Phoenix Medical Psychiatric Hospital, LLC

“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: 50979 Based on hospital policy and procedure, on-site tour observation, and employee interview, it was determined that the Hospital failed to ensure that the caulking located in patient bathrooms was non-pick. This deficient practice poses a potential risk to patients to pick the coating and ingest non-edible material or reveal a tie-off point. Findings Include: Policy #12508548, titled “Ligature and Ligature Anchor Points-Risk Assessment,” last approved 11/2025, revealed: “...For each ligature and/or ligature anchor point identified through risk assessment, the Safety/Environment of Care Committee shall be responsible for developing plans for removal from the facility if possible, or mitigation ....” On-site tour observation conducted on March 17, 2026, of Unit 200 and Unit 400 revealed caulking around grab bars, light switches, sinks, and soap dispensers all located in patient bathrooms. Surveyors were able to peel caulking off, which could reveal a tie-off point. Employee #3 confirmed in an interview conducted on March 17, 2026, that the caulking in patient bathrooms had the ability to be peeled off and would reveal a tie-off point.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 52829 Based on review of policies/procedures, medical record, direct observation, review of Centers for Medicare and Medicaid Services Memorandum, American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). Center for Disease Control reconditions (CDC), and interview, it was determined that the hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. This deficient practice places patients at risk for acquiring an infection leading to possible harm and or death. Findings include: Review of CDC guidelines titled “Water Management in Healthcare Facilities” March 15, 2024 revealed “ ... CDC recommends that healthcare facilities develop and implement comprehensive water management programs (WMPs) ... CDC recommends that healthcare facilities included in the scope of ASHRAE Standard 188 (Section 5.2) develop and implement comprehensive WMPs ... Hot water temperature is usually measured at the point of use ... the hot water temperature in hospital patient-care areas is no greater than a temperature within the range of 105°F–120°F ....” Review of ASHRAE guideline 12-2023 titled “Managing the Risk of Legionellosis Associated with Building Water Systems” revealed, “ ... Temperature ... water temperature is a significant factor that influences the survival and growth of legionella ... the optimal temperatures ... are between 85 F and 108 F ... Maintaining hot water temperature above 120 F ....” Review of hospital policy titled “Hot Water Temperatures” policy #12508284 last approved 11/2025 revealed, “ ... It is the policy of Neuropsychiatric Hospital that hot water supplied to sinks, tubs, and showers shall be regulated to a maximum temperature of 120°F at the terminal end ....” Review of hospital document titled “Infection Control Plan” effective 11/2025 revealed, “ ... RISK ASSESSMENT The surveillance activities outlined in this document are based on the ongoing assessment of external and internal risks ... CORE GOALS 1. Minimize unprotected exposure to pathogens throughout the hospital. Limiting transmission of infections ....” Review of hospital document titled “PMPH Monthly Temperature Logs-Two Samples per Unit and office area-2026” revealed, “ ... Unit 100 Jan, Room 101 fixture sink temperature 73.1 room 103 fixture sink temperature 71.3 ... Feb Room NE Fixture sink Temperature 98.3 Room NEB fixture sink Temperature 103.6 ... Mar Room 105 Fixture sink Temperature 75.1 Room 107 Fixture sink Temperature 75.6 ... Unit 200 Jan Room showers Fixture sink Temperature 79.1 Room showers Fixture shower Temperature 85.7 ... Feb Room nurses Fixture sink Temperature 86.5 Room showers Fixture sink Temperature 71.8 ... Mar Room B nurses Fixture sink Temperature 73.1 Room showers Fixture sink Temperature 71.8 ... Unit 300 Jan, Room 301 fixture sink temperature 74.5 room 303 fixture sink temperature 92.1 ... Feb Room NE Fixture sink Temperature 95.1 Room NEB fixture sink Temperature 92.1 ... Mar Room nurse Fixture sink Temperature 73.1 Room showers Fixture sink Temperature 71.8 ... Unit 400 Jan, Room 401 fixture sink temperature 73.9 Room 403 fixture sink temperature 80.1 ... Feb Room NE Fixture sink Temperature 93.1 Room NEB fixture sink Temperature 93.5 ... Mar Room nurse Fixture sink Temperature 92.3 Room nurse Fixture sink Temperature 89.3 ....” Interview conducted while on survey from 3/17/2026 through 3/18/2026, employee #3 confirmed that the referenced temperatures were consistently below the recommendation temperature range of 105°F–120°F facility wide.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 49638 Based on hospital policy and procedure, medical record request and employee interview, it was determined that the hospital failed to ensure a patient medical record was maintained with all required documentation for at least 5 years. This deficient practice can result in a patient not getting appropriate psychiatric and medical care if they need further treatment. Findings Include: Hospital policy #12197131, titled “...Intake Sheet-Accepting Referrals,” last approved 08/2022, revealed “...POLICY: ...The Intake Department staff shall complete a Triage Assessment Form for each caller inquiring or seeking assessment for inpatient care...PROCEDURE: ...A copy, fax, or email of completed Triage Assessment Form for patients being admitted to the hospital shall be sent to the nursing station and admitting staff as well as uploaded into the Wellsky document storage. Nursing staff shall review information on the Intake Sheets and incorporate it into the nursing assessment of the patient....” Hospital policy titled “NEUROPSYCHIATRIC HOSPITALS Medical Staff Bylaws PMHP,’ last amended 11/2024, revealed “...BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP...5. Prepare and complete in a timely fashion medical and other records for the patients the Medical Staff member admits, or to whom the member provides care in the hospital....” EMTALA Log dated 12/4/2025 showed Patient #4 arrival at 1610 with note stating “ ...sent out for medical clearance ....” A request was made for hospital medical records, including “Medical Screening Exam,” for Patient #4. None were provided. Employees #1, #3 and #4 confirmed during a joint interview conducted on May 14, 2025, that no hospital medical records for Patient #4 were available for review at the time of the survey.”

“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, facility documents, medical records and employee interview, it was determined the hospital failed to ensure intake screening and admission documentation was completed pursuant to facility policy. This deficient practice poses the potential risk that a patient will not receive needed emergency medical care, resulting in patient harm or death. Findings include: Policy titled “EMTALA,” Policy #12508324, Last Approved: October 2022, revealed “...Evaluation shall be performed...for an individual with an EMC (Emergency Medical Condition) which has not been stabilized...” Policy titled “Intake Sheet-Accepting Referrals,” Policy #12197131, Last Approved: October 2022, revealed “...Policy: The Intake Department staff shall complete a Triage Assessment Form for each caller inquiring or seeking assessment for inpatient care...Original completed Triage Assessment Form shall be retained by the Intake Department....” Policy titled “Criteria for Admission,” Last Approved: March 2024, revealed “...Purpose: To implement appropriate admission of patients to the hospital by identifying inclusionary and exclusionary criteria for admission....” Policy titled “Behavioral Health Admission Assessment-Nursing,” Policy #12195052, Last Approved: October 2022, revealed “...Policy: Each patient’s needs shall be assessed by an RN at the time of admission and documentation completed within twelve (12) hours upon admission by the RN....” Facility document titled “EMTALA Log” revealed the following: Patient #15 arrived at the hospital on May 10, 2025, at 9:48 AM, “ ...Arrival Mode ...(Ambulance) ...Disposition ...Sent out for medical clearance ...” Medical Screening Examination requested for Patient #15. None was provided. Employee #3 confirmed during interviews conducted on May 15, 2025 and May 16, 2025, that no Medical Screening Examination documentation for Patient #15, from the May 10, 2025, at 9:48 AM arrival, was available for review at the time of the survey.”

“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 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 is denied necessary medical treatment. Findings include: Hospital policy titled “EMTALA,” Policy #12508324, Last Approved: 10/2022, revealed “ ...After the hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC (emergency medical condition) who is not medically stable, the hospital may arrange an appropriate transfer for the individual to another more appropriate or specialized facility. Evaluation and treatment shall be performed ...as quickly as possible ...” A total of 20 patient medical records were randomly selected for review from the Hospital’s EMTALA Log. Hospital documents revealed the following: Patient # 20 Hospital document titled “EMTALA Log” revealed Patient #20 arrived at the hospital on May 7, 2025, at 2:15 PM as a “walk-in,” with an Intake Start Time of 3:03 PM, and the Disposition was “ ...admitted ...” Hospital document titled “Nursing Admission Assessment” revealed “ ...Date: 5/7/25 ...Time: 1550 ...” Hospital document titled “Admission Orders” revealed “ ...Date of Order: 5/7/25 ...Time of Order: 1530 ...” Hospital document containing patient demographic information revealed “ ...Admit Date & Time ...5/07/2025 16:30 ...” Employee #3 acknowledged during interviews on May 15, 2025, and May 16, 2025, that documentation for Patient #20 revealed a delay between patient arrival and medical screening examination and/or treatment.”

