necessitates use of an intramuscular agent ...intramuscular (IM) haloperidol with IM lorazepam with IM diphenhydramine. This recommendation is so common that it even has its own name: B52 or Benadryl (diphenhydramine), haloperidol 5 mg, and lorazepam 2 mg ....” Emergency Psychiatry article “Physical and Chemical Restraint in the Psychiatric Emergency Service” June 2000, revealed: “ ...The concept of chemical restraint hinges on whether an agent is given as a part of the treatment of the patient ’ s condition or simply to control the patient ’ s behavior ... If prescribed simply as a reaction to the patient ’ s behavior, it is a restraint ....” CMS defines a “drug used as a restraint” (CMS CoP 482.13(e)(1)(i)(A) as follows: “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.” Findings include: (1) A request for a chemical restraint policy was made on May 29, 2025 to May 30, 2025 and the following policy was provided. Policy titled “Restraint, Physical,” policy #17373123, last revised 04/2024, revealed “...POLICY ...Mechanical and Chemical restraint is not utilized at this hospital...Restraint may be ordered by a practitioner (Physician or Nurse Practitioner)...PROCEDURE ...2. The order shall indicate the reason and maximum duration of restraint ...7. A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status ....” Hospital documentation review for patient #2 revealed the following: A “Seclusion or Restraint Packet,” dated 3/20/2025, revealed “...Received order from Dr. ...Patient medicated with intramuscular medications including, ativan 2mg, haldol 5mg, benadryl 50 mg ....” An incident report, dated 3/20/2025, revealed “...Patient medicated with ...medications including, ativan 2mg, haldol 5mg, benadryl 50 mg ....” Medical record review for patient #2 revealed in a Medication Administration Record (MAR), dated “03/20,” “...diphenhydrAMINE (Benadryl) 50 mg into muscle NOW for Agitation ...Administered ...03/20/2025 ...04:53 ...haloperidol (Haldol) 5 mg NOW for Psychosis ...Administered ...03/20/2025 ...04:54 ....” Hospital document titled “Patient Observations” dated 3/30/2025 revealed, “...04:45 ...Location: Room ...Activity: Lying/Sitting ...Behavior: Mumbling incoherently, uncooperative ...05:00 ...Location: Room ...Activity: Lying/Sitting ...Behavior: Quiet ...05:45 ...Location: Day Room ...Activity: Watching TV ...Behavior: Quiet ...06:00 ...Location: Room ...Activity: Sleeping ...Behavior: Quiet ...13:15 ...Location: Dining Room ...Activity: Walking/Pacing ...Behavior: Quiet ....” The patient was asleep after injections for seven (7) hours. A request was made on May 29, 2025, for patient #2 ’ s practitioner order on 3/20/2025 for a chemical restraint. None was provided at the time of survey. An interview with employee #4, completed on May 30, 2025, confirmed that a practitioner order on 3/20/2025 for patient #2 ’ s chemical restraint could not be provided. Hospital documentation review for patient #7 revealed the following: A “Seclusion or Restraint Packet,” dated 4/26/2025, revealed “...Medications that were administered included Versed 5 mg intramuscular NOW, Benadryl 50 mg intramuscular NOW, and Haldol 5 mg intramuscular NOW ....” An incident report, dated 4/29/2025, revealed “...Doctor was notifuied ...and ordered Versed 5 mg intramuscular NOW, Benadryl 50 mg intramuscular NOW, and Haldol 5 mg intramuscular NOW ....” Medical record review for patient #7 revealed in a MAR, dated “4/29,” “...diphenhydrAMINE (*Benadryl) 50 mg into muscle NOW for Psychosis ...Administered ...4/29/2025 ...17:36 ...haloperidol (Haldol) 5 mg into muscle NOW for Agitation ...Administered ...4/29/2025 ...17:36 ...midazolam (*Versed) 5 mg into muscle NOW To give 5 mg use 1 ml of 5 mg/mL for Anxiety *IM only ...Administered ...4/29/2025 ...17:36....” A request was made on May 29, 2025, for patient #7 ’ s practitioner order on 4/29/2025 for a chemical restraint. None was provided at the time of survey. An interview with employee #4, completed on May 30, 2025, confirmed that a practitioner order on 3/20/2025 for patient #7 ’ s chemical restraint could not be provided. Hospital documentation review for patient #10 revealed the following: Incident report, dated 3/5/2025, revealed “...On call provider contacted ...Thorazine 100 mg into the muscle now for psychosis and Versed 5 mg into the muscle now for Anxiety ....” Medical record review for patient #10 revealed in a MAR, dated “3/5,” “...chlorproMAZINE (*Thorazine) 100 mg into muscle NOW To give 100 mg use 4 ml of 25 mg/mL for Agitation ...Administered ...3/5/2025 ...09:12 ...midazolam (*Versed) 5 mg To give 5 mg use 1 ml of 5 mg/mL for Anxiety/EPS * IM only...Administered ...3/5/2025 ...09:12 ....” Hospital document titled “Patient Observations” dated 3/5/2025 revealed, “...09:15 ...Location: Room ...Activity: Lying/Sitting ...Behavior: Quiet ...09:30 ...Location: Room ...Activity: Sleeping ...Behavior: Quiet ...12:30 ...Location: Room ...Activity: Lying/Sitting ...Behavior: Quiet ....” The patient was asleep after injections for three (3) hours. Hospital document titled “Patient Observations” dated 3/5/2025 further revealed, “...20:00 ...Location: Room ...Activity: Sleeping ...Behavior: Quiet ...21:00 ...Location: Bathroom/Shower ...Activity: Toileting ...Behavior: Quiet ...21:15 ...Location: Room ...Activity: Sleeping ...Behavior: Quiet ...05:15 ...Location: Room ...Activity: Lying/Sitting ...Behavior: Quiet. ...” The patient was asleep after injections for nine (9) hours. A request was made on May 29, 2025, for patient #10 ’ s practitioner order on 3/5/2025 for chemical restraint. None was provided at the time of survey. An interview with employee #4, completed on May 30, 2025, confirmed that a practitioner order on 3/20/2025 for patient #10 ’ s chemical restraint could not be provided. (2) A request for a chemical restraint policy was made on May 29, 2025 to May 30, 2025 and the following policy was provided. Policy titled “Restraint, Physical,” policy #17373123, last revised 04/2024, revealed “...POLICY ...Mechanical and Chemical restraint is not utilized at this hospital...Restraint may be ordered by a practitioner (Physician or Nurse Practitioner)...PROCEDURE ...2. The order shall indicate the reason and maximum duration of restraint ...7. A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status ....” Hospital documentation review for patient #10 revealed the following: Hospital document titled “Narrative Note” dated 3/7/2025 and timed 00:00 revealed, “...At approximately 20:50, Patient attempted to cheek oral medication and threw an object at this nurse during medication administration ...On call provider contacted, Thorazine 100 mg and versed 5 mg administered for psychosis and anxiety ...Patient resting in bed with eyes closed ....” Medical record review for patient #10 revealed in a MAR, dated 3/7, “....chlorproMAZINE (*Thorazine) 100 mg into muscle NOW To give 100 mg use 4 ml of 25 mg/mL for Agitation ...Administered ...3/7/2025 ...20:51 ...midazolam (*Versed) 5 mg To give 5 mg use 1 ml of 5 mg/mL for Anxiety/EPS * IM only....Administered ...3/7/2025 ...20:52 ....” Hospital document titled “Patient Observations” dated 3/7/2025 revealed, “...20:45 ...Location: Day Room ...Acitivity: Watching TV ...Behavior: Quiet ...21:15 ...Location: Day Room ...Acitivity: Sleeping ...Behavior: Quiet ...21:45 ...Location: Room ...Activity: Sleeping ...Behavior: Quiet ...02:00 ...Location: Room ...Acitivity: Lying/Sitting ...Behavior: Quiet ....” The patient was asleep after injections for over four (4) hours. A request was made on May 29, 2025, for patient #10 ’ s restraint documentation including an Incident Report for the chemical restraint on 3/7/2025 and a one hour face to face evaluation after the chemical restraint was administered. None was provided at the time of survey. Medical record for patient #16 revealed the following: Hospital document titled “Nursing Reassessment” dated 4/29/2025 and timed 19:42 revealed, “...2135 Patient has been pacing around nurses station, turning round in circles, reported auditory hallucinations ...Unable to redirect patient, reported to Dr ...medicated with intramuscular medications of benadryl 50mg right vastus lateralis, ativan 2mg right ventrogluteal , haldol 5mg right ventrogluteal, patient assisted to side so ...would not flinch, tolerated well ...Patient lied down in bed ...2215 Patient is resting in bed with spontaneous respirations, is calm ...0145 Resting in bed, no complaints reported ...0345 Resting in