Quail Run Behavioral Health

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49638 Based on review of Hospital policy and procedure, document request, medical records and employee interview it was determined the Hospital failed to establish, document and implement policy requirements: 1. for providing services to patients in excess of its occupancy limits, and 2. to ensure compliance with the requirements of CFR 489.24. These deficient practices pose the potential risk that patients will not receive services in the manner required of and by policy and procedure, thus adversely impacting patient care. Findings include: 1. Hospital policy titled “Intake and Assessment Policy” revealed “...PROCEDURE ...B. Individuals will be screened for the presence of an emergency medical condition; if present, Nursing Supervisor, or designee, will call 911 and stabilizing treatment will be provided until EMS arrives ...If a possible medical emergency is identified, stabilizing treatment will be provided and the on-call physician will be notified for appropriate disposition ....” Hospital policy titled “Bed Availability” revealed “...The Director of Intake is responsible for monitoring bed availability throughout the facility ...A. On a daily basis, the Director of Intake or designee will verify the number of beds available for patients by unit ...B. All departments or individuals requiring bed availability information will contact only the Director of Intake or designee ....” Request was made for Hospital policy documenting requirements for providing services to patients in excess of its occupancy limits. None was provided. Medical record for Patient #5 revealed the following: EMTALA Log revealed Patient #5 arrival at the Hospital on October 16, 2024, at 0934. The Log further specified “...Arrival Mode walk in ...Emergency Medical Condition (Yes/No) Yes ...Disposition Transferred to (other hospital)...Departure Time 1130 ...” Document titled “Memorandum of Transfer,” dated October 16, 2024, revealed “...Reason for Transfer ...Unavailable Resources (box checked)...” Document titled “Standardized Intake Assessment,” dated October 16, 2024, revealed “...Disposition: Admit to Inpatient Services (box checked)...Disposition Comments: Being sent to (other hospital) where there is a bed ...” Medical Record for Patient #16 revealed the following: EMTALA Log revealed Patient #16 arrival at the Hospital on January 26, 2025, at 0926. The Log further specified “...Arrival Mode walk in ...Emergency Medical Condition (Yes/No) Yes ...Disposition sent to (other hospital)...Departure Time 1214 ...” Document titled “Memorandum of Transfer,” dated January 26, 2025, revealed “...transfer to (other hospital) - no bed available at (Hospital)...” 2. Request was made for the Hospital EMTALA policy. Employee #3 stated Hospital policy titled “Intake and Assessment Policy” addresses the screening process when a patient presents to the Hospital. No policy, however, addressing EMTALA and the requirements of CFR 489.24 was provided. Employees #2 and #3 confirmed during an interview conducted on June 5, 2025, that the Hospital has no policy documentation of requirements for providing services to patients in excess of its occupancy limits. Employee #2 also confirmed the Hospital has no policy documentation addressing EMTALA.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 49638 Based on review of Hospital Medical Staff Bylaws, policy and procedure request, and employee interview it was determined the Hospital failed to ensure policy is established, documented, and implemented to address a physician on-call list, in accordance with CFR 489.20(r)(2). This deficient practice poses the potential risk that gaps in Hospital physician on-call coverage may occur, adversely impacting patient care. Hospital document titled “QRBH Facility Medical Staff Bylaws” revealed “...4.2.3 Responsibilities. Each member of the Active Staff shall:...f. perform all on call duties as assigned ...4.3.3 Responsibilities. Each member of the Associate Staff shall:...e. perform all on call duties as assigned ...4.4.3 Responsibilities. Each member of the Consulting Staff shall:...(c) participate equitably in Staff functions ...including ...serving on the on-call roster ...” Request was made for Hospital policy documenting Hospital physician on-call requirements. None was provided. Employee #3 confirmed during an interview conducted on June 5, 2025, that Hospital Medical Staff Bylaws represent the documented policy addressing physician on-call, that no other Hospital policy addressing physician on-call requirements is available for review.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49638 Based on review of Hospital policy and procedure, medical record review and employee interview, it was determined that the Hospital failed to implement and enforce Hospital policy for medically screening arriving patients. This deficient practice poses a potential risk of harm to patients by not properly screening patients for the presence of an EMC (Emergency Medical Condition), thus delaying appropriate medical care and treatment. Findings Include: Hospital policy titled “Intake and Assessment,” Policy ID 12746524, revised 6/2023 , revealed “ ... Individuals will be screened for the presence of an emergency medical condition; if present, Nursing Supervisor, or designee, will call 911 and stabilizing treatment will be provided until EMS arrives. If a possible medical emergency is identified, stabilizing treatment will be provided and the on-call physician will be notified for appropriate disposition ....” Hospital Policy titled “Format and Content of the Medical Record,” Policy ID 12746493, revised 7/2023 revealed “ ...INTAKE ASSESSMENT: An Intake assessment will be completed at the time of admission by the admissions department staff. Each individual presenting for assessment at the facility will be screened by a Qualified Medical Professional (QMP) for the presence of an “emergency medical condition” and a full admission assessment ... If such a patient presents with an “emergency medical condition” (sic) that cannot be treated at the facility, such patient will be stabilized to the extent possible and, transferred to a facility equipped to their condition ... with respect to EMTALA ...”Emergency” in this context means a condition in which serious or permanent harm could result to an individual ....” Hospital Medical Records For Patients #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #15, #19, #20 each revealed that no “Intake Assessment” was present. Employees #2 and #4 stated during an interview conducted on June 5, 2025, that the Medical Screen is included in the facility document titled “Intake Assessment” and this document was not present in the medical records for Patients #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #15, #19, #20”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 49638 Based on review of Hospital policy and procedure, hospital documents, medical records and employee interview, it was determined the Hospital delayed examination and/or treatment for a patient who presented to the Hospital seeking emergency treatment. Failure to provide timely medical examination and treatment poses a potential risk that a patient’s medical condition could worsen without medical treatment. Findings include: Hospital policy titled “Intake and Assessment,” Policy ID 12746524, revised 6/2023 , revealed “...Individuals will be screened for the presence of an emergency medical condition; if present, Nursing Supervisor, or designee, will call 911 and stabilizing treatment will be provided until EMS arrives. If a possible medical emergency is identified, stabilizing treatment will be provided and the on-call physician will be notified for appropriate disposition ....” Hospital document titled “EMTALA Log” revealed Patient #15 arrived at the Hospital on January 21, 2025. The document further specified “...Arrival Time 1637...Arrival Mode walk in...Emergency Medical/Psych Condition (Yes/No) Yes...Disposition Medical Clearance...Departure Time 2009...Departure Mode...Ambo...” Medical records for Patient #15 revealed a document titled “Patient Risk Summary,” dated January 21, 2025 and timed at 2009, that stated “...Patient came in due to suicidal ideations although an assessment was never done due to patient not being alert...Patient arrived to (Hospital) at 1637 and wasn’t seen till 1810...Patient was staffed with (Employee #6) @1825, he/she stated that the patient needed to be sent back to the assisted living home hasn’t been able to be contacted...(Employee #6) stated that she needs to go to the ER and be medically cleared because he/she isn’t A&O...Patient left at 2009...” Employee #2 acknowledged during interview on June 5, 2025, that an emergency medical condition had been identified and that it had been determined Patient #15 required medical clearance. Employee #2 further acknowledged that documentation of stabilizing care provided to Patient #15 from the time of arrival to the time of departure was not available for review.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49638 Based on review of Hospital policy and procedure, medical record review and employee interview, it was determined that the Hospital failed to implement and enforce Hospital policy that specifies the process by which the Hospital personnel coordinate patient transfer and the medical services provided to protect the health and safety of a patient during the transfer. This deficient practice poses a potential risk of harm to a patient when coordination of care activities for patient transfer are not completed pursuant to Hospital policy. Findings Include: Hospital policy titled “Emergency Transfer,” Policy ID 14626599, Revision Date: 7/2024, revealed “ ...5. The Nursing Supervisor/designee is responsible for completion of the Memorandum of Transfer (MOT) form, indicating chief complaint, presenting symptoms and duration, current medication, and any pertinent laboratory data ... vital signs, emergency clinical interventions, response to treatment, and patient’s condition at time of discharge/transfer ....” Hospital Policy titled “Format and Content of the Medical Record,” Policy ID 12746493, revised 7/2023, revealed “ ...INTAKE ASSESSMENT: An Intake assessment will be completed at the time of admission by the admissions department staff. Each individual presenting for assessment at the facility will be screened by a Qualified Medical Professional (QMP) for the presence of an “emergency medical condition” [sic] and a full admission assessment ... If a Patient presents with an “emergency medical condition” [sic] that cannot be treated at the facility, such Patient will be stabilized to the extent possible and, [sic] transferred to a facility equipped to their condition ... with respect to EMTALA ...”Emergency” [sic] in this context means a condition in which serious or permanent harm could result to an individual ....” Hospital medical records for Patients #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #15, #19, #20 each revealed that a “Memorandum of Transfer” form was not present. The “Memorandum of Transfer” form was requested for each patient. Employees #2 and #4 reported none were available for review. Hospital medical record for Patient #10 revealed a “Memorandum of Transfer” form dated May 13, 2025, but was missing the following components: “ ... chief complaint, presenting symptoms and duration, current medication, and any pertinent laboratory data ... vital signs, emergency clinical interventions, response to treatment, and patient’s condition at time of discharge/transfer ....” Employee #4 confirmed during an interview conducted on June 5, 2025, that a “Memorandum of Transfer form was missing from the medical records for Patients #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #15, #19, #20. Employee #4 also confirmed that the “Memorandum of Transfer” form dated May 13, 2025, for Patient #10 was missing the following components: “ ... chief complaint, presenting symptoms and duration, current medication, and any pertinent laboratory data ... vital signs, emergency clinical interventions, response to treatment, and patient’s condition at time of discharge/transfer ....””