“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 hospital policy review, medical record review, and employee interview, it was determined that the administrator failed to implement and enforce hospital policy for transferring of patients to another facility. This deficient practice poses a potential risk of harm to patients by not receiving needed care in a safe and timely manner. Findings Include: Hospital Policy titled, “Transfer of Patient,” Policy #10623375, Last Reviewed June 2023, revealed “...Patient transfers will be carried out per physician order in a safe and timely manner, keeping quality patient care a focus, with consideration for patient status. Appropriate patient information will accompany the patient during transfer ...PROCEDURE:...A. Routine/Non-Emergent Transfer:...1. The hospital will ensure a report regarding the patient’s condition is called to the facility the patient is transferring to...Social Services or designee to arrange appropriate transfer and notify/contact the patient’s receiving facility...Arrange transportation for the transfer as ordered by provider...All decisions regarding the type of transportation require approval from patient/Power of Attorney/Guardians prior to arrangement and the approval will be documented...Types of transportation must be decided based on the patient’s condition...The nurse shall conduct a Nurse to Nurse phone report with the accepting facility and document the report in the nurse’s notes....” Medical record of Patient #20, revealed a document titled “Daily Nursing Assessment,” dated May 14, 2025, that revealed “ ...around 2150 BHA was going to take patient to bed ...patient was non responsive ...RN assessed unresponsiveness and called code blue ...patient had week [sic] pulse ...EMS arrived patient taken to Banner University Medical Center (BUMC) ....” Medical record of Patient #5 revealed an untitled document timed at 1704 that showed “ ...Talked to his primary nurse ...patient would be returning due to his altered mental status ...she was informed that patient would have to be returned ....” Medical record of Patient #5 failed to show “...a physician order,... report regarding the patient’s condition ... transfer as ordered by provider ...document the report in the nurse’s notes ....” Medical record of Patient #8, revealed document titled “Phoenix Medical Psychiatric Hospital medical screening exam” that revealed “reason for transfer” “patient needed medical clearance”. Medical record of Patient #8 failed to show “...a physician order,... report regarding the patient’s condition ... transfer as ordered by provider ... Nurse to Nurse phone report with the accepting facility ... document the report in the nurse’s notes ....” Medical record of Patient #14 revealed “Physician/NP/PA Progress Note,” timed 1808, revealed “ ...patient sent to ER for medical clearance ....” Medical record of Patient #14 failed to show “...a physician order,... report regarding the patient’s condition ... transfer as ordered by provider ... Nurse to Nurse phone report with the accepting facility ... document the report in the nurse’s notes ....” Medical record of Patient # 20 failed to show “...a physician order,... report regarding the patient’s condition ... transfer as ordered by provider ... Nurse to Nurse phone report with the accepting facility ... document the report in the nurse’s notes ....” Employees #3 and #4 confirmed during an interview conducted on May 14, 2025, that the medical record for Patients #5, #8, #14 and #20 failed to show “...a physician order,... report regarding the patient’s condition ... transfer as ordered by provider ... Nurse to Nurse phone report with the accepting facility ... document the report in the nurse’s notes ....””

“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: 45202 Based on review of facility policy and procedure, facility documents, medical record request and employee interview, the Department determined the administrator failed to ensure a medical screening exam (MSE) was completed for a patient referred to the facility for an emergency medical condition. This deficient practice poses a potential risk to the health and safety of a patient if life-threatening or potentially life threatening conditions are not recognized and stabilizing treatment provided. Findings include: Facility policy #12197131, titled “...Intake Sheet-Accepting Referrals,” last approved 08/2022, revealed “...POLICY: ...The Intake Department staff shall complete a Triage Assessment Form for each caller inquiring or seeking assessment for inpatient care...PROCEDURE: ...A copy, fax, or email of completed Triage Assessment Form for patients being admitted to the hospital shall be sent to the nursing station and admitting staff as well as uploaded into the Wellsky document storage. Nursing staff shall review information on the Intake Sheets and incorporate it into the nursing assessment of the patient....” Facility policy #12508324, titled “EMTALA,’ last approved 10/2022, revealed “...POLICY: A hospital with specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units, dedicated behavioral health units, or regional referral centers in rural areas) shall accept from a transferring hospital an appropriate transfer of an individual with an emergency medical condition (EMC) who requires specialized capabilities if the receiving hospital has the capacity to treat the individual...The transfer of an individual shall not consider age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law...” Facility document titled “Referrals” had the following patients, referral dates, “Disposition Comment” and “Facility Reason Status” noted: Patient #42: 08/18/2024 “Pt is legally blind requires 1:1” and “Not Medically Approved” Patient #43: 08/19/2024 “Full Transgender/Private Room” and “Other” Facility medical records for Patients #42 and #43, including MSE and Triage Assessment Form were requested. None were provided. Employees #2 and #8 confirmed during a joint interview on September 13, 2024, both patients #42 and #43 were referred to the facility due to psychiatric emergency, that neither patient was accepted and that no medical records, including MSEs or Triage Assessment Form, for either patient were available for review at the time of the survey.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48110 Based on record reviews, staff interviews, and observations, it was determined the hospital failed to ensure the Governing Body evaluated hospital services related to patient rights, nursing services, and medical record services. This deficient practice poses the risk of the Governing Body being unaware of the overall function and management of the hospital and the inability to improve patient care services. Findings include: The Condition level deficiency is the result of the standard deficiencies found in the following tags: Cross reference A-0043: The facility failed to ensure medical staff were held accountable providing patient care that involved restraint and selucsion. Cross reference A-0057: The CEO failed to ensure the day-to-day operations of the facility. Cross reference A-0119: The facility failed to ensure grievances were acknowledged and investigated. Cross reference A-0130: The facility failed to ensure phone calls from patient’s representative and family were answered, and therefore could prevent participation in the patient’s care plan. Cross reference A-0131: The facility failed to ensure consent for treatment was obtained from the representative of a patient who was deemed incompetent. Cross reference A-0144: The facility failed to ensure patients safety: 1. By not having appropriate monitoring of patients after restraint and seclusion episode. 2. By lack of fall evaluation after they occurred, and included fall precaution in the patient’s treatment plan. Cross reference A-0145: The facility failed to ensure a patient was free from harassment and not secluded in the bedroom. Cross reference A-0160: The facility failed to ensure chemical restraints were recognized and documented as restraints. Cross reference A-0162: The facility failed to ensure a patient timeout did not occur in a seclusion room. Cross reference A-0168: The facility failed to ensure patients had a physician order before receiving a restraint and/or seclusion. Cross reference A-0176: The facility failed to ensure providers writing restraints and seclusion, had working knowledge of restraint and seclusion rules and facility policies. Cross reference A-0178: The facility failed to ensure registered nurses performing face-to-face evaluations received training on face-to-face evaluations after use of restraint/seclusion. Cross reference A-0179: The facility failed to ensure patients placed in restraints received a face-to-face evaluation within one hour of initiation of the restraint. Cross reference A-0182: The facility failed to ensure registered nurses performing face-to-face evaluations consulted with the attending physician. Cross reference A-0213: The facility failed to ensure CMS was notified within 24 hours after a patient death associated with a chemical and physical restraint and seclusion occurred. Cross reference A-0386: The facility failed to ensure the Director of Nursing was responsible for the quality of care provided by nursing services. Cross reference A-0395: The facility failed to ensure registered nurses supervise the care behavioral health technician (BHT) provide to psychiatric patients. Cross reference A-0396: The facility failed to ensure high fall risk patient had fall prevention care plan in place. Cross reference A-0398: The facility failed to ensure the nursing staff monitored and reacted in a timely manner to a patient requiring cardiopulmonary resuscitation. Cross reference A-0438: The facility failed to ensure patient’s medical record were properly filed and accessible to surveyors. Cross reference A-0450: The facility failed to ensure contents of medical record were accurately dated, timed and authenticated, and had proper patient identifying information. Cross reference A-0467: The facility failed to ensure: 1. Medical records contained all laboratory results and reports. 2. Patient’s weight was documented in the medical record per facility’s policies and procedures. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Governing Body.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48110 Based on record reviews, staff interviews, and observations, it was determined the hospital failed to comply with protecting and promoting patient’s rights. Findings include: The Condition level deficiency is the result of the standard deficiencies found in the following tags: Cross reference A-0119: The facility failed to ensure grievances were acknowledged and investigated. Cross reference A-0130: The facility failed to ensure phone calls from patient’s representative and family were answered, and therefore could prevent participation in the patient’s care plan. Cross reference A-0131: The facility failed to ensure consent for treatment was obtained from the representative of a patient who was deemed incompetent. Cross reference A-0144: The facility failed to ensure patients safety: 1. By not having appropriate monitoring of patients after restraint and seclusion episode. 2. By lack of fall evaluation after they occurred, and included fall precaution in the patient’s treatment plan. Cross reference A-0145: The facility failed to ensure a patient was free from harassment and not secluded in the bedroom. Cross reference A-0160: The facility failed to ensure chemical restraints were recognized and documented as restraints. Cross reference A-0162: The facility failed to ensure a patient timeout did not occur in a seclusion room. Cross reference A-0168: The facility failed to ensure patients had a physician order before receiving a restraint and/or seclusion. Cross reference A-0176: The facility failed to ensure providers writing restraints and seclusion, had working knowledge of restraint and seclusion rules and facility policies. Cross reference A-0178: The facility failed to ensure registered nurses performing face-to-face evaluations received training on face-to-face evaluations after use of restraint/seclusion. Cross reference A-0179: The facility failed to ensure patients placed in restraints received a face-to-face evaluation within one hour of initiation of the restraint. Cross reference A-0182: The facility failed to ensure registered nurses performing face-to-face evaluations consulted with the attending physician. Cross reference A-0213: The facility failed to ensure CMS was notified within 24 hours after a patient death associated with a chemical and physical restraint and seclusion occurred. The cumulative effect of these systemic deficient practices resulted in the facility’s failture to meet the requirement for the Condition of Participation for Patient Rights.”