bed has spontaneous reparations, having quiet night. ...” Medical record review for patient #16 revealed in a MAR, dated 4/29, “...diphenhydraMINE (Benadryl) 50 mg into muscle NOW for Agitation ...Administered ...4/29/2025 ...21:35...Haloperidol (Haldol) 5 mg into muscle NOW for Psychosis ...Administered ...4/29/2025 ...21:35 ...LORazepam (Ativan) 2 mg into muscle NOW for Agitation ...Administered ...4/29/2025 ...21:35. ...” Hospital document titled “Patient Observations” dated 4/29/2025 revealed, “...21:30 ...Location: Hallway ...Acitivity: Walking/Pacing ...Behavior: Quiet ...21:45 ...Location: Room ...Acitivity: Lying/Sitting ...Behavior: Quiet ...22:00 ...Location: Room ...Acitivity: Sleeping ...Behavior: Quiet ...05:00 ...Location: Room ...Acitivity: Lying/Sitting ...Behavior: Quiet ...” The patient was asleep after injections for seven (7) hours. A request was made on May 29, 2025, for patient #16 ’ s restraint documentation including an Incident Report for the chemical restraint on 4/29/2025 and a one hour face to face evaluation after the chemical restraint was administered. None was provided at the time of survey. Medical record for patient #18 revealed the following: An incident report, dated 3/7/2025, revealed “...Patient then began calling staff out their names, when ...approached about getting an emergency injection, patient agreed to it ....” An incident report, dated 3/8/2025, revealed “...Patient refused to take PO PRNs but asked for injections, Dr ...notified and order received to give Ativan 2mg IM, Benadryl 50mg IM, and Haldol 10mg IM ...were given without incident ....” Hospital document titled “Nursing Reassessment” dated 3/7/2025 and timed 18:34 revealed, “...Medication administered and tolerated well. ...” Hospital document titled “Nursing Reassessment” dated 3/8/2025 and timed 18:49 revealed, “....Medication administered and tolerated wel. ...” Medical record review for patient #18 revealed in a MAR, dated 3/7-3/8, “... diphenhydraMINE (Benadryl) 50 mg into muscle NOW for EPS ...Administered ...3/7/2025 ...15:47 ...Haloperidol (Haldol) 10 mg into muscle NOW for Psychosis ...Administered ...3/7/2025 ...15:47 ...LORazepam (Ativan) 2 mg into muscle NOW for Anxiety ...Administered ...3/7/2025 ...15:46 ...diphenhydraMINE (*Benadryl) 50 mg into muscle NOW for EPS ...Administered ...3/8/2025 ...14:40 ...Haloperidol (Haldol) 10 mg into muscle NOW for Psychosis ...Administered ...3/8/2025 ...15:21 ...LORazepam (Ativan) 2 mg into muscle NOW for Anxiety ...Administered ...3/8/2025 ...14:40. ...” Hospital document titled “Patient Observations” dated 3/8/2025 revealed, “...14:30 ...Location: Hallway ...Acitivity: Lying/Sitting ...Behavior: Quiet ...14:45 ...Location: Hallway ...Acitivity: Walking/Pacing ...Behavior: Quiet ...15:00 ...Location: Quiet Room ...Acitivity: Watching TV ...Behavior: Quiet ...15:15 ...Location: Hallway ...Acitivity: Walking/Pacing ...Behavior: Quiet ...15:30 ...Location: Room ...Acitivity: Lying/Sitting ...Behavior: Quiet ...15:45 ...Location: Room ...Acitivity: Sleeping ...Behavior: Quiet ...18:00 ...Location: Room ...Acitivity: Lying/Sitting ...Behavior: Quiet ...18:15 ...Location: Room ...Acitivity: Lying/Sleeping ...Behavior: Quiet ...20:30 ...Location: Room ...Acitivity: Lying/Sleeping ...Behavior: Quiet ....” The patient was asleep after injections for over three (3) hours. A request was made on May 29, 2025, for patient #18 ’ s one hour face to face evaluation after the chemical restraint was administered on 3/7/2025 and 3/8/2025. None was provided at the time of survey. Employees #4 and #5 confirmed in an interview on May 29, 2025 that there was no IR or one hour face to face evaluation for Patient #16 for the incident on 4/29/2025 and Patient #10 for the incident on 3/7/2025 or any other restraint documentation. Employees #4 and #5 also confirmed there was no one hour face to face evaluations for Patient #18 after either incidents on 3/7/2025 and 3/8/2025.