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 49638 Based on review of Hospital policy and procedure, medical records, and employee interview, it was determined the Hospital failed to adhere to policy during intake and assessment for patients presenting from a referring hospital, resulting in refusal to accept. This deficient practice poses the potential risk that patients will not receive timely care, causing possible patient harm. Findings include: Hospital policy titled “Intake and Assessment Policy” revealed “...Individuals will be screened for the presence of an emergency medical condition; if present, Nursing Supervisor, or designee, will call 911 and stabilizing treatment will be provided until EMA arrives. If a possible medical emergency is identified, stabilizing treatment will be provided and the on-call physician will be notified for appropriate disposition ....” Medical record for Patient #2 revealed the following: Document titled “EMTALA Log” revealed Patient #2 arrival at the Hospital on October 25, 2024, at 2225. The Log further specified “...Arrival Mode ambo ...Emergency Medical Condition (Yes/No) Yes ...” Document titled “Progress Note,” dated October 5, 2024, and authored by Employee #12, revealed “...Pt is not oriented with no guardian to sign ...House Supervisor stated to call Intake Director for further information ...no answer ...left vm ...called House Sup back at 2320 was advised we both call AOC (Administrator On Call) for further recommendations ...(AOC) stated we would have to send patient back to (referring hospital) d/t his/her inability to consent or give information for treatment ...” Documentation of an emergency medical screen, physician staffing, and stabilizing treatment provided was requested. None was provided. Medical record for Patient #20 revealed the following: Document titled “EMTALA Log” revealed Patient #20 arrival at the Hospital on April 6, 2025, at 1408. The Log further specified “...Arrival Mode ambo ...Departure Time 1559 ...Disposition Medical Clearance ...” Document titled “Summary,” dated April 7, 2025, and authored by Employee #22, revealed “...Patient was not mentally capable of signing himself/herself in, and per EMTs transporting him/her, was not physically able to walk or care for himself/herself ...After EMTs were informed that this RN would not sign for patient, some collateral paperwork regarding patient was emailed to intake, which stated patient was alert and oriented ...Due to limited documentation provided, patient ’ s inability to sign himself/herself in, and the patient ’ s clinical presentation that differed from the documentation provided, the EMTs were told that this RN would not sign for patient, and it was recommended that patient be taken to an ER for medical clearance ....” Documentation of an emergency medical screen, physician staffing, and stabilizing treatment provided was requested. None was provided. Employee #4 confirmed during interviews conducted on June 4, 2025 and June 5, 2025, that no documentation of an emergency medical screen, physician staffing, and stabilizing treatment provided for Patients #2 and #20 were available for review.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45202 Based on review of hospital policy, medical record review and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient’s rights as evidenced by: Cross reference A-0144: Failure to ensure a patient receive care in a safe setting. Specifically, an immediate jeopardy situation was identified including a patient receiving medication they were allergic to and a patient not being evaluated for a change in condition and being found two hours later unresponsive. The egregious nature of this deficient practice resulted in harm to two patients and therefore 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.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 45202 Based on the review of records and staff interviews, it was determined that the Medical Staff failed to implement a process to provide quality patient care as stated in the by-laws as evidenced by: 0340: Failed to implement and conduct periodically conduct appraisals of its members. 0358: Failed to ensure a History and Physical examination was completed within the timeframe determined by medical staff rules and regulations. The substantial lack of oversight of medical staff resulted in the medical staff’s inability to ensure the provision of quality patient care.”

“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: 45202 Based on record reviews and staff interviews, it was determined the hospital failed to provide organized nursing services assessed the individual needs of each patient, and deliver and supervise the care required in accordance with physician orders, policies and procedures, and nursing standards of care. Findings include: The Condition level deficiency is the result of the standard deficiencies found in the following tags: Cross reference A-0395: The facility failed to ensure nursing care for each patient was implemented with regard to ensuring a patient suicide risk assessment was completed according to guidelines and training. Cross reference A-0396: The facility failed to ensure patient nursing care plans include planning for discharge. Cross reference A-0405: The facility failed to implement changes to medication administration based on new guidance given by the Medical Executive Committee on April 24, 2024, with regard to PRN (As needed) medication for sleep. Cross reference A-0411: The facility failed to identify, investigate and determine if reporting was necessary for an adverse drug reaction and errors in administration of drugs. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for Condition of Participation for Nursing Services.”