“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: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to provide organized nursing services 24 hours per day to assess 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-0386: The facility failed to ensure the Director of Nursing was responsible for the quality of care provided by nursing services. Cross reference A-0395: The facility failed to ensure registered nurses supervise the care behavioral health technician (BHT) provide to psychiatric patients. Cross reference A-0396: The facility failed to ensure high fall risk patient had fall prevention care plan in place. Cross reference A-0398: The facility failed to ensure the nursing staff monitored and reacted in a timely manner to a patient requiring cardiopulmonary resuscitation. 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.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 48110 Based on record reviews an staff interviews, it was determined the hospital failed to ensure each patient’s medical record was complete and maintained. Findings include: The Condition level deficiency is the result of the standard deficiencies found in the following tags: Cross reference A-0438: The facility failed to ensure patient’s medical record were properly filed and accessible to surveyors. Cross reference A-0450: The facility failed to ensure contents of medical record were accurately dated, timed and authenticated, and had proper patient identifying information. Cross reference A-0467: The facility failed to ensure: 1. Medical records contained all laboratory results and reports. 2. Patient’s weight was documented in the medical record per facility’s policies and procedures. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for Condition of Participation for Medical Record Services.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure the quality of care provided by the medical staff was reported to and evaluated by the Governing Body. This failure poses the risk of medical staff providing patient care that does not align with Governing Board standards, and no analysis of the quality of care is provided. Cross reference A-0043 Findings include: Document titled “Rules and Regulations of the Medical Staff PMPH,” revealed: “...The “attending Medical Staff Member” is ultimately the responsible physician who has the overall responsibility for the patient’s care...All medical record entries must be legible, complete, accurate, dated, timed and authenticated promptly, in written or electronic form, by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished...A general consent for, signed by or on behalf of every patient admitted to the hospital, must be obtained at the time of admission or as close to the time of admission as possible....” Document titled “NeuroPsychiatric Hospitals Medical Staff Bylaws PMPH,” revealed: “...Purpose 1. To provide oversight for the quality of patient care, treatment, and services provided by Members. To provide leadership for performance improvement activities and patient safety, and to report and be accountable to the Governing Body....” The medical staff was not held accountable as evidenced by: A-0131: Failure to receive informed consent to treat on a cognitively impaired patient; A-0162: Failure to use the seclusion room appropriately and not for a timeout; A-0176: Failure to write appropriate restraint and seclusion orders, and not on an as needed basis; A-0179: Failure to ensure patients placed in restraints received a face-to-face evaluation; A-0182: Failure to ensure the registered nurse performing the face-to-face evaluation after a restraint/seclusion episode consulted with the attending physician;”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the Chief Executive Officer (CEO) failed to manage the daily operation of the hospital. This deficient practice poses a risk to the health and safety of patients when leadership does not provide proper guidance, enforcement of policies and procedures, and provide resources to deliver care to meet the needs of patients. Cross reference A-0043 Findings Include: Document titled, “NeuroPsychiatric Hospitals Job Description”, revealed: “ ...Job Title ...Facility Chief Executive Officer ...Position Summary ...The Board of Directors in conjunction with the President and COO, shall appoint a CEO who is responsible for the overall administrative management and operation of the hospital(s). This includes functions in Planning ...Continuous Quality Improvement ...and day-to-day Operational Management ....Oversees and directs total hospital operation ....Job Functions ...Monitors the adequacy of the hospital(s) medical activities through coordination with the board, medical staff, and nursing personnel, and the policies needed to assure acceptable health care services ....Verifies that policies are in place for communicating with physicians concerning an inpatient emergency ....Ensures compliance with regulations of governing hospitals and the rules of accrediting bodies by continually monitoring the organization’s service delivery and initiating changes as required ....Ensures that the staff are trained and evaluated on their knowledge of and adherence to compliance policies and procedures specific to their jobs ....” It was determined the CEO failed to manage the day-to-day operations of the hospital as demonstrated by the following: Cross reference A-0119: The facility failed to ensure grievances were acknowledged and investigated. Cross reference A-0130: The facility failed to ensure phone calls from patient’s representative and family were answered, and therefore could prevent participation in the patient’s care plan. Cross reference A-0131: The facility failed to ensure consent for treatment was obtained from the representative of a patient, who was deemed incompetent. Cross reference A-0144: The facility failed to ensure patients safety: 1. By not having appropriate monitoring of patients after restraint and seclusion episode. 2. By lack of fall evaluation after they occurred, and included fall precaution in the patient’s treatment plan. Cross reference A-0145: The facility failed to ensure a patient was free from harassment and not secluded in the bedroom. Cross reference A-0160: The facility failed to ensure chemical restraints were recognized and documented as restraints. Cross reference A-0162: The facility failed to ensure a patient timeout did not occur in a seclusion room. Cross reference A-0168: The facility failed to ensure patients had a physician order before receiving a restraint and/or seclusion. Cross reference A-0176: The facility failed to ensure providers writing restraints and seclusion, had working knowledge of restraint and seclusion rules and facility policies. Cross reference A-0178: The facility failed to ensure registered nurses performing face-to-face evaluations received training on face-to-face evaluations after use of restraint/seclusion. Cross reference A-0179: The facility failed to ensure patients placed in restraints received a face-to-face evaluation within one hour of initiation of the restraint. Cross reference A-0182: The facility failed to ensure registered nurses performing face-to-face evaluations consulted with the attending physician. Cross reference A-0213: The facility failed to ensure CMS was notified within 24 hours after a patient death associated with a chemical and physical restraint and seclusion occurred. Cross reference A-0386: The facility failed to ensure the Director of Nursing was responsible for the quality of care provided by nursing services. Cross reference A-0395: The facility failed to ensure registered nurses supervised the care behavioral health technician (BHT) provide to psychiatric patients. Cross reference A-0396: The facility failed to ensure high fall risk patient had fall prevention care plan in place. Cross reference A-0398: The facility failed to ensure the nursing staff monitored and reacted in a timely manner to a patient requiring cardiopulmonary resuscitation. Cross reference A-0438: The facility failed to ensure patient’s medical record were properly filed and accessible to surveyors. Cross reference A-0450: The facility failed to ensure contents of medical record were accurately dated, timed and authenticated, and had proper patient identifying information. Cross reference A-0467: The facility failed to ensure: 1. Medical records contained all laboratory results and reports. 2. Patient’s weight was documented in the medical record per facility’s policies and procedures.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 45618 Based on review of hospital records and interview, it was determined the hospital failed to acknowledge and investigate grievances of patients’ family members (Patient #3 and #17). This failure poses the risk of decreased patient satisfaction and the inability of the Governing Board to become aware of potential patient care issues within the hospital. Cross Reference A-0115, A-0043, A-0057 Findings include: Hospital policy titled “Patient Grievance Procedure,” revealed: “...The Hospital shall provide a system whereby patients and/or their significant other or representatives, can voice a grievance/complaint about the quality of care and/or services received at the Hospital. This organization shall respond to such concerns in a timely, reasonable and consistent manner...A written complaint is always considered a grievance, whether from an inpatient, released/discharged patient or his/her representative regarding the patient care provided, abuse or neglect, or the hospital’s policies and procedures...Upon notification of a complaint/grievance, information sufficient to identify the individual registering the concern will be recorded: The name of the patient (if not the individual submitting the information); Date of receipt; Nature of the concern. The hospital will investigate the grievance, reviewing any documentation, obtaining statements if needed, and reviewing patient records (as needed)...After thorough research has been conducted, the CEO or designee will work in tandem with the Compliance Officer and any staff identified as key individuals critical to problem resolution for the specific identified concern...All complaints and grievances will be addressed in a timely manner. This organization will make every attempt to provide a response within seven (7) business days of receiving a complaint/grievance...The complainant will be provided with written notice of: The name of the CEO and Compliance Officer or designee; The steps taken to identify and resolve the grievance; The final result of the Grievance process; The date of completion of the grievance process...All complaints and grievances will be logged into a reporting system. Grievance logs may be requested....” Policy titled “Patient Rights and Responsibilities,” revealed : “...You have the right to...File a grievance or complaint verbally, by phone or in writing to any staff member. All grievances will be addressed in a timely manner. This organization will make every attempt to provide a response within seven (7) business days of receiving a complaint/grievance. All grievances will be investigated with efforts made toward reolsution within seven (7) days of receiving a grievance....” Patient #3’s family member provided a grievance submitted to the hospital on 04/17/2023. Patient #3’s family member provided the email response, dated 04/21/2023,/ that was received which revealed: “...In response to the report you submitted, NeuroPsychiatric Hospitals has sent the following message: Our providers have done a great job in addressing [her] needs...It is not fair for this patient’s [mother] to say they have not called back as requested...While the [mother] feels that [her daughter] may need more attention than [she] is getting, providers see the [daughter] on a daily basis and there is no way this patient is dehydrated....” Patient #17’s family member provided an email sent to Employee #6, on 08/09/2023, concerning care provided to Patient #17, missing items, and the cost of denture repairs that were broken when Patient #17 sustained a fall at the facility. Patient #17’s family member provided the following email received from Employee #42, on 08/29/2023: “...