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 51960 Based on hospital policy and procedure review, hospital documentation review, medical record review, medical record request, and employee interview, it was determined the hospital failed to ensure an order was made before restraint/seclusion was initiated. This deficient practice poses a health and safety risk to patients being placed in restraints/seclusion without a physician order. Findings include: Policy titled “Restraint, Physical,” policy #17373123, approved 02/2025, revealed “...Restraint may only be ordered by a practitioner (Physician or Nurse Practitioner)...A trained registered nurse may initiate restraint in the absence of a practitioner ...the ...practitioner will be contacted during the initiation of restraint or immediately after ...The order shall indicate the reason and maximum duration of restraint ...Restraint episodes will be documented in the ...Restraint/Seclusion Practitioner Order ...Patients will be physically restrained using CPI approved techniques only ...CPI holds are considered a physical restraint ....” A review of patient #2 ’ s hospital documentation titled “Seclusion or Restraint Packet,” dated 3/20/2025, revealed “...Patient ...received order from Dr ....Patient medicated with intramuscular medications ...Necessary to hold patient for five seconds ....” A request was made on May 29, 2025, for a Restraint/Seclusion Practitioner Order for patient #2 ’ s physical restraint. None was provided at the time of survey. An interview with employee #4, completed on May 30, 2025, confirmed that a Restraint/Seclusion Practitioner Order for patient #2 ’ s physical restraint could not be provided. A review of patient #6 ’ s hospital documentation titled “Seclusion or Restraint Packet,” dated 4/26/2025, revealed “...refused to take the ...injection willingly, so staff engaged in a therapeutic safety hold to safely administer the intramuscular injections. The patient was placed in a brief 1-minute therapeutic safety hold ...The hold took place from approximately 1045-1047 ....” A request was made on May 29, 2025, for a Restraint Seclusion Practitioner Order for patient #6 ’ s physical restraint. None was provided at the time of survey. An interview with employee #4, completed on May 30, 2025, confirmed that a Restraint/Seclusion Practitioner Order for patient #6 ’ s physical restraint could not be provided. A review of patient #7 ’ s hospital documentation titled “Seclusion or Restraint Packet,” dated 4/29/2025, revealed “...patient was put into another physical restraint at 1630 ...Patient continued in this restraint for the next 6 minutes ...Patient was released from restraint at 1637 ....” A request was made on May 29, 2025, for a Restraint Seclusion Practitioner Order for patient #7 ’ s physical restraint. None was provided at the time of survey. An interview with employee #4, completed on May 30, 2025, confirmed that a Restraint/Seclusion Practitioner Order for patient #7s physical restraint could not be provided. A review of patient #9 ’ s hospital documentation titled “Seclusion or Restraint Packet,” dated 4/29/2025, revealed “...Date/Time of Initiation ...5/26/2025 16:40 ...patient ...was safely taking(sic) to his room but he kept trying to run out to ...hallway ...staff had to content(sic) patient by restraining him ...Released Date/Time ...5/26/2025 17:10 ....” A request was made on May 29, 2025, for a Restraint Seclusion Practitioner Order for patient #9 ’ s physical restraint. None was provided at the time of survey. An interview with employee #4, completed on May 30, 2025, confirmed that a Restraint/Seclusion Practitioner Order for patient #9 ’ s physical restraint could not be provided.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 51960 Based on a review of policy and procedure, medical record review, hospital document review, and staff interview, it was determined the hospital failed to ensure patients receiving a chemical restraint were not administered it on an as needed basis (PRN). This deficient practice poses a risk to the health and safety of patients if they are being chemically restrained when not warranted which could result in patient harm. Findings include: Policy titled “Restraint, Physical,” policy #17373123, last revised 04/2024, revealed “...POLICY ...Restraint may only be ordered by a practitioner (Physician or Nurse Practitioner)...Orders for restraint shall never be written as a standing order or on as needed basis (PRN)...” The National Institute of Health, National Library