“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: 45202 Based on observation, document review, medical record review, and interview, it was determined the Administrator and Nurse Executive failed to ensure patients receive care in a safe setting. Specifically, an immediate jeopardy situation was identified including a patient receiving medication they were allergic to and a patient not being evaluated for a change in condition and being found two hours later unresponsive. Findings: Immediate Jeopardy situation #1 Facility policy titled “HIM Organizational Plan for Information Management” revealed “...Patient Care Services...1. Medical staff, nursing staff, and other hospital clinical departments require comprehensive consistent information to conduct their work...Data Accuracy...A. Integrity of the patient information data must must be accurate, valid and useful. Ensuring the accuracy of patient information is essential...” Facility document titled “QRBH Hospital Medication Error/Variance Report,” identifying Patient #13 and dated 8/24/24, revealed “...Description of Error: ...Per collateral packet and patient report, patient has allergy to Haldol. Per collateral packet s/s of allergy is rash, per pt. personal report s/s of allergy is akathesia which is not an allergy reaction, possibly adverse reaction...” Facility document titled “9/11/23-Complaint Received from (Employee #23)-Unreported Medication Error” revealed “...The patient did receive Haldol IM as a chemical restraint. (Employee #11) did look into the matter when (Employee #23) brought it to his/her attention. The collateral information indicated pt had reported he/she would get a rash from Haldol. After the administration of the Haldol here he/she did not develop a rash/hives. Pt complained 13 hrs after the injection of jerky movements and discomfort. The symptoms he/she was having at this time could not be connected to the Haldol injection. The patient is a known epileptic...Spoke with (Employee #31) who indicated this is not an allergy. There is no med error. Any mention of allergy should be removed from the record....” Medical record for Patient #13 revealed the following: Document titled “ED Summary” states “...haloperidol [From Haldol] Allergy (verified 08/22/24 04:21)...Rash...” Document titled “Medication Administration Record” states “...Allergies: HALOPERIDOL (Hives, Akathesia), PROMETHAZINE (Akathesia)...haloperidol SOLUTION 5mg...Administered 9:16 8/24/24...” Document titled “Physician Progress Note” states “...Assessment/Recommendation: ...2. Haldol - drug allergy...8/25/24 0830...” Document titled “Discharge Summary” states “...Discharge Date: 08/27/2024...History and Physical was completed upon admission where the patient reported ALLERGIES TO HALDOL AND PROMETHAZINE...” Employee #6 confirmed during interview conducted on October 2, 2024, that the medical record for Patient #13 contains references of medication allergies to Haldol and Promethazine, confirmed Employee #31 determined administration of Haldol on 8/24/24 was not a medication error and that references of Patient #13 allergy to Haldol should be removed from the medical record. Immediate Jeopardy Situation #2 Facility policy #12741903 titled “Risk Management Plan” revealed “...Occurrence or Incident Follow Up:...A. Four Step Approach to Incident Follow Up:...Immediate Response...Further Investigation...Step 1: Immediate Response:...Verify that the patient now is receiving appropriate medical management...Review the documentation for completeness, contradictions and clues to the cause...Interview those involved...Involvement of medical staff, department directors, supervisors, and administration as appropriate....” Facility incident report “(RM) LOG#: 24-272504, dated 10/8/2024 identified Patient #33 and revealed “...On Tuesday 10/08/24 @1745 Pt. Climb on kitchen cabinet onto the fridgerator [SIC] into the ceiling roof. Pharametics [SIC] were called to get pt. down. Pt was assisted by Pharametics [SIC] to come down from the ceiling.... Facility investigation of the incident documented in “(RM) LOG#: 24-272504” was requested, none was provided. A review of Patient #33 medical record revealed no nursing assessment, clinical assessment or medical assessment after climbing into the ceiling and being up there for approximately 30 minutes, in which there were times where no staff were observing the patient. A request was made for evidence that the patient was assessed for injury or self harm while unobserved in the ceiling was requested. None was provided. Interview with employee #41 on October 17, 2024, confirmed that the internal area of the ceiling that Patient #33 was in had multiple items in which a patient could self harm or injure themselves. Interview with Employee #1 on October 17, 2024 confirmed that no clinical, nursing or medical staff evaluated the patient after the incident.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 45202 Based on review of facility policy and procedure, facility documents, document request, and employee interview, the Department determined the facility administrator failed to ensure the facility implemented its policy pertaining to incident reporting and the incident resolution process in order to measure, analyze and track adverse patient events. This deficient practice poses a risk to the health and safety of patients if incidents involving patient care are not reported and investigated according to policy, enabling the implementation of corrective actions to prevent incidents from recurring. Findings include: Facility policy #12741873 titled “Critical Incident Reporting” revealed “...After completing guidelines set forth in policy Critical Incident/Untoward Event Response, Quail Run Behavioral Health will report as necessary and required the following:...A. Holds, serious injuries, abuse, neglect, need for emergency services, death, major facility incident, injury of unknown origin unexpected outcomes or any other event as required by outside agencies or by facility discretion....” Facility policy #12741903 titled “Risk Management Plan” revealed “...Occurrence or Incident Follow Up:...A. Four Step Approach to Incident Follow Up:...Immediate Response...Further Investigation...Step 1: Immediate Response:...Verify that the patient now is receiving appropriate medical management...Review the documentation for completeness, contradictions and clues to the cause...Interview those involved...Involvement of medical staff, department directors, supervisors, and administration as appropriate....Step 1: Further Investigation:...Gather all pertinent facts about the incidents...Scene - where, when, was equipment involved, patient and circumstances at the time...Parties - names and addresses of all those involved...Description - include quotes of described events.... Facility incident report “(RM) LOG#: 24-272504, dated 10/8/2024 identified Patient #33 and revealed “...On Tuesday 10/08/24 @1745 Pt. Climb on kitchen cabinet onto the fridgerator [SIC] into the ceiling roof. Pharametics [SIC] were called to get pt. down. Pt was assisted by Pharametics [SIC] to come down from the ceiling.... Facility investigation of the incident documented in “(RM) LOG#: 24-272504” was requested, none was provided. Employee #15 confirmed in interviews conducted from October 11, 2024 to October 16, 2024, that no investigation of the incident documented in “(RM) LOG#: 24-272504” was conducted.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 45202 Based on review of Medical Staff Bylaws, policy, credential files and staff interviews, it was determined the medical staff failed to periodically conduct appraisals of its members. This deficient practice can result in practitioners not being provided oversight resulting in inappropriate patient care and operating outside their scope. Findings include: Document titled “Medical Staff Bylaws” states, “...The Medical Director, or his designee, shall have responsibility for oversight of the care provided by the professional, and for the assignment and management of duties. this shall be done through the monitoring of medical records...” Policy titled “Performance Improvement Plan & Policy” Policy #12741919, dated September 2024, states “Peer Review-OPPE/FPPE...The Medical Executive Committee, through the Medical Director, is responsible to investigate, verify and consider each application for appointment or reappointment to any staff status and each request for modification of staff status and to make recommendations to the governing body...Ongoing Professional Practice Evaluation (OPPE) is a proactive practice of establishing a monthly assessment of performance along an established set of measures....” Evidence of the monthly OPPE assessments was requested for the past year for Employee #35, #36, #37, #38, #39 & #40. A spreadsheet was provided for Employee #35, #36, #37, #38, #39 & #40 detailing a list of measures per month that were were completed including peer review results, timeliness of documentation among other quality measures. For Employee #35, #36, #37, #38, #39 & #40, the months of January, February, March, April, June 2024 were blank. For Employee #35, #36, #37, #38, #39 & #40 the months of July, August, and September had two of five measures completed. Interview with Employee #15 on October 17, 2024, confirmed that the Medical Director or designee has not been completing the required oversight and OPPE as required in the Medical Staff Bylaws and Performance Improvement Plan & Policy for Employee #35, #36, #37, #38, #39 & #40.”