[Randy], this invoice was sent to our corporate team and after internal investigation it was determined that PMPH was not responsible to the damage to the dentures. Please reach out if you have further questions....” Patient #17’s medical record contained a note titled “Nursing Admission Assessment,” dated 07/29/2023, which revealed a Morse Fall Scale Score of 70, and a check in the box for High Risk (>45 points). Patient #17’s medical record contained a note titled “Admission Orders,” dated 07/29/2023, which revealed the patient was not placed on fall precautions on admission. Patient #17’s medical record contained an “Interdisciplinary Treatment Plan,” dated 07/29/2023, which did not identify falls on the problem list. Patient #17’s medical record contained a note titled “Daily Nursing Narrative,” dated 08/01/2023, which revealed: “...Patient was ambulating to the bathroom when [she] tried to get up from [her] wheelchair to go to the bathroom [she] fell and hit the side of [her] head on the floor; fall was unwitnessed. V/S were taken, patient was examined by the medical provide on the unit and neuro checks put in place...Patient came out complaining of blurry vision and a headache. Called the medical provider, obtained an order to send pt out via AMR to [Valleywise] for post fall CT scan d/t patient being on anticoagulants....” The Post Fall Huddle Form was requested for the fall Patient #17 sustained on [08/01/2023]. None was provided. Falls were not added to the Interdisciplinary Treatment Plan as a problem after the 08/01/2023 fall. Patient #17’s medical record contained a note titled “Daily Nursing Narrative,” dated 08/07/2023, which revealed: “...Roommate came to nurses’ station and reported “Patient got up from bed to go to bathroom and [she] is on the floor”. Went to room Patient found lying across bed laying on [her] abdomen...noted small 0.4cm long cut to upper inner lip. Patient also noted to have blue bruising to left cheek bone. Patient stated “I had to go pee so I stood up when I took a step I got off balance and I tried to get next to the wall but I fell and landed on the floor.” As patient speaking noted dentures are broken to upper left side...Notified Psych provider received order for 1:1 for patient safety d/t fall....” Patient #17’s medical record contained a note titled “Interdisciplinary Care Plan,” which revealed: “...Problem: Fall Risk; As Evidenced By: Fall at Bedside; Date Initiated: 08/07/2023...” The internal investigation referred to by Employee #42 in the 08/29/2023, email response to Patient #17’s family member, was requested and could not be provided. Hospital document titled “Grievance Log,” for 2023 and 2024 revealed the grievances from Patient #3’s and Patient #17’s family members were not on the log. Employee #1 and Employee #5 confirmed in an interview on 02/21/2024, there was no record of investigation for the grievances submitted by Patient #3’s and Patient #17’s family members, or record of a grievance being submitted.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48110 Based on record reviews, staff interview, and observations, it was determined the hospital failed to ensure phone calls from patient’s representative and family were answered in a timely manner. This deficient practice poses a potential risk that patient rights are violated when patient’s representative could not call to file a grievance, or communicate with the facility and participate in the patient’s care plan. Cross reference A-0115, A-0043, A-0057 Findings include: Policy titled, “Patient Rights and Responsibilities”, revealed: “ ...Purpose: Every person who enters the hospital for care has rights ...He/she may exercise these rights while hospitalized ....Procedure: ...You have the right to: ...have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes, in order to participate in current and future decisions affecting your care and to participate in the development and implementation of your plan of care ....” Policy titled, “Patient Phone Use”, revealed: “ ...Policy: The hospital recognizes that when a patient is in the hospital, communication with family and friends is an essential element for support and comfort ....” Policy on the call tree, in how phone calls are answered, was requested. None was provided. Document titled, “Phone Communication Expectations”, revealed: “ ...We at NeuroPsychiatric Hospital consider communication with families, caregivers, friends, community partners, referral sources, vendors and other related professionals, to be a primary factor in delivering quality care and treatment to our patients. Although some employees have specific duties assigned to answer phones, all employees of NPH have the expectation to work as a team to ensure our phones get answered in a timely fashion. If employees are working at any of our hospital or office locations, (including nursing units) and hear a phone ring, they are expected to answer the phone within three rings ....Employees should listen and ask questions to ensure they understand the nature of the phone call to either assist the caller in the moment, transfer the call to the appropriate employee/department .....Additionally, any employee receiving a phone message should place a return phone call as the situation demands. Urgent phone calls should be returned as soon as the message is received. All other non-urgent messages should be returned as soon as possible, preferably within twenty-four (24) hours of the initial phone call ....” Observations on tour on 02/15/2024 revealed four units and each unit had a telephone in the hallway for patient use. Employee #1 confirmed during an interview conducted on 02/15/2024 that if the patient’s representative and family want to communicate with the patient, they have to call the hospital’s main phone line and the call goes to the lobby. The receptionist at the lobby then transfers the call to the nurses’ station of the unit, and the nursing staff transfers the call to the telephone in the hallway for the patient to answer. Employee #1 also confirmed the lobby is not staffed 24 hours a day, 7 days a week. Employee #1 also confirmed if nobody answered the call in the lobby, then it is transferred to the nurses’ station in each unit after a number of rings until someone answered the call. Employee #1 further confirmed often times phone calls do not get answered, and it is a common complaint.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to ensure consent for treatment was obtained from a mentally incompetent patient’s (Patient #9) representative or mental health power of attorney. This deficient practice poses the risk of patients who are deemed incompetent giving consent for treatment, and not fully comprehend the risks and benefits of the treatment. Cross reference A-0115, A-0043, A-0057 Findings include: Policy titled, “Admission of Patients (IN)”, revealed: “ ...Purpose: To ensure a safe and appropriate admission process occurs....Procedure:...Patients or their designees (POA/Guardian) must sign a voluntary consent and authorization for treatment during the admission process ....” Policy titled, “Informed Consent Process”, revealed: “ ...Policy: All patient medical records shall contain evidence of informed consent for medical care and psychiatric treatment specified by state or federal laws/regulations. The Hospital’s informed consent process assure patients or their legal representatives are given the information and disclosures needed to make an informed decision about whether to consent to medical care and psychiatric treatment. Arizona Administrative Code 9-21-206.01 notes the consent by mentally incompetent patients. This section applies to a patient who is deemed incompetent shall provide consent for treatment through the informed consent of one of the following: The patient’s legal guardian or other court appointed representative. The patient’s health care representative. An appointed attorney in fact for health care .....Procedure: The informed consent process includes at least the following: ...The following signatures are required as part of the informed consent: Patient or representative/legal guardian ...If the patient is under to provide a signature, document the verbal agreement by the patient or patient’s legal representative. Written consent will be obtained as soon as practicable. Hospital representative witnessing the patient or patient’s legal representative/guardian signing the consent form, including the date and time .....Date and time consent is signed by the patient or the patient’s legal representative/guardian ....” Policy titled: “Legal Guardian, Power of Attorney and Admitting Procedures”, revealed: “ ...Policy: It is the policy of the Hospital to help assure that decisions made by mentally competent patients 18 years of age or older regarding their own medical care ...should the persons become incapable of expressing their own wishes ....Procedure: 1. When a patient referral is obtained by the hospitals Intake department, Intake staff will make every attempt to obtain the Power of Attorney or Guardianship paperwork from the patient’s family or referring facility. 2. If the Power of Attorney or Guardianship paperwork were obtained by the Intake staff then these documents will be provided to the receiving hospital with the Intake admission documentation. 3. The receiving hospitals receptionist will make sure that all Power of Attorney and Guardianship paperwork is received prior to any patient being admitted. 4. Once this paperwork is received by the receptionist, only the Power of Attorney or Guardian may sign the consent for treatment forms required for admission ....” Patient #9’s medical record identified a Montreal Cognitive Assessment (MOCA), and it revealed Patient #9 scored 7 out of 30, indicating they had severe cognitive impairment. Patient #9’s medical record dated [08/27/2023] identified a nursing note, and it revealed: “ ...AOx1 {sic}(alert and oriented) ...Patient was cooperative at [her] best ability; unable to completely answer questions and stay on topic ....Patient was observed confused at times and had to be redirected to [her] room ....” Patient #9’s medical record dated [08/28/2023] identified a psychiatric evaluation, and it revealed: “ ...admitted to Phoenix Medical Psychiatric Hospital increased psychosis and paranoia ....During assessment, [she] presents with tangential and disorganized thinking, racing thoughts and paranoia. [She] continues to be paranoid, and presents with flat affect. [She] appears to be confused, [she] confused to self but didn’t know date, place and reason for being in the hospital ....Past Psychiatric History: ...son ...Medical POA, will seek emergency guardianship if needed ....” Patient #9’s medical record dated [09/02/2023] identified a social services progress note, and it revealed: “ ...[he]{sic}(Patient #9’s [son]) needs a physician statement to state (Patient #9) needs emergency guardianship from physician at PMPH ....” Patient #9’s medical record dated [09/06/2023] identified a social services progress note, and it revealed: “ ...Writer received a call from (Patient #9’s [son]), who states [he] is speaking w/ a lawyer to assist w/ guardianship ....” Patient #9’s medical record dated [08/27/2023] revealed Patient #9 initialed and signed the Conditions of Admission and Authorization for Medical Care and Psychiatric Treatment forms at admission. Employee #2 confirmed during an interview conducted on 02/15/2024 that medical power of attorney is insufficient and patient’s representative must have mental health power of attorney, to be authorized to sign consent for treatment forms on the patient’s behalf. Employee #2 also confirmed patients who are mentally incompetent, their representative or mental health power of attorney is to sign the consent for treatment forms at admission. Employee #2 also confirmed Patient #9 signed their new admission paperwork, including consent for treatment. Employee #2 also confirmed Patient #9 was cognitively impaired and mentally incompetent on admission. Employee #2 further confirmed Patient #9 did not have mental health power of attorney paperwork in their medical record. Employee #1 confirmed the facility would not accept a patient who is mentally incompetent, and without a mental health power of attorney to represent the patient.”