of Medicine, Journal of Education & Teaching in Emergency Medicine, October 15, 2020 article “Agitated Psychiatric Patient” revealed: “ ...The main classes of medications utilized for chemical restraint include first-generation antipsychotics (eg, haloperidol and droperidol), second-generation antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone), benzodiazepines (eg, lorazepam and midazolam), and N-methyl-D-aspartic acid (NMDA) receptor antagonists (eg, ketamine) ....” The Journal of Clinical Psychiatry, May, 2021 article titled “Intramuscular B52” revealed “ ...a patient ’ s aggression is so severe that it necessitates use of an intramuscular agent ...intramuscular (IM) haloperidol with IM lorazepam with IM diphenhydramine. This recommendation is so common that it even has its own name: B52 or Benadryl (diphenhydramine), haloperidol 5 mg, and lorazepam 2 mg ....” Emergency Psychiatry article “Physical and Chemical Restraint in the Psychiatric Emergency Service” June 2000, revealed: “ ...The concept of chemical restraint hinges on whether an agent is given as a part of the treatment of the patient ’ s condition or simply to control the patient ’ s behavior ... If prescribed simply as a reaction to the patient ’ s behavior, it is a restraint ....” CMS defines a “drug used as a restraint” (CMS CoP 482.13(e)(1)(i)(A) as follows: “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.” Patient #6 ’ s medication administration record (MAR) revealed: The following scheduled medications: “...divalproex sodium ERT (*Depakote ER) 500 mg Oral NOW for Mood ...9:13 4/26 ....” “...Lorazepam (*Ativan) 2 mg Oral Now to give 2 mg use 2 of 1 mg for Anxiety ...8:55 4/26 ....” “...OLANZapine (Zyprexa) 10 mg Oral NOW for Psychosis ...8:54 4/26 ....” “...risperiDONE (*RisperDAL) 1 mg Oral NOW for Psychosis ...9:14 4/26 ....” “...risperiDONE (*RisperDAL( 1 mg Oral TWICE A DAY for Psychosis ...21:00 4/26 ....” The following PRN medications: “...diphenhydrAMINE (*Benadryl) 50 mg into muscle TWICE A DAY PRN for STP ...9:15 4/26 ....” “...haloperidol (Haldol) 5 mg into muscle TWICE A DAY PRN for STP ...9:14 4/26 ....” “...midazolam (*Versed) 5 mg into muscle TWICE A DAY PRN for STP *IM only ...9:15 4/26 ....” A review of hospital documents titled “Seclusion or Restraint Packet,” dated 4/26/2025, revealed “...patient ...stating that she was unwilling to take her oral medication(s)...and was going to need her Special Treatment Plan (STP) injections for medication refusal, which she was also refusing to take willingly ....” A request was made for patient #6 ’ s STP on May 30, 2025. None was provided at the time of survey. Employee # 4 confirmed in an interview completed on May 30, 2025, that patient #6 was administered injections per the MAR on April 26, 2025, but could not provide patient #6 ’ s STP. Patient #14 ’ s MAR revealed: The following scheduled medications: “...risperiDONE (*RisperDAL) 1 mg Oral TWICE A DAY for Psychosis ...Administered ...5/20/25 ...09:13 ...20:15 ...5/21/25 ...08:23 ...20:11 ...5/22/25 ...08:56 ...” “...risperiDONE (*RisperDAL) 2 mg Oral TWICE A DAY for Psychosis ...Administered ...5/22/25 ...20:18 ...” “...ARIPiprazole (*Abilify) 10 mg Oral AT BEDTIME for Mood/psychosis ...Administered ...5/18/25 ...20:50 ...” “...ARIPiprazole (*Aristada) 882 mg into muscle EVERY 28 DAYS (28 Days) for SCHIZOAFFECTIVE DISORDER and BIPOLAR TYPE **Disp. 5-19-25 #1 ...Administered ...5/19/25 ...08:52 ...” “...ARIPiprazole (*Abilify) 15 mg Oral AT BEDTIME for Mood ...Administered ...5/19/25 ...20:13 ...5/20/25 ...20:15 ...5/21/25 ...20:10 ...5/22/25 ...20:16 ...” “...divalproex sodium ERT (*Depakote ER) 1,500 mg Oral AT BEDTIME To give 1,500 mg use 3 of 500 mg for Mood ...Administered ...5/17/25 ...21:00 ...5/18/25 ...20:50 ...5/19/25 ...20:13 ...5/20/25 ...20:15 ...5/21/25 ...20:11 ...5/22/25 ...20:17 ...” The following PRN medications: “...chlorproMAZINE (*Thorazine) 100 mg into muscle TWICE A DAY PRN ...To give 100 mg use 4 ml of 25 mg/mL ...for STP ...give with midazolam 5 mg im and benadryl 50 mg im for refusing scheduled medication ...” “...diphenhydrAMINE (*Benadryl) 50 mg into muscle TWICE A DAY PRN ...for STP ...give with midazolam 5 mg im and thorazine 100 mg im for refusing scheduled medication ...” “...midazolam (Versed) 5 mg into muscle TWICE A DAY PRN ...To give 5 mg use 1 ml of 5 mg/mL ...for STP ...give with thorazine 100 mg im and benadryl 50 mg im for refusing scheduled medication ...” Employee #4 confirmed in an interview on May 29, 2025 that patient #14 had injections ordered PRN as part of the STP if the patient refused their scheduled medications. Employee #5 confirmed in an interview on May 29, 2025 that the patient had a STP but no medications were selected on the documentation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 51960 Based on review of hospital policy and procedure, review of hospital documentation, and employee interview, it was determined the hospital failed to ensure a patient requiring restraint for a violent episode also received one to one observations during the restraint to ensure safety. This failure poses the risk of a patient suffering injury during the restraint episode and restraint not being discontinued at the earliest possible time. Findings include: A review of hospital policy titled “Restraint, Physical,” policy #17373123, approved 02/2025, revealed “...Patients will be physically restrained ...The patient shall be monitored and reassessed through continuous in-person observation ...The nurse in charge will assign trained staff to continuously monitor the patient during the restraint event. Continuous means ongoing without interruption ....” A review of hospital documentation for patient #9 on May 29, 2025, revealed in a “Seclusion or Restraint Packet,” dated 5/26/2025, “...Initial Assessment (Restraint or Seclusion)...Date/Time of Initiation ...5/26/2025 16:40 ...Patient Monitoring - Document Minimum Every 15 Minutes ...1710 ...mumbling incoherently ...1725 ...Quiet ...1745 ...Quiet ...ReleasedDate/Time ... 5/26/2025 17:10 ....” A request for 15 minute patient monitoring documentation on 5/26/2025 from 16:40 to 17:10 was made for patient #9. None was provided. Employee #4 confirmed during an interview conducted on May 30, 2025, that 15 minute patient monitoring documentation for patient #9 could not be provided on 5/26/2025 from 16:40 to 17:10.”

“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: 51960 Based on hospital policy and procedure review, personnel file review, and employee interview, it was determined The Nurse (RN) Executive failed to document that clinical oversight was provided to Behavioral Health Technicians (BHT) at least once each two-week period if the BHT provides services related to patient care at the health care institution during the two-week period. This deficient practice resulted in Behavioral Health Professionals (BHP) not accurately rounding on patients resulting in an adverse event. Findings include: Policy titled “BHT Clinical Oversight Program,” policy #16796610, approved 02/2025, revealed “...A BHT receives clinical oversight at least once during each two-week period, if the BHT provides services related to patient care at the hospital during the two-week period ...After the observation and evaluation are completed by the supervising RN the RN will complete the BHT Clinical Oversight form ...The supervising RN will meet with the BHT to provide clinical supervision ...The BHT Clinical Oversight Program will be monitored for compliance by the Director of Nursing ....” Clinical oversight documentation was reviewed on May 30, 2025, for employees #7, #8, #9, #10, #11, #12, #13, and #14. The following was revealed: Employee #7 was missing one clinical oversight for May 2025. Employee #8 was missing two clinical oversights for May 2025. Employee #9 was missing two clinical oversights for May 2025. Employee #10 was missing two clinical oversights for May 2025. Employee #11 was missing two clinical oversights for May 2025. Employee #12 was missing two clinical oversights for May 2025 Employee #13 was missing one clinical oversight for May 2025. Employee #14 was missing one clinical oversight for May 2025. Employee #4 confirmed in an interview on May 30, 2025 that employees #7, #13, and #14 were missing one clinical oversight; and employees #8, #9, #10, #11, and #12 were missing two clinical oversights for the month of May, despite providing services related to patient care at the facility during that time frame.”