“MEDICAL STAFF RESPONSIBILITIES - H&P CFR(s): 482.22(c)(5)(i) [ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 45202 Based on facility medical records and employee interview, the Department determined the administrator failed to ensure a History and Physical examination was completed within the timeframe established in regulation. This deficient practice poses the risk that patients will not receive timely healthcare services, leading to potential injury or death. Findings include: Facility medical record for Patient #37 documented an admission date and time of October 14, 2024 at 15:50. Review of document titled “History and Physical Examination” revealed a completion date and time of October 15, 2024 at 16:20. Employee #15 confirmed during interviews from October 11, 2024 to October 18, 2024, that the date and time of completion of the History and Physical Examination for Patient #37 was October 15, 2024 at 16:20, more than 24 hours from date and time of admission.”

“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: 45202 Based on review of facility medical records, training curriculum and employee interview, the Department determined the Nursing Executive failed to ensure nursing care for each patient was implemented with regard to ensuring a patient suicide risk assessment was completed according to guidelines and training. This deficient practice poses the potential risk that patient suicide risk would not be assessed, placing patients at risk of harm or death. Findings include: Facility medical records revealed the following: Patient #34 - Document titled “Daily Nurse Progress Note,” dated 10/10/24, revealed AMSR (Assessing & Managing Suicide Risk) Daily Screen missing one (1) of two (2) shift assessments completed. Patient #35 - Document titled “Daily Nurse Progress Note,” dated 10/11/24 and 10/14/24, revealed AMSR Daily Screen missing one (1) of two (2) shift assessments completed for both dates. Patient #36 - Document titled “Daily Nurse Progress Note,” dated 10/11/24 and 10/13/24, revealed AMSR Daily Screen missing one (1) of two (2) shift assessments completed for both dates. Facility training curriculum titled “Assessing & Managing Suicide Risk Core Competencies for Behavioral Health Professionals - AMSR” revealed “...The “When” of Getting the Right Information: Routine Assessment Touch Points (Inpatient)...Reassessment (shift/daily)...Review precautions and info from previous shift; reflect changes and new information...” Employee #6 confirmed during interviews conducted from October 11, 2024 to October 16, 2024, that Daily Nursing Progress Notes contained missing AMSR assessments.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45202 Based on facility policy and procedure, reference to State Operations Manual (SOM) Appendix A Section 482.23 Condition of Participation: Nursing Services, medical records and employee interview, the Department determined the facility administrator failed to ensure that patient nursing care plans include planning for discharge. This deficient practice poses a potential risk to the health and safety of a patient when a nursing care plan does not address post-hospital needs. Findings include: Facility policy titled “Nursing Standards of Practice” revealed “...Standard IV Planning...1. Nursing collaborates with other health team members and participates in the development of the Initial and Master Treatment Plan...7. Criteria for discharge are identified...18. The plan includes appropriate discharge planning....” State Operations Manual (SOM) Appendix A Section 482.23 Condition of Participation: Nursing Services states “...Nursing care planning starts upon admission. It includes planning the patient ’ s nursing care to meet the patient ’ s needs and interventions toward meeting patient treatment goals while in the hospital as well as planning for discharge to meet post-hospital needs....” Facility medical records revealed the following: Patient #5 - Document titled “Initial Nursing Treatment Plan,” dated September 28, 2024, did not include discharge planning. Patient #6 - Document titled “Initial Nursing Treatment Plan,” dated September 22, 2024, did not include discharge planning. Patient #10 - Document titled “Initial Nursing Treatment Plan,” dated October 8, 2024, did not include discharge planning. Patient #34 - Document titled “Initial Nursing Treatment Plan,” dated October 4, 2024, did not include discharge planning. Patient #35 - Document titled “Initial Nursing Treatment Plan,” dated October 16, 2024, did not include discharge planning. Patient #36 - Document titled “Initial Nursing Treatment Plan,” dated October 11, 2024, did not include discharge planning. Patient #37 - Document titled “Initial Nursing Treatment Plan,” dated October 14, 2024, did not include discharge planning. Employee #15 confirmed during interviews conducted from October 11, 2024 to October 18, 2024, that facility Initial Nursing Treatment Plans do not include patient discharge planning.”

“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: 45202 Based on facility document review, medical record review and interview the Nursing Executive failed to implement changes to medication administration based on new guidance given by the Medical Executive Committee on April 24, 2024, with regard to PRN (As needed) medication for sleep. This deficient practice resulted in patients receiving PRN medication contraindicated by the Medical Executive Committee and can result in hypersedation of patients causing harm or death. Findings include: A review of the Medical Executive Committee on April 24, 2024, notes indicate that patients are no longer to be given “...PRN for sleeping should not be given within 2hrs of scheduled medication....” Evidence that this direction was implemented and incorporated into policy for evaluated further to not be implemented was requested. None was provided. Patient #1 was prescribed Hydroxyzine, 50mg “PRN” for “Insomnia.” Patient #1 Medication Administration Record (MAR) reveals Patient #1 was administered PRN Hydroxyzine at the same time as their standard medication on the following dates: September 24, September 25, September 26, 2024. Hydroxyzine PRN for insomnia was administered at the same time as Lithium oral 300mg and Prozosin 1mg. Interview with Employee #6 on October 11, 2024, confirmed that the direction from the medical executive committee was not implemented and patient#1 was given PRN medication for sleep at the same time as their scheduled night medication.”