“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: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure: 1. Falls for two patients (Patient #5 and Patient #17) were discussed and evaluated after the falls. This deficient practice poses a risk to the health and safety of patients when patient falls are not addressed and evaluated to prevent future occurrences. 2. Patients requiring every 15 minute observations were being observed by hospital staff every 15 minutes. This failure poses a risk of patients having a medical emergency, or needing medical assistance and it going unnoticed. Cross reference A-0115, A-0043, A-0057 Findings include: 1. Policy titled, “Fall Prevention Program”, revealed: “ ...Policy: ...A Fall Prevention Program will be implemented and maintained to assure the safety of all patients admitted to the facility ....All falls occurring during hospitalization will be evaluated to determine the potential causative factors and discern appropriate interventions ....Procedure: Risk Identification/Precaution/Prevention: 1. All patients presenting for admission to the hospital will be assessed and identified for the level of fall risk during the nursing admission assessment using the Morse Fall Scale ...2. All patients will be placed on a low, moderate, or high fall risk. 3. Patients who score a low risk for falls (scoring <24 on the Morse Fall Scale) will be monitored ....4. Patients who score a moderate risk for falls (scoring 25-44 on the Morse Fall Scale) and high risk for falls (scoring 45 and higher on the Morse Fall Scale) will receive red colored non-skid socks, as well as any other potential interventions ....Procedure: Post Fall Evaluation: 1. Each time a patient falls, the patient will be assessed by the nurse directly after the fall and the nurse will notify the provider to obtain any necessary orders. 2. Interventions necessary to stabilize the patient will be completed in a timely manner ....5. The Incident Report will be submitted through Wellsky...Individualized fall prevention interventions will be developed in the Interdisciplinary Treatment Plan for all fall risk patients. Fall prevention interventions specific to the patient’s needs will be implemented as needed ....” Document titled, “Q1 2023 Governing Board Meeting” dated 05/18/2023, revealed: “ ...Compliance/Regulatory: ...Fall Prevention Program ...Post fall safety huddle to be completed by staff after each fall for debriefing ....” Review of Patient #5’s medical record dated [06/09/2023] identified a nursing admission assessment, and it revealed they were high risk for falls with a Morse Fall Scale score of 80. Review of Patient #5’s medical record dated [06/09/2023] identified a nursing note, and it revealed: “ ...Patient is found on the floor next to [her] bed approximately 1215hrs head facing down and patient bleeding. Quick assessment completed. Vital signs; pulse 97, resp 20, B/P 119/75, oxygen 84%. Patient glasses (edge) stuck on the right eyebrows. Laceration/bleeding noted on the right eyebrow, Provider called and 911 activated ....” The Post Fall Huddle Form was requested for the fall Patient #5 sustained on [06/09/2023]. None was provided. Patient #17’s medical record contained a note titled “Nursing Admission Assessment,” dated 07/29/2023, which revealed a Morse Fall Scale Score of 70, and a check in the box for High Risk (>45 points). Patient #17’s medical record contained a note titled “Admission Orders,” dated 07/29/2023, which revealed the patient was not placed on fall precautions on admission. Patient #17’s medical record contained an “Interdisciplinary Treatment Plan,” dated 07/29/2023, which did not identify falls on the problem list. Patient #17’s medical record contained a note titled “Daily Nursing Narrative,” dated 08/01/2023, which revealed: “...Patient was ambulating to the bathroom when [she] tried to get up from [her] wheelchair to go to the bathroom [she] fell and hit the side of [her] head on the floor; fall was unwitnessed. V/S were taken, patient was examined by the medical provide on the unit and neuro checks put in place...Patient came out complaining of blurry vision and a headache. Called the medical provider, obtained an order to send pt out via AMR to [Valleywise] for post fall CT scan d/t patient being on anticoagulants....” The Post Fall Huddle Form was requested for the fall Patient #17 sustained on [08/01/2023]. None was provided. Falls were not added to the Interdisciplinary Treatment Plan as a problem after the 08/01/2023 fall. Patient #17’s medical record contained a note titled “Daily Nursing Narrative,” dated 08/07/2023, which revealed: “...Roommate came to nurses’ station and reported “Patient got up from bed to go to bathroom and [she] is on the floor”. Went to room Patient found lying across bed laying on [her] abdomen...noted small 0.4cm long cut to upper inner lip. Patient also noted to have blue bruising to left cheek bone. Patient stated “I had to go pee so I stood up when I took a step I got off balance and I tried to get next to the wall but I fell and landed on the floor.” As patient speaking noted dentures are broken to upper left side...Notified Psych provider received order for 1:1 for patient safety d/t fall....” Patient #17’s medical record contained a note titled “Interdisciplinary Care Plan,” which revealed: “...Problem: Fall Risk; As Evidenced By: Fall at Bedside; Date Initiated: 08/07/2023...” A fall log was requested for the previous 12 months. Patient’s #5 and #17 were not on the log. Employee #2 confirmed during an interview conducted on 02/20/2024 that Patient #5 fell in the facility on [06/09/2023]. Employee #2 also confirmed there was no documentation that a post fall safety huddle was completed. Employee #2 confirmed during an interview conducted on 02/21/2024 Patient #17 was not placed on fall precautions on admission, per policy, nor had falls identified as a problem on the Interdisciplinary Care Plan, until after two falls had occurred. 2. Document titled “Job Title Registered Nurse; Department Name Nursing,” revealed: “...Directs non-professional personnel in implementing nursing care plans, and provides guidance and demonstrates appropriate methods, as necessary, to correct deviations from established standards... Maintains the standards of accurate and complete recording and reporting. Reports patient’s condition, medications given and treatments administered to nursing administration and the following shift...Makes regular rounds of assigned patients independently and with physicians. Observes and evaluates patient’s symptoms, progress and reactions to treatments and mediations {sic}, Takes corrective actions as indicated...Observes and supports hospital policy, mission statement, and vision....” Hospital policy titled “Patient Observation,” revealed: “...All patients will be admitted to the patient care unit with a minimum of “every 15 minutes” observation level...Level 1 - General Observation a. All patients on this level are on every 15 minute observation, at a minimum. B. This is the minimum acceptable level for all patients....” Hospital document titled “NeuroPsychiatric Hospitals Code of Conduct,” revealed: “...We expect all officers, employees, members of the System’s Governing Board, members of the System’s Medical Staff...(collectively, “System’s Representatives”) to adhere to the highest standards of conduct whenever acting on behalf of the System...Accuracy, Retention and Disposal of Records: Every System Representative is responsible for the integrity and accuracy of the System’s records. Records must not only comply with regulatory and legal requirements, but should also support our business practices and actions. Alteration or falsification of information on any record or document is strictly prohibited....” A review of “Patient Observation Rounds” forms, dated 01/28/2024, for Patients #19, #25, #26, #27, and #29, revealed Employees #29 and #39 documented every 15 minute rounds from 01:55 until 04:35. Employee #30 documented every 15 minute patient rounds on Patient #28 in the same time frame. All patients were documented as a location of P (Patient Room), and a behavior code of 1 (Resting/Eyes Closed), during this time frame. Patients #26 and #27’s observation rounds were signed by Employee #28 in the space “Night Nurse Signature,” on the morning of 01/29/2024. Patients #25 and #29’s observation rounds were signed by Employee #40, in the space “Night Nurse Signature,” on the morning of 01/29/2024. Patients #19 and #28’s observation rounds were signed by Employee #41 in the space “Night Nurse Signature,” on the morning of 01/29/2024. Patient #19’s medical record contained a note titled “Daily Nursing Narrative,” which revealed: “...Patient became upset exit seeking with bag in hand. Patient went into female Peers room when BHT assisting Patient from room Patient turned and swung on BHT...RN notified Psych Provider obtained order for seclusion, and 2mg Ativan IM. Patient taken to seclusion room per 3 staff. Patient given IM Patient pinched BHT in stomach. Patient stayed in seclusion room after 2nd attempt with IM was successful in left gluteus Maximus muscle. First attempt unsuccessful to Left Deltoid muscle d/t patient moving side to side and up and down with 2 staff hold. Patient was removed from seclusion at 0105 and taken to [his] room...Staff will continue performing Q15 safety supervision and Q 2 hrs. nurses round to ensure wellness of the patient. Writer checked