“Psychological Services CFR(s): Standard: Psychological Services The hospital must provide or have available psychological services to meet the needs of the patients. This Standard is not met as evidenced by: 51960 Based on review of hospital documents and staff interview, it was determined that the hospital failed to ensure there was a full-time, part-time, or consulting psychologist available to provide necessary services to psychiatric patients. This deficient practice poses a potential risk to affect all psychiatric patients receiving services in the hospital. Findings include: Employees #2 confirmed in an interview on May 30, 2025 that the hospital did not have a psychologist employed full-time, part-time, or as a consultant.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 45167 Based on facility record review and staff interview, the facility failed to maintain the contact information for all staff, entities providing services under arrangement, resident physicians and other hospitals, at least annually. Failure to have an emergency preparedness communication plan that includes specific information could lead to harm to both patients and/or staff during an emergency. Findings include: A review of the Haven Behavioral Hospital Emergency Operations Plan approved June 2024 and accompanying documentation revealed phone lists for key leaders and staff within the succession org chart only. No phone numbers for other staff could be found. No phone numbers for patients’ physicians could be found. Although a transfer agreement exists with another hospital, no phone numbers for other hospitals or facilities could be found. No phone numbers of volunteers could be found. In an interview conducted with Employees #3 and #4 on August 1, 2024, Employees #3 and #4 confirmed that additional phone numbers could not be found in the documentation provided to Compliance Officer.”

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Health Care Facilities Sections of health care facilities classified as other occupancies meet all of the following: o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access. o They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. o The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served. 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623 This Standard is not met as evidenced by: 45167 Based observation, facilty documentation and interview, the Department has determined the facility failed to maintain at least a 2-hour fire resistant separation for the hospital from other occupancies. Failure to provide the minimum fire protection features could cause serious injury or death in the event of a fire. NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies 19.1.2 Classification of Occupancy. 6.1.5.1 * Definition - Health Care Occupancy. An occupancy used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants’ control. 19.1.3.4 Contiguous Non-Health Care Occupancies. 19.1.3.4.1 * Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction, and the facility is not intended to provide services simultaneously for four or more in patients who are litter borne. 19.1.3 Multiple Occupancies. 19.1.3.3 * Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: 1. They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation. 2. They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. 3. For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA 101 2012 Edition, Section 8.2 Construction and Compartmentation. 8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters. 8.2.1.2 * NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. 8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following: (1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls, exists between the portions of the building. (2) Separate buildings, if provided with previously approved separations. (3) Least fire-resistive construction type of the connected portions, if separation as specified in 8.2.1.3(1) or (2) is not provided. Findings include: During observation while on tour conducted on August 1, 2024, after consulting blueprints and consulting the feedback of Employees #1 and #5, Compliance Officers observed a set of fire doors connecting Haven Behavioral Health to an outpatient health care occupancy on the second floor of the facility near the elevators. The fire wall was observed to stop at the top of the fire door assembly. Various wires and pipes were observed in the empty space above the fire door assembly connecting Haven Behavioral Health to the other occupancy.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 47669 Based on record review the facility failed to perform the monthly inspection for the facility’s sprinkler systems. Failing to perform the required inspections may cause harm to patients and staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. “Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.” Section 9.7.5 “All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, “Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.” NFPA 25, 2011 Edition, “Water Based Extinguishment Systems,” requires monthly, quarterly, and annual testing of automatic sprinkler systems. Findings Include: Observations while on tour August 01, 2024, revealed the facility failed to show proof of monthly testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Employees # 1, #3, and #5 confirmed during the exit conference that the facility did not have documentation verifying the required monthly testing of the sprinkler systems.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 47669 Based on record review and interview the facility failed to provide all required fire drills per NFPA 101. Failing to conduct fire drills in accordance with the life safety code one per shift per quarter to familiarize staff with conditions under an actual fire can result in harm to patients and/or staff during a an actual fire or emergency situation. NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.7.1.4* “Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.” Section 19.7.1.6 “Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.” Section 19.7.1.7 “When drills are conducted between 9:00 PM and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms.” Findings include: Based on record review and interview on August 1, 2024, revealed that the facility failed to conduct fire drills during the second shift for the entire past year. During the exit conference on August 1, 2024, the above findings were again acknowledged by Employees # 1, #3, and #5.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 47669 Based on record review and interview, the facility failed to provide documentation of the annual fire door inspection. Failing to inspect and test fire-rated door assemblies annually could cause harm to the patients and/or staff. NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 “Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code.” NFPA 80 Section 5.2* Inspections Section 5.2.1*”Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.” NFPA 80 Section 13.4 Automatic closing Section 5.2.5 Horizontal sliding, Vertically Sliding, and Rolling Doors. Section 5.2.14.3 “All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation.” Findings include: Based on record review and interview on August 01, 2024, revealed the facility failed to provide documentation for the 2023/2024 annual fire door inspections. The last documented fire door inspection was in 2020. During the exit conference on August 01, 2024, the above findings were again acknowledged by Employees # 1, #3, and #5.”