“REPORTING ADVERSE REACTIONS AND ERRORS CFR(s): §482.23(c)(5) - There must be a hospital procedure for reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs. This Standard is not met as evidenced by: 45202 Based on facility policy and procedure, facility medical records, hospital emergency department records, and employee interview, the Department determined that the administrator failed to identify, investigate and determine if reporting was necessary for an adverse drug reaction and errors in administration of drugs. This deficient practice resulted in Patient #14 requiring emergency department assessment for adverse effect to medication provided and the facility failing to identify and investigate it. Findings Include: Policy titled “Assessment of Allergies” revealed “...Upon admission, the nurse will obtain a history of any known allergies from the patient, family or both...Once the nurse obtains an allergy history, the nurse will: ...Document patient allergies in the Nursing Assessment....” Policy titled “Medication Administration Policy” revealed “...Medication Administration Policy...Before administering a medication, the authorized individual administering the medication completes the following: ...Verifies there is no contraindication with respect to allergy, sensitivity or diagnosis....” Medical record for Patient #14 revealed the following: Document titled “Standardized Intake Assessment,” assessment date 8/2/24, assessment time 1829, revealed “..Allergies: ...Olanzapine...” Document titled “Seclusion/Restraint/Chemical Restraint Order” revealed “...Date and Time of Order: ...8/2/24...2010...Type of Intervention...Chemical Restraint (box checked)...involuntarily (box checked)...Olanzapine 2.5mg IM...” Document titled “Seclusion/Restraint/Chemical Restraint Order” revealed “...Date and Time of Order: ...8/3/24...0045...Type of Intervention...Chemical Restraint (box checked)...involuntarily (box checked)...Olanzapine 2.5mg IM...” Document titled “Medication Administration Record” revealed “...Allergies...OLANZAPINE...Olanzapine INJ PWD 2.5 mg...scheduled 21:00 8/2/24...Administered 1:39 8/3/24...Olanzapine INJ PWD 2.5 mg...scheduled 2:00 8/3/24...administered 1:40 8/3/24...” Emergency Department document titled “ED Provider Note” revealed “...Date of Service” 8/3/2024...Time Seen: 8/3//2024 2:22 AM...Chief Complaint...Patient present with...agitation...Pt BIBA from Quail Run for agitation following administration of olanzapine. Patient repeatedly grating jaw and combative per Quail Run staff...presenting to the ED with reported adverse effect to medication provided...was provided with 2.5 mg of olanzapine at 8:15 pm...subsequently ay 0045 patient awoke and was agitated again, at this point provided with additional 2.5 mg of IM olanzapine...Diagnoses...Extrapyramidal reaction...Agitation...” Employee #6 confirmed during interview conducted on October 3, 2024, that Patient #14 had been administered a medication that was identified in the medical record that Patient #14 is allergic to twice and it has not been identified and investigated.”

“Treatment Plan - Adequate Documentation CFR(s): [The written plan must include] Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out. This Standard is not met as evidenced by: 45202 Based on review of facility policy and procedure, medical records and employee interview, the Department determined the facility administrator failed to ensure adequate documentation to justify treatment and activities was carried out by ensuring a patient interdisciplinary treatment plan was updated at a minimum every seven (7) days. This deficient practice poses a potential risk to the health and safety of a patient when a treatment plan is not re-evaluated and updated regularly and after a qualifying event to determine whether the current treatment plan is effective or needs to be modified, per facility policy. Findings include: Facility policy #12743793 titled “Interdisciplinary Patient Centered Care Planning” revealed “...The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) seven days. Facility medical records revealed the following: Patient #5 - Document titled “Interdisciplinary Master Treatment Plan” dated October 2, 2024 identified “Date of Next Treatment Plan Update” as October 7, 2024. No update was found in the medical record. Patient #6 - Document titled “Interdisciplinary Master Treatment Plan” dated September 24, 2024 identified “Date of Next Treatment Plan Update” as October 2, 2024. No update was found in the medical record. Patient #34 - Document titled “Interdisciplinary Master Treatment Plan” dated October 6, 2024 identified “Date of Next Treatment Plan Update” as October 14, 2024. No update was found in the medical record. Employee #15 confirmed during interviews conducted from October 11, 2024 to October 18, 2024, that Interdisciplinary Master Treatment Plans for Patients #3, #6, and #34 were not updated by the required dates.”

“Social Services CFR(s): Standard: Social Services There must be a director of social services who monitors and evaluates the quality and appropriateness of social services furnished. The services must be furnished in accordance with accepted standards of practice and established policies and procedures. This Standard is not met as evidenced by: 45202 Based on review of facility policy, medical record review and interview, the Department determined the Director of Social Services failed to ensure that treatment provided by the social services department was carried out and documented according the a patient’s care plan. This deficient practice results in patients not obtaining therapeutic care necessary for their treatment at the hospital in order to be stabilized and discharge. Findings include: Policy titled “Interdisciplinary Patient Centered Care Planning, Policy #12743793, last reviewed July 2024, states “...It is the policy of Quail Run Behavioral Health Hospital to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient’s progress and determine if any modifications are needed... Each patient’s written Treatment Plan must include: ...Short-term and long term goals for each active problem, developed with patient input;....” Patient #1 care plan dated September 26, 2024, states “...Social service will provide patient with daily processing group ....” Review of Patient #1’s medical record revealed no social work processing group notes with patient attendance or a reason why the patient did not attend on the following dates: September 29, October 2, October 9, October 11, October 13, 2024. Evidence that Patient #1 was offered a process group on these dates was requested. None was provided. Patient #5 care plan dated September 30, 2024, states “...Social services will meet with Patient #5 to develop goals for treatment...Modality...Process Group...Frequency of Intervention...Daily....” Review of Patient #5’s medical record revealed no social work processing group notes with patient attendance or a reason why the patient did not attend on the following dates: September 29, September 30, October 2, October 5, October 6, and October 9. Evidence that Patient #5 was offered a process group on these dates was requested. None was provided. Patient #6 care plan dated September 24, 2024, states “...Social services will facilitate a daily psychoeducation or process group....” Review of Patient #6’s medical record revealed no social work processing group or psyschoeducation notes with patient attendance or a reason why the patient did not attend on the following dates: September 26, September 27, September 29, October 5, October 6 and October 9, 2024. Evidence that Patient #6 was offered a process group on these dates was requested. None was provided. Interview with Employee #6 on October 16, 2024, confirmed that evidence of daily social work groups were offered to patients was not available for Patient #1, #5, and #6.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45202 Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient’s rights as evidenced by: Cross reference A-0144: Failure to ensure a patient bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk. Cross reference A-0145: Failure to protect Patient #9 from potentially abusive behavior by Employee #15. Cross reference A-0167: Failure to ensure restraints were conducted according to facility policy for proper technique. Cross reference A-0175: Failure to ensure a patient requiring seclusion for a violent episode also received one to one observations during the seclusion to ensure safety. Cross reference A-0178: Failure to ensure the patients were evaluated (seen face to face) by a physician or other appropriately trained Registered Nurse within one hour of the restraint. 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.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 45202 Based on the review of facility records and interviews it was determined that the Hospital failed to ensure: Cross reference A0273: They measure, analyze, and track quality indicators by ensuring that the hospital followed their policies and procedures related to quarterly data analysis for episodes of restraint and seclusion. Cross reference A0315: They evaluated if the hospital was provided with adequate personnel and resources to provide the adequate scope of services and care to patients. The cumulative effect of these systemic problems directly related to patient care with regard to restraint, resulted in the hospital’s inability to have an effective quality assurance performance improvement program to assess opportunities for improvement, and improve health outcomes.”

“Special Provisions for Psychiatric Hospitals CFR(s): Special Provisions Applying to Psychiatric Hospitals - Psychiatric hospitals must... This Condition is not met as evidenced by: 45202 Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. Based on the review of facility records and interviews it was determined that the Hospital failed to ensure: Cross reference A1600: Ensuring a Registered Nurses (RN) were present on a unit overseeing patient care of unqualified staff and to provide active treatment measures. The egregious nature of this deficient practice on multiple dates for extended periods of time could result in patient’s not being properly monitored and placed at risk for harm. .”