on patient at 0255, patient resting in bed with eyes closed, snoring. Respiration unlabored, writer visualized chest rising up and down. At 0452 staff performing rounds and called on nurses to come check on patient. Upon assessment, patient had a weak pulse, sternum rub done, crackles heard, writer called for help and code was called. CPR started immediately, 911 called....” The note was signed by Employee #27 with a time and date of 05:15 on 01/29/2024. Patient #19’s medical record contained a document titled “Seclusion and Restraint Individual Reporting Form,” dated 01/29/2024, which revealed Patient #19 was in a physical hold from 00:13 to 00:15, and again from 00:38, until 00:40. Patient #19 was also administered 2mg of IM Ativan, used as a chemical restraint at 00:40. Patient #19 was in seclusion from 00:15 to 01:05. Hospital documentation dated 01/29/2024, revealed: “...Review of RN documentation indicates...patient was rounded on multiple times by RN afterward prior to code event...1/31 pt reported as expired per DON who contacted BUMC....” A review of recorded security footage, showing room numbers 108 through 111, in which Patients #19, 25, 26, 27, 28, and 29, were staying, dated 01/29/2024, revealed: (Video Timestamp/Estimated actual time) 00:30/01:54 - Patient rounding performed 01:46/03:11 - Patient #28 left room #108 02:02/03:27 - Patient #28 returned to room #108 02:15/03:40 - Patient rounding performed 02:48/04:13 - Patient rounding performed 03:14/04:39 - Patient rounding performed; Employee #30 enters Patient #19’s room 03:16/04:41 - Employee #30 leaves Patient #19’s room 03:18/04:43 - Employee #27 and #30 enter Patient #19’s room There were several times the timestamp of the recording skipped to different times including jumps from: 00:30/01:55 to 01:46/03:11 (1 hour, 16 minutes skipped) 01:51/03:15 to 02:01/03:26 (10 minutes skipped) 02:16/03:41 to 02:27/03:52 (11 minutes skipped) 02:25/03:53 to 02:48/04:13 (23 minutes skipped) Employee #1 and Employee #5 confirmed in separate interviews, conducted on 02/22/2024, patient rounds were not performed every 15 minutes per policy on night shift on 01/28/2024. Employee #1 further confirmed, the department in charge of the security cameras has said, if no activity is detected by the video cameras, then that footage is not recorded. The recording is triggered by movement detected by the cameras. Employee #1 also confirmed the timestamp on the video footage being watched was approximately 1 hour and 25 minutes behind the actual time. Employee #1 additionally confirmed Patient #19 had received a physical and chemical restraint, as well as being placed in seclusion, shortly before Patient #19 was found unresponsive.”

“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: 45618 Based on a review of hospital records and interview, it was determined the hospital failed to ensure a patient (Patient #20), was not secluded in the bedroom, unable to leave, for nine hours. This failure poses the risk of a patient being confined, without observation or assessments, and a violation of the patient’s right to move about freely. Cross reference A-0115, A-0043, A-0057 Findings include: Policy titled, “Restraint or Seclusion Use”, revealed: “...Patients at the Hospital have the right to be free from restraints of any form that are not medically necessary...Restraint and Seclusion are never used as a means of coercion, discipline, convenience, or retaliation by staff...The hospital is committed to...limiting the use of restraints and/or seclusion through the assessment of risk potential by determining and addressing underlying causes of behavior, triggers, and by promoting preventive strategies and use of safe, effective and least restrictive alternatives to the use of restraints; maintaining restrained and/or secluded patient’s rights and dignity...Assuring staff are competent in the safe and effective use of Handle With Care, restraints and/or seclusion...Seclusion- the confinement of a person alone in a room or an area where the person is physically prevented from leaving...Restraint/Seclusion Orders: Restraints/seclusion may only be utilized upon the written or telephone order of a Licensed Independent Practitioner, Nurse Practitioner or Physician’s Assistant permitted by the hospital and state law to write orders or through emergency application. The LIP, Nurse Practitioner or Registered Nurse must have a working knowledge of the restraint/seclusion policy....” Hospital documentation dated 02/04/2024, concerning an event with Patient #20, revealed: “...Morning BHT’s and CNA’s began doing new shift rounds when the CNA heard a patient crying In {sic} room 113. This room has two doors and a short hallway to get Into {sic} the room. The Second door to the patient room which opens outward was blocked shut with a heavy weighted chair. The patient was not able to exit [his] room and was found Inside {sic} the room on the floor In {sic} the fetal position In {sic} distress crying. This Is a Dementia oatient who Is AOx1{sic}... (Employee #33) stated [he] placed a weighted chair at the door approximately about 10:15 PM....” Documentation further revealed that Employees #33, #35, #36, and #37, all night shift BHA’s on the unit on 02/03/2024, were interviewed, and Employees #33 and #36 were terminated based on this event. Patient #20’s medical record contained a form titled “Patient Observation Rounds,” dated 02/03/2024, which revealed documentation that rounds were performed every 15 minutes on Patient #20 by the BHT, and was signed by Employee #34 in the space “Night Nurse Signature,” on the morning of 02/04/2024. A review of recorded security footage, showing room number 113, the room Patient #20 was in, revealed patient rounding performed by Employees #33, 35, and 37, identified as BHT’s. Employee #2 confirmed in an interview on 02/22/2024, that the two night shift RN’s on duty 02/03/2024, Employees #34 and #38, were interviewed, however there is no documentation for it. Employee #2 further confirmed that the Patient #20 was confined to the room for approximately nine hours, from 22:15 on 02/03/2024, until 07:15 on 02/04/2024, and Employees #34 and #38 had no knowledge of the incident. Employee #2 also confirmed there is no time requirement for nurse rounding in the unit.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure two patients (Patient #22 and Patient #23) receiving a chemical restraint were recognized and documented as being under restraint. This deficient practice poses a risk to the health and safety of patients if they are not monitored, assessed, and evaluated when under chemical restraint. Cross reference A-0115, A-0043, A-0057 Findings include: Policy titled, “Restraint or Seclusion Use”, revealed: “ ...Definitions: ...Chemical Restraint (Medication used as a Restraint) - a medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is NOT a standard treatment or dosage for the patient’s condition ....Restraint/Seclusion Orders: Restraints/seclusion may only be utilized upon the written or telephone order of a Licensed Independent Practitioner, Nurse Practitioner or Physician’s Assistant permitted by the hospital and state law to write orders or through emergency applications ....One-Hour Face-To-Face Assessment: A LP {sic}(licensed practitioner) or Registered Nurse with a working knowledge of the restraint/seclusion policy and trained to do so will provide a Face-to-Face assessment in person within 1 hour of the use of restraint/seclusion using the restraint/seclusion packet ....Ongoing Assessment, Monitoring and Evaluation During Restraint/Seclusion: ...A nurse shall observe and assess patients in restraints or seclusion approximately every 60 minutes including respiratory and circulatory status, skin integrity and vital signs ....The patient’s response to the intervention or interventions used shall be documented every fifteen (15) minutes throughout the duration of the restraint or seclusion ....Nursing assessments shall be documented using the restraint/seclusion packet ....Post Restraint/Seclusion Debriefing: ...Staff Team debriefing will include events leading to restraint/seclusion, staff interventions, patient signs/behaviors, patient injuries, positive outcomes, recommendations for improvement and overall process evaluation ....Plan of Care: Patients placed in restraint/seclusion will have their plan of care modified during the next interdisciplinary team meeting to include the need and use of restraint/seclusion to assist with appropriate assessment of the patient’s medical and psychological conditions ....” Document titled, “PMPH Seclusion & Restraint Tracking Tool 2023”, revealed six restraint/seclusion occurred in December 2023, and none on [12/04/2023 and 12/11/2023]. Review of Patient #22’s medical record dated [12/04/2023] identified a nursing note, and it revealed: “ ...