“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: 45618 Based on a review of medical records and staff interview, it was determined the hospital did not receive informed consent from four patients who required transport to another hospital for a higher level of care. This deficient practice poses the risk of patients making uninformed decisions about the risks and reasons for transfer, or family members not being informed in an emergency of the patient transfer or the risks of transport. Findings include: Policy titled “Patient Transfer and Transport,” revealed: “...In the event the transfer is planned the physician or designee is responsible for obtaining informed consent from the patient or legal representative. Informed consent includes review of risks and benefits of transfer based on the patient ’ s medical condition and the mode of transfer. This information must be documented in the patient ’ s medical record...Documentation in the patient ’ s medical record includes: For a planned transfer or transport, consent by the patient or the patient ’ s legal representative or why consent could not be obtained such as an emergency transfer to Emergency Department for evaluation and treatment....” A review of medical records revealed four out of four patients (Patients #1, #6, #9, and #19) who were transferred to another hospital for a higher level of care did not have consent documented for the transfer in their medical record. Employee #3 confirmed in an interview conducted on 07/16/2024, the hospital did not get informed consent when patients were transferred to another facility.”

“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: 45618 Based on a review of hospital records, interview, and observation, it was determined the hospital failed to ensure patient bathrooms were ligature free. This deficient practice poses the risk of a patient who is receiving psychiatric treatment with possible suicidal ideation, the opportunity to create a ligature, which could result in serious injury or death. Findings include: Document titled “Patient Handbook,” revealed: “...Here at Haven Behavioral Hospital we provide an inviting, secure and safe environment. We have attractively decorated semi-private rooms with large bathrooms...Patient safety, security and comfort are of the upmost importance to us....” A tour of the facility and patient rooms, conducted on 07/16/2024, revealed in each patient room, and common bathrooms in each of three units, toilets with hinged toilet seats attached to the base of the toilet by a curved bar with an open space that can be used as a tie off point, creating a ligature risk. The hinge mechanism also created a ligature risk by allowing a tie off point between the hinge of the toilet and the toilet seat. Employees #2, #3, #5, and #12 confirmed in an interview conducted on 07/16/2024, they recognized the ligature risk to patients, and would immediately work on a plan to remove the risk.”

“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: 51056 Based on a review of hospital records and interview, it was determined the hospital failed to ensure patients who were restrained by a chemical restraint were documented as a restraint. This deficient practice poses the risk of a patient being chemically restrained unnecessarily, and proper restraint procedures, such as de-escalation, and appropriate monitoring, not being performed. Findings Include: Policy titled, “Restraint, Physical” revealed, ...”Mechanical and Chemical restraint is not utilized at this hospital....” Patient #15 ‘s medical record contained a note titled “Nursing Reassessment,” dated 07/12/2024 at 00:56, which revealed: “...(Patient #15) threw a bottle of shampoo and sandwich at patient hitting her in the head ...(Provider #1) notified and ordered Benadryl, Versed and Haldol x1, given ....” Patient #15 was administered 50 mg Benadryl, 5mg Haldol and 5mg Versed intramuscularly on 07/11/2024 at 22:51, 22:52 and 22:53, respectively. Patient #15 was also administered 50 mg Benadryl, 5mg Haldol and 5mg Versed intramuscularly on 07/14/2024 at 20:28. No chemical restraint orders or documentation was found in Patient #15 ’ s medical records for this time. Patient #8 ‘s medical record contained a note titled “Nursing Reassessment,” dated 12/06/2023, at 12:33, which revealed: “...(Patient #8) displays impulsive behaviors such as disrobing and urinating in the hallway. Patient received IM medication for severe agitation with no physical hold required ....” Patient #15 was administered 50 mg Benadryl, 5mg Haldol and 2mg Ativan intramuscularly on 12/06/2023 at 11:42. No chemical restraint orders or documentation were found in Patient #8 ’ s medical records for this time. Patient #16 ‘s medical record contained a note titled “Discharge MAR,”, which revealed Patient #16 was administered 50 mg Benadryl, 100mg Thorazine and 5mg Versed Intramuscularly on 07/11/2024 at 21:15. No chemical restraint documentation or orders were found in the Patient ’ s medical records for this time. Employee #6 confirmed in an interview conducted on 07/16/2024, that patients were being administered the combination of intramuscularly injected Benadryl, an antipsychotic medication and an anxiolytic medication without classifying the process as a chemical restraint.”