“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: 45202 Based on observation, review of documents and staff interviews, it was determined the Hospital failed to ensure a patient bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk. This deficient practice provides opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients. Findings include: Observation on tour on July 23, 2024, revealed patient bathroom paper towel dispensers were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point. Interview with Employee #24 on tour confirmed that the issue had been identified but only six patient bathrooms had been fixed and did not have a timeframe for the rest. Document titled “Environmental Ligature Risk Assessment” for January 2024 to June 2024, did not identify the issue. Interview with Employee #1 and Employee #2 confirmed in an interview on July 23, 2024, that the paper towel dispensers were not flush creating a tie off point.”

“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: 45202 Based on a review of hospital record and interview, it was determined the hospital failed protect Patient #9 from potentially abusive behavior by Employee #15. This deficient practice poses the risk of further injury or death to patients while under the care of the facility. Findings Include: Review of facility policy titled “Patient Rights and Responsibilities” revealed “...18. The patient has the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation by anyone including staff, students, visitors, other patients or family members. The hospital has oriented facility staff to assess and immediately report signs or suspicions of patient abuse or neglect. Any reports of patient abuse by the patient, their family or facility staff will be immediately followed up and investigated by hospital administration....” Review of facility video titled “2024-07-13 19-30-00 4th Fl. Day Room South.106 (1).avi” revealed Patient #9 attempting to enter the Seclusion Anti Room at 17:35/1:15:01 of the video timer, Employee #15 exiting the Seclusion Anti Room at that time, placing his/her hands on Patient #9’s upper body and pushing Patient #9 with enough force to move him/her backward and off-balance. Employees #1 and #4 confirmed during a joint interview on July 24, 2024, that the video revealed Employee #15 did not use an approved physical restraint technique in his/her encounter with Patient #9. Employee #1 stated “(Employee #15) definitely pushes (Patient #9). Employee #4 confirmed an employee pushing a patient “is ordinarily an investigated incident”, that “for egregious incidents” an employee would be sent to “Corporate training”, and confirmed that the video showing Employee #15 pushing Patient #9 revealed an egregious incident. Employee #4 confirmed Employee #15 remains employed with the facility and has not received corrective action or training related to the incident.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45202 Based on review of facility policies and procedures, review of facility video and employee interview, the Department determined the administrator failed to ensure restraints were conducted according to facility policy for proper technique. This deficient practice poses the risk of patient injury or death. Findings include: Policy titled “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” revealed “...Definitions: ...Physical Escort: ...Using a ‘light’ grasp to escort a patient to a desired location...If the patient cannot easily remove or escape the grasp this would be a physical restraint...If physical restraint is indicated, at least 2 staff must participate in the physical hold application...Physical restraints (holds) may only be done using techniques trained through the aggression management program...Additionally, except in extreme emergency, one person holds are not to be used... The following facility videos were reviewed and facility employee interviews accompanied each: Patient #3: Facility video titled “2024-06-21 08-12-00 4th Flr Activity North.110.avi” at 1:14/6:00 of the video timer revealed Employee #16 place his/her hands on the upper body of Patient #3, lift him/her off her feet and carry him/her with his/her right arm around the midsection of Patient #3, moving him/her to the doorway to the nurse’s station hallway, at 1:19/6:00 of the video timer. Facility video titled “2024-06-21 08-12-00 4th Floor Nurse Station North.107.avi” at 1:19/6:00 of the video timer revealed Employee #16 continuing to move Patient #3 with his/her right arm around the midsection of Patient #3 and using both arms to attempt to place Patient #3 in a wheelchair next to the nurse’s station. The hold was released at 1:22/6:00 of the video timer. Employees #1 and #4 confirmed the hold within the videos titled “2024-06-21 08-12-00 4th Flr Activity North.110.avi” at 1:14/6:00 of the video timer and “2024-06-21 08-12-00 4th Floor Nurse Station North.107.avi” at 1:19/6:00 of the video timer was not an approved/trained physical restraint technique. Facility video titled “2024-06-21 08-12-00 4th Flr Activity North.110.avi” at 2:44/6:00 of the video timer revealed Employee #17 holding Patient #3 from behind with both arms around the waist of Patient #3. The hold was released at 3:47/6:00 of the video timer. Employees #1 and #4 confirmed the hold within the video titled “2024-06-21 08-12-00 4th Flr Activity North.110.avi” at 2:44/6:00 of the video timer was not an approved/trained physical restraint technique. Patient #10: Facility video titled “2024-07-13 19-30-00 4th Floor Nurse Station South.109.avi” revealed Employee #15 holding the upper body of Patient #10 from behind, with arms interlocked and hands on the shoulders of Patient #10, walking him/her through and outside the nurse’s station at 16:40/1:15:00 of the video timer. Employee#15 and Patient #10 leave view of the video at 16:52/1:15:00 of the video timer. Facility video titled “2024-07-13 19-30-00 4th Fl. Day Room South.106 (1)avi” at 16:41/1:15:01 of the video timer revealed Employee #15 continuing to move Patient #10 outside the nurse’s station, walking behind Patient #10 with arms and hands holding the upper body and arms of Patient #10. Employee #15 stopped at the door leading to the seclusion anti room. While an unidentified employee opened the seclusion anti room door, Patient #10 attempted to leave the hold and Employee #15 struggled to maintain the hold, grasping at the arms and upper body of patient #10, pulling and pushing him/her with force that caused Patient #10 collide with a linen cart and lose balance. Employee#15 and Patient #10 left view of the video at 17:26/1:15:01 of the video timer. Facility video titled “2024-07-13 19-30-00 4th FLR SECLUSION ANTI.105.avi” revealed Employee #15 continuing to move Patient #10 to the seclusion room. At 17:27/1:15:00 of the video timer Employee #15 is seen holding the shoulder area of Patient #10, his/her shirt lifted to shoulder level, and moving him/her into the seclusion room and closing the door with Patient #10 inside. The hold was released at 17:30/1:15:00 of the video timer. Employees #1 and #4 confirmed the hold within the videos titled “2024-07-13 19-30-00 4th Floor Nurse Station South.109.avi” at 16:40/1:15:00 of the video timer, “2024-07-13 19-30-00 4th Fl. Day Room South.106 (1)avi” at 16:41/1:15:01 of the video timer, and “2024-07-13 19-30-00 4th FLR SECLUSION ANTI.105.avi” at 17:27/1:15:00 of the video timer was not an approved/trained physical restraint technique. Patient #14: Facility video titled “2024-06-21 08-12-00 4th Flr Activity North.110.avi” at 1:00/6:00 of the video timer revealed Employee #18 place his/her hands on the shoulders and upper body of Patient #14, first holding and pushing Patient #14 from the front away and from an unidentified patient, then with arms around the shoulders of Patient #14 and finally with hands grasping and holding the arms of Patient #14 from behind, holding and pulling him/her away from the unidentified patient. Employee #18 released the hold at 1:22/6:00 of the video timer. Employees #1 and #4 confirmed the hold within the video titled “2024-06-21 08-12-00 4th Flr Activity North.110.avi” at 1:00/6:00 of the video timer was not an approved/trained physical restraint technique. Employees #1 and #4 confirmed the holds listed above did not demonstrate approved restraint techniques.”