[He] was running in hallways of this unit, used sanitizing gels to rub [his] head and face, pulling the clip board and BHT charting forms from BHT. [He] walked into [his] room and sat on [his] bed but then [he] tried to grab the BHT and shove the second BHT. [He] broke [his] glasses by squeezing them in [his] fist (no injury resulted). This nurse administered all scheduled and PRN medications and since they were not effective, this nurse called ...the on-call psych PA ....called me back with order for B52 IM. This nurse provided this injection per MD order ....” Review of Patient #22’s medication administration record (MAR) revealed they received intramuscular (IM) injection of Benadryl 50mg, Haldol 5mg, and Ativan 2mg on [12/04/2023 at 2230 hours]. Further review of Patient #22’s medical record revealed no documentation of restraint packet for the chemical restraint administered on [12/04/2023]. Review of Patient #23’s medical record dated [12/11/2023] identified a nursing note, and it revealed: “ ...Patient then hit this writer in abdomen with one hand and pushed this writer on chest with other hand knocking this writer back x 2-3 steps ....Night supervisor came to unit. Patient attacked Supervisor by grabbing his glasses and breaking them. Female Peer approached Patient and this Patient pushed Peer down onto floor. Received order for Benadryl 50mg IM now only, Haldol 5mg IM now only, and Ativan 1mg IM now only. Noted order and sent to Pharmacy ....RN Supervisor administered medication to bilat deltoids ....” Review of Patient #23’s MAR revealed they received IM injection of Benadryl 50mg, Haldol 5mg, and Ativan 1mg on [12/11/2023 at 2145 hours]. Further review of Patient #23’s medical record revealed no documentation of restraint packet for the chemical restraint administered on [12/11/2023]. Employee #5 confirmed during an interview conducted on 02/22/2024 that Patient #22 and Patient #23 received IM injections to manage their behaviors. Employee #5 also confirmed Patient #22 and Patient #23 did not have orders for a chemical restraint. Employee #5 further confirmed there were no restraint/seclusion packets for the chemical restraint for Patient #22 on [12/04/2023] and Patient #23 on [12/11/2023].”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(ii) Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure the timeout for one patient (Patient #22) did not take place in a seclusion room. This deficient practice poses the risk of patients and staff not recognizing what constitutes a timeout or seclusion, and patient’s misunderstanding whether they are allowed to leave the seclusion room. Cross reference A-0115, A-0043, A-0057 Findings include: Policy titled, “Restraint or Seclusion Use”, revealed: “ ...Definitions: ...Seclusion - the confinement of a person alone in a room or an area where the person is physically prevented from leaving ....” Document titled, “PMPH Seclusion & Restraint Tracking Tool 2023”, revealed: “ ...Date Started ...[12/03/2023] ...Seclusion ...Start 15:55 ...End 16:55 ...Comments ...Quiet time that turned into seclusion ....” Review of Patient #22’s medical record dated [12/03/2023] identified a nursing note, and it revealed: “ ...[His] anxiety is increasing and [he] is encouraged to deep breathe. Which [he] tries to do but then [he] starts to yell and suddenly drops [himself] to the floor. Then gets up abruptly, rips off [his] gown, and runs naked down the hall. [He] is intercepted verbally and is able to get back to [his] room. [He] reports having a panic attack. [He] starts to slam [his] body against the wall. Pt is escorted down to seclusion room for a time out (for safety and to prevent injury) while doctor is notified. Door is never closed > 5 min. NP gives ok to let patient remain in seclusion until calm ....” Further review of Patient #22’s medical record dated [12/03/2023] identified a restraint/seclusion packet, and it revealed: “ ...Event Information...Pt was explained that provider ordered for use of seclusion for a “time-out” during a panic attack...Reason for Restraint and/Seclusion ...Member Behaviors: Pt is having high anxiety close to a panic state ....[He] was having poor impulse control and slammed [his] body up against the wall several times ...At this time, provider was notified again and gave OK to use seclusion room for safety (due to the walls being protective) until patient was calm and anxiety level decreased and no longer a danger to self ....” Employee #5 confirmed during an interview conducted on 02/22/2024 that Patient #22 was placed in the seclusion room for a timeout. Employee #5 also confirmed seclusion room can only be used for seclusion, and facility’s policies and procedures were not followed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48110 Based on record reviews, staff interviews, and observations, it was determined the hospital failed to ensure four patients (Patients #20, #22, #23, and #24) placed in restraints and/or seclusion, had an order from a physician or other licensed practitioner for the use of physical or chemical restraint and seclusion. This deficient practice poses a risk to the health and safety of patients if patients are restrained or secluded unnecessarily, and do not receive adequate care and monitoring during a restraint/seclusion episode. Cross reference A-0115, A-0043, A-0057 Findings include: Policy titled, “Restraint or Seclusion Use”, revealed: “ ...Definitions: Restraint (Health Care, Physical) - any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Chemical Restraint (Medication used as a Restraint) - a medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is NOT a standard treatment or dosage for the patient’s condition ....Restraint/Seclusion Orders: Restraints/seclusion may only be utilized upon the written or telephone order of a Licensed Independent Practitioner, Nurse Practitioner or Physician’s Assistant permitted by the hospital and state law to write orders or through emergency application. The LIP, Nurse Practitioner or Registered Nurse must have a working knowledge of the restraint/seclusion policy ....” Review of Patient #22’s medical record revealed they received a chemical restraint on [12/04/2023], and there was no documentation of a physician order for the restraint. Review of Patient #22’s medical record revealed they were in seclusion on [12/03/2023] from 1555 to 1655 hours. The seclusion form revealed: “ ...Pt was explained that provider ordered for use of seclusion room for a “time-out” during a panic attack” ....” Review of Patient #22’s medical record revealed a handwritten order and it revealed: “can use seclusion room until calm and no longer danger to self”. Below the order was an added note with a different handwriting and it revealed: “may advance to seclusion if needed start 1555 to end 1655”. The addendum was not authenticated by the ordering provider. Review of Patient #23’s medical record revealed they received a chemical restraint on [12/11/2023], and there was no documentation of a physician order for the restraint. Patient #24’s medical record revealed the patient was placed in a physical hold on 12/19/2023 at 21:10 until 21:11. There was no order present for this restraint. Patient #24’s medical record revealed the patient was placed in a physical hold on 12/19/2023 at 21:25 until 21:26. An order was written on 12/28/2023 for the restraint on 12/19/2023. Patient #24’s medical record revealed the patient was placed in seclusion on 12/20/2023 from 04:15 until 04:20. A seclusion order was written on 12/19/2023 at 21:30 with a note on the order “...ok to modify times to 0420 ’ 0450 12/20/2023 TORB (Provider #6)...” The telephone order was signed by Employee #5 and dated 12/27/2023 at 1415. Hospital documentation dated 02/04/2024, concerning an event with Patient #20, revealed: “...Morning BHT’s and CNA’s began doing new shift rounds when the CNA heard a patient crying In {sic} room 113. This room has two doors and a short hallway to get Into {sic} the room. The Second door to the patient room which opens outward was blocked shut with a heavy weighted chair. The patient was not able to exit [his] room and was found Inside {sic} the room on the floor In {sic} the fetal position In {sic} distress crying. This Is a Dementia oatient who Is AOx1{sic}... (Employee #33) stated [he] placed a weighted chair at the door approximately about 10:15 PM....” Observations during the tour of facility on 02/15/2024 revealed the seclusion room was locked, and the seclusion room was in a hallway that required facility personnel’s badge to enter and exit, where patients cannot enter and exit freely. Employee #1 confirmed during an interview conducted on 02/15/2024 that the seclusion room was located in a hallway that patients cannot enter and exit freely. Employee #5 confirmed during an interview conducted on 02/22/2024 that Patients #22, #23, and #24, received a restraint or seclusion, and there was either no documentation of a restraint or seclusion order in the medical records, or an order was not received as soon as possible. Employee #5 also confirmed that Patient #20 was placed under an unauthorized seclusion, without an order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 45618 Based on a review of hospital records and interview, it was determined the hospital failed to ensure providers did not write seclusion and restraints on a prn or as needed basis and with an understanding of seclusion and restraint rules and policies. This failure poses the risk of a patient being restrained or secluded unnecessarily, a violation of patient rights, and allows non provider staff to perform restraint or seclusion without an order specific to a restraint or seclusion episode. Cross reference A-0115, A-0043, A-0057 Findings include: Hospital policy titled “Restraint or Seclusion Use,” revealed: “...Seclusion- the confinement of a person alone in a room or an area where the person is physically prevented from leaving...Restraint/seclusion may only be utilized upon the written or telephone order of a Licensed Independent Practitioner, Nurse Practitioner or Physician’s Assistant permitted by the hospital and state law to write orders...The LIP, Nurse Practitioner, or Registered Nurse must have a working knowledge of the restraint/seclusion policy...Orders for restraints must never be written as standing orders or as PRN or otherwise “as needed” orders....” Hospital document titled “NeuroPsychiatric Hospitals Code of Conduct,” revealed: “...We expect all officers, employees, members of the System’s Governing Board, members of the System’s Medical Staff...