“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: 45202 Based on review of facility policy and procedure, facility video, document request and employee interview, , it was determined the hospital failed to ensure a patient requiring seclusion for a violent episode also received one to one observations during the seclusion to ensure safety. This failure poses the risk of a patient suffering injury during the seclusion episode and seclusion not being discontinued at the earliest possible time. Findings include: Review of facility policy revealed “Definitions: ...Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not [sic]...Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room...The physician/APP (Advanced Practice Provider) order for use of restraint or seclusion will be recorded in the medical record...” Review of facility video titled “2024-07-13 19-30-00 4th Fl. Day Room South.106 (1).avi” revealed Employee #15 with his/her arms around the upper torso of Patient #10, holding and walking him/her into the Seclusion Anti Room at 17:26/1:15:01 of the video timer. Review of facility video titled “2024-07-13 19-30-00 4TH FLR SECLUSION ANTI.105.avi” revealed Employee #15 with his/her arms around the upper torso of Patient #10, holding and walking him/her through the Seclusion Anti Room door, into the seclusion room and closing the seclusion room door with Patient #10 inside at 17:33/1:15:00 of the video timer. Employee was seen in the same video exiting the seclusion anti room at 17:36/1:15:00 of the video timer. Physician order for seclusion was requested, none was provided. Employee #4 confirmed during interview conducted on July 13, 2024, that the videos noted above revealed Employee #15 holding and walking Patient #10 into the seclusion anti room and then into the seclusion room, shutting the door with Patient #10 inside and leaving the seclusion anti room with Patient #10 unsupervised. Employee #4 confirmed patients in seclusion are required to receive “constant supervision.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 45202 Based on facility records and staff interview, the hospital failed to ensure the patients were evaluated (seen face to face) by a physician or other appropriately trained Registered Nurse within one hour of the restraint. This deficient practice poses the risk of physical and/or psychological harm not identified and treated after the restraint. Findings include: Policy titled “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” revealed: “...Face to Face evaluation by the Physician, RNP, or trained RN/PA...Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized RNP(APRN), or trained RN/PA....” Patient #16 “Post Intervention Face to Face Evaluation” revealed “...To be completed by RN with at least 1 year of Behavioral Health experience within 1 hour of initiation of intervention....” Evaluation dated July 14, 2024 was signed by Employee #24 on July 14, 2024. Employee #24 was identified as an LPN. Employee #4 confirmed in an interview on July 24, 2024, that Employee #24 does not have the required credentials to complete the assessment.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 45202 Based on review of policies and procedures, facility documents, medical records, and interview, it was determined the facility failed to measure, analyze, and track quality indicators by ensuring that the hospital followed their policies and procedures related to quarterly data analysis for episodes of restraint and seclusion. This deficient practice poses a potential risk to the health and safety of patients when potential systemic issues or individual performance problems may not be addressed, resulting in potential patient harm or abuse. Findings include: Policy titled “Proper use and Monitoring of Physical/Chemical Restraints and Seclusion” revealed: “...Data is collected on all restraint/seclusion episodes, aggregated, analyzed, and reported to the Hospital Quality Council, medical Executive Committee, and Governing Body at least Quarterly...Data Includes:...Staff who initiated the process; Gender of the patient...Results of the debriefing...Analysis of data includes particular attention to...Multiple instances of restraint/seclusion use experienced by a patient within a 12 hour time frame....” Review of medical records and restraint logs revealed at least three incidents of multiple seclusion or restraint within a 12 hour timeframe by three patients in January and February 2024. Documentation demonstrating review and analysis of restraint and seclusion episodes by Governing Body was requested. Document titled “Medical Executive Committee...April 2024...Review 1st Qtr 2024....” was provided. This document did not address aggregate data or analysis of: Staff who initialed the process, gender of patients, and instances of multiple seclusion or restraint within a 12 hour timeframe by one patient. This document also failed to address results of debriefings. Employee #3 and Employee #5 confirmed on July 25, 2024 that they did not have data to present on seclusion and restraint that met their policy requirements.”

“PROVIDING ADEQUATE RESOURCES CFR(s): 482.21(e)(4) [The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients. This Standard is not met as evidenced by: 45202 Based on the review of policy, hospital documents and staff interviews, it was determined the Governing Authority failed to ensure that they evaluated if the hospital was provided with adequate personnel and resources to provide the adequate scope of services and care to patients. This deficient practice poses a risk to the health and safety of patients if the hospital is unable to provide the proper care and resources to meet the patient’s medical needs. Findings include: Policy titled “Plan for the Provision of Inpatient Care” states, “...Adjustments to the core staffing levels are made on the basis of acuity. Such adjustments for planned staffing are made daily by the CNO or their designee based on the individualized needs of those being served on the units....” Policy titled “Appropriate Staffing Levels” revealed, “...The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences....” Review of Seclusion and Restraint Staff Debriefing notes revealed: Note for Patient #16 dated June 15, 2024, at 1305”...Procedures that can be implemented to prevent reoccurrence....” The staff completing the packet wrote: “...Increased staff...1 observation....” Note for Patient #16 dated June 15, 2024, at 1446, states: “...Procedures that can be implemented to prevent reoccurrence....” The staff completing the packet wrote: “...Increase staff...1:1 observations....” Note for Patient #16 dated June 21, 2024, at 1657, states: “...Procedures that can be implemented to prevent reoccurrence....” The staff completing the packet wrote: “...Increase staff....” Note for Patient #16 dated June 21, 2024, at 1905, states: “...Procedures that can be implemented to prevent reoccurrence....” The staff completing the packet wrote: “...Increase staff...Increase observation....” Note for Patient #3 dated June 21, 2024, at 1109, states: “...Procedures that can be implemented to prevent reoccurrence....” The staff completing the packet wrote: “...Increase staff/observation....” Note for Patient #16 dated June 29, 2024, at 1830, states: “...Procedures that can be implemented to prevent reoccurrence....” The staff completing the packet wrote: “...Staffing ratios....” Note for Patient #10 dated July 14, 2024, at 1830, states: “...Procedures that can be implemented to prevent reoccurrence....” The staff completing the packet wrote: “...Staffing to acuity....” Request for documentation that the CNO reviews ongoing staffing requirements based on outcomes and restraint was requested. None was provided. Interview with Employee #3 and Employee #4 on July 24, 2024, confirmed that they did not have documentation that review of the above incidents were reviewed and action taken on the documenting staffs continual notes of inadequate resources.”

“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: 45202 Based on facility records and staff interview, the hospital failed to a registered nurse supervised and evaluated the nursing care for each patient by allowing a LPN to conduct an assessment without oversight. This deficient practice could result in patient harm and not receiving appropriate care after a restraint. Based on review of facility policy and procedure, facility documents, facility video, and employee interview, the Department determined the administrator failed to ensure patient observation rounds occurred and was documented according to facility policy. This deficient practice resulted in Patient #1 choking himself/herself to unconsciousness with his/her sweatshirt. Findings include: Policy titled “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” revealed: “...Face to Face evaluation by the Physician, RNP, or trained RN/PA...Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized RNP(APRN), or trained RN/PA....” Patient #16 “Post Intervention Face to Face Evaluation” revealed “...To be completed by RN with at least 1 year of Behavioral Health experience within 1 hour of initiation of intervention....” Evaluation dated July 14, 2024 was signed by Employee #24 on July 14, 2024. Employee #24 was identified as an LPN. Employee #4 confirmed in an interview on July 24, 2024, that Employee #24 does not have the required credentials to complete the assessment and operated outside their scope of practice. Based on review of facility policy and procedure, facility documents, facility video, and employee interview, the Department determined the administrator failed to ensure patient observation rounds occurred and was documented according to facility policy. This deficient practice poses the risk that patients left unsupervised may engage in self-injurious behavior, leading to injury or death. Findings include: Review of facility policy titled “Patient Observation Rounds/Level of Observation” revealed “...1. Q15 Minute Observations...Staff assigned to complete patient observation rounds will: ...a. Review and update patient observation forms...d. Observe each patient a minimum of every 15 minutes and according to precaution level, and document observation on the patient observation form...” Review of facility document titled “Patient Safety Log by Date of Incident” revealed Patient #1 involved in an incident on 07/04/2024 at 1737, documented as “...Suicidal Behavior...Outcome/Injury...Loss of Consciousness...” Review of facility document titled “Patient Observation Record & Milieu Group” and dated “7/4/24” revealed the Level of Observation for Patient #1 to be Q15 and at 1730 documented “Behavior...3. Isolative...Location...QR: Quiet Room...Position...B-Back...” The entry was initialed by Employee #8, who documented entries on 17:00, 17:15, 17:30, and 17:45. Review of facility document titled “Employee Corrective Action Report” revealed “...On 7/4/24 (Employee #8) falsified documentation on a patients Q-15 round sheet for 4 rounds (42 minutes) without getting up to check the patient’s location and wellbeing. Patient was left unattended in the music room throughout this time. During this time the patient tied a sweater around his/her neck attempting suicide...” The document also revealed “...Corrective Action...Termination...” Review of facility video titled “2024-07-04 16-30-00 4th Floor Patient Hall Look West.91.avi” revealed Employee #25 opening the door to the “Quiet Room” door at 22:18/1:30:01 of the video timer, observed Patient #1 enter the room and the door close. Employee #25 then walked down the unit hallway to the nurse’s station. No employee is seen on the video completing observation with Patient #1 until Employee #25 returns and opens the “Quiet Room” door at 1:02:01/1:30:01 of the video timer. Employee’s #3 and #4 confirmed during a joint interview conducted on July 12, 2024, that Employee #8 was assigned to perform observation with Patient #1 from 17:00-18:00 on July 4, 2024. Employee #3 confirmed an internal facility investigation determined Employee #8 was found to have falsified documentation on the Patient Observation Record & Milieu Group log from 17:00-18:00 on July 4, 2024, that Employee #8 did not complete observation of Patient #1 during this time/on this date, and it was during this time/on this date that Patient #1 choked himself/herself to unconsciousness with his/her sweatshirt. Employee #3 confirmed Employee #8 was terminated from employment.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 45202 Based on a review of facility policies and procedures, facility documents, observation during on-site tour and employee interview on July 12, 2024, the Department determined the administrator failed to ensure that four (4) of four (4) emergency code carts, located on Units #2, #3, #4 and Intake, were sufficiently checked to ensure no expired medical supplies were in use. This deficient practice poses a potential risk to patient health and safety, including death, if the required emergency supplies are expired and no longer efficacious. Findings include: Review of facility policy titled “Medical Equipment Management Plan” revealed “...The Director of Plant Operations, in conjunction with clinical director and/or medical equipment vendors/contractors, identifies, in writing, the activities used for maintaining, inspecting, and testing all medical equipment on the inventory to assure safety and maximum useful life....” Review of facility documents titled “Emergency Medical Equipment Daily Checklist” for April 2024 through July 12, 2024, revealed instructions that included “...Once per week, locks should be opened, all supplies should be accounted for and checked for expiration dates, ensure no rips or tears are noted to emergency supply packaging...” and identified no expired supplies or ripped/torn emergency supply packaging. Observation during on-site tour revealed: Unit #2 Urethral Catheterization Tray - Expiration Date 2019-10-31 Unit #3 Laerdal Suction Unit NiMH Battery - Install before 2023-11 Unit #4 Laerdal Suction Unit NiMH Battery - Install before 2023-11 Intake Laerdal Suction Unit NiMH Battery - Install before 2023-11 Medical Suction Tube, Lot No: 20220715, Art No: WKT47/FR30, Size: FR30/1.8m, Single Use - Package Open and Unsealed Employee #4 confirmed in interview conducted during on-site tour on July 12, 2024, that the emergency medical supplies identified in the emergency code carts noted above were expired and/or packaging was open and unsealed.”

“Staffing Requirements CFR(s): [Psychiatric hospitals must] Meet the staffing requirements specified in §482.62. This Standard is not met as evidenced by: 45202 Based on review of policy and procedures, facility video footage, and interview, the Department determined the facility failed to ensure Registered Nurses (RN) were present on a unit overseeing patient care of unqualified staff and to provide active treatment measures. This deficient practice could result in patient’s not being properly monitored and placed at risk for harm. Findings include: Policy titled “Appropriate Staffing Levels” states, “...It is the policy of Quail Run Behavioral Health Hospital (QRBH) to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients...The staffing will include a combination of Registered Nurses (RN’s) and unlicensed nursing support personnel in sufficient quantities to meet the needs of the population served...Each patient care unit will have a minimum of one RN at all times. If only one RN is scheduled to a unit for a shift, relief coverage for the RN will be planned and documented, including a coverage plan for meal/break times...A minimum of two staff will be assigned to all units, one of which will be an RN on each shift. In addition, if a unit has more than one patient a minimum of 1 RN and 1 additional nursing personnel member will be scheduled on that unit....” Chief Nursing Officer (CNO) email titled “LPN Scope of Practice” states, “...An RN must be present on the unit at all times...If the door in the adolescent nursing station is closed, there must be an RN on both sides....” Review of unit video footage revealed: On July 18, 2024, an adolescent patient was observed on a unit from 1411 to 1552, and again from 1900 to 1952, with an Employee identified as a Behavioral Health Technician (BHT). The door between the units and the door in the nursing station was closed At no time was an RN identified in the footage. On July 19, 2024, an adolescent patient was observed on a unit from 0900 to 1030, 1200 to 1300, and 1800 to 1900, with an Employee identified as a Behavioral Health Technician (BHT). The door between the units and the door in the nursing station was closed At no time was an RN identified in the footage. On July 21, 2024, an adolescent patient was observed on a unit from 1902 to 1953, with an Employee identified as a Behavioral Health Technician (BHT). The door between the units and the door in the nursing station was closed At no time was an RN identified in the footage. Employee #2 and #3 confirmed in an interview on July 23, and July 24, 2024, during video review, that the unit had a patient present and the unit was not appropriately staffed with a minimum of 2 staff, one of which was an RN, to provide active treatment measures.”