(collectively, “System’s Representatives”) to adhere to the highest standards of conduct whenever acting on behalf of the System...Accuracy, Retention and Disposal of Records: Every System Representative is responsible for the integrity and accuracy of the System’s records. Records must not only comply with regulatory and legal requirements, but should also support our business practices and actions. Alteration or falsification of information on any record or document is strictly prohibited....” Patient #24’s medical record revealed the patient was placed in seclusion on 12/20/2023 from 04:15 until 04:20. A seclusion order was written on 12/19/2023 at 21:30 with a note on the order “...ok to modify times to 0420--> 0450 12/20/2023 TORB (Provider #6)....” The telephone order was signed by Employee #5 and dated 12/27/2023 at 1415. The order was not authenticated by Provider #6. Patient #24’s medical record revealed the following order written by Provider #3 on 12/01/2023: “...Haladol {sic} 5mg BID PRN...Benadryl 50 mg IM BID PRN...Ativan 2 mg IM BID PRN....” Patient #22’s medical record contained a telephone order from Provider #7 to Employee #8 on 12/03 at 15:55, which revealed: “...Seclusion until calm and no longer danger to self. 1:1 monitoring....” The order was amended to say “...Can use Seclusion room...” and “...may advance to seclusion if needed start 1555 to end 1655....” in visibly different handwriting, with no additional authentication. Patient #22’s medical record contained a document titled “Seclusion and Restraint Individual Reporting Form,” dated 12/03/2023, which revealed: “...Was the reason for restraint/seclusion and the conditions for release explained to the member?...Pt was explained that provider ordered for use of seclusion room for a “time-out” during a panic attack....” A tour conducted on 02/20/2024 revealed the seclusion rooms were off a hallway which could only be entered or exited with a wristband containing a sensor. Employee #5 confirmed during the tour on 02/20/2024, that a patient would not be able to leave the hallway and area containing the seclusion rooms because they do not have access to the wristbands. A patient would need an employee to release them from the seclusion area and hallway, and can not enter and exit freely on their own. Employee #5 confirmed in an interview on 02/23/2024, that these orders were not appropriate restraint and seclusion orders written by the providers.”

“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: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure patients who were placed in restraint/seclusions had a face-to-face evaluation performed by a qualified practitioner or trained registered nurse. This deficient practice poses a risk to the health and safety of patients when registered nurses are not trained to complete the face-to-face evaluation, and assess the patient’s physical and behavioral condition. Cross reference A-0115, A-0043, A-0057 Findings include: Policy titled, “Restraint or Seclusion Use”, revealed: “ ...One-Hour Face-to-Face Assessment ...A LP {sic}(Licensed Practitioner) or Registered Nurse with a working knowledge of the restraint/seclusion policy and trained to do so will provide a Face-to-Face assessment in person within 1 hour of the use of restraint/seclusion using the restraint/seclusion packet ....The one-hour face-to-face assessment will include: An evaluation of the patient’s immediate situation; The patient’s reaction to the intervention; The patient’s medical and behavioral condition; The need to continue or terminate the restraint or seclusion ....” Review of Patient #22’s medical record revealed they were placed in seclusion on [12/03/2023 at 1555 hours], and face-to-face assessment was performed by Employee #8. Review of Patient #23’s medical record revealed they were placed in seclusion on [12/12/2023 at 2150 hours], [12/01/2023 at 2330 hours], [11/30/2023 at 2330 hours], and [11/22/2023 at 2100 hours]. The face-to-face assessments were performed by Employee #27, #21, #22, and #23. Documentation that Employee #8, #21, #22, #23, and #27 received training on restraint/seclusion face-to-face assessment was requested. None was provided. Employee #1 confirmed during an interview conducted on 02/22/2024 that Employee #8, #21, #22, #23, and #27 were registered nurses. Employee #1 also confirmed there was no documented training to demonstrate Employee #8, #21, #22, #23, and #27 were qualified to perform the face-to-face assessment on patients placed in restraint/seclusion.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure two patients (Patients #22 and #23) who were placed in restraints received a face-to-face evaluation. This deficient practice poses a risk to the health and safety of patients if patients are not evaluated and assessed for their medical and behavioral condition after restraint placement. Cross reference A-0115, A-0043, A-0057 Findings include: Policy titled, “Restraint or Seclusion Use”, revealed: “ ...Definitions: Restraint (Health Care, Physical) - any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Chemical Restraint (Medication used as a Restraint) - a medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is NOT a standard treatment or dosage for the patient’s condition ....One-Hour Face-To-Face Assessment: A LP {sic}(licensed practitioner) or Registered Nurse with a working knowledge of the restraint/seclusion policy and trained to do so will provide a Face-to-Face assessment in person within 1 hour of the use of restraint/seclusion using the restraint/seclusion packet. The one-hour face-to-face assessment will include: An evaluation of the patient’s immediate situation. The patient’s reaction to the intervention. The patient’s medical and behavioral condition. The need to continue or terminate the restraint or seclusion ....” Review of Patient #22’s medical record revealed they received a chemical restraint on [12/04/2023], and there was no documentation a face-to-face evaluation was performed. Review of Patient #23’s medical record revealed they received a chemical restraint on [12/11/2023], and there was no documentation a face-to-face evaluation was performed. Employee #5 confirmed during an interview conducted on 02/22/2024 that Patients #22 and #23 received a chemical restraint, and a face-to-face evaluation within one hour of the initiation of the restraint was not completed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure trained registered nurses, who conducted the face-to-face evaluation after a restraint/seclusion episode, consulted with the attending physician as soon as possible for two patients (Patients #19 and #23). This deficient practice poses a risk to the health and safety of patients when the attending physician is not consulted of the patient’s medical and behavioral condition after a restraint/seclusion episode. Cross reference A-0115, A-0043, A-0057 Findings include: Policy titled, “Restraint or Seclusion Use”, revealed: “ ...Policy: Patients at the Hospital have the right to be free from restraints of any form that are not medically necessary ....One-Hour Face-To-Face Assessment: A LP or Registered Nurse with a working knowledge of the restraint/seclusion policy and trained to do so will provide a Face-to-Face assessment in person within 1 hour of the use of restraint/seclusion using the restraint/seclusion packet ....If one hour face-to-face completed by an RN, the attending provider must be consulted as soon as possible upon completion of the face-to-face. Consult to include - Discussion of the findings of the 1-hour face-to-face evaluation, the need for other interventions or treatments, and the need to continue or discontinue the use of restraint or seclusion ....Ongoing Assessment, Monitoring and Evaluation During Restraint/Seclusion: ...The nurse shall notify the LP of any changes in the patient’s physical condition or mental status and document in the medical record ....All documentation should include date, time and staff signature/initials ....” Review of Patient #23’s medical record revealed they were in seclusion on [11/30/2023] from 2330 to 0120 hours, and [12/12/2023] from 2150 to 2250 hours. Further review of Patient #23’s medical record revealed they had both face-to-face assessments completed by a registered nurse, and there was no documentation the attending physician was consulted upon completion of both face-to-face assessments. Patient #19’s medical record, dated 01/29/2024, revealed a seclusion episode from 00:15 until 01:05, that included two physical holds, at 00:13 to 00:15, and 00:38 to 00:40. The one hour face to face assessment was performed by an RN (Employee #27), with no provider notification afterwards. Employee #1 confirmed during an interview conducted on 02/22/2024 that there was no documentation the registered nurses, who performed the face-to-face evaluation for Patients #19 and #23, consulted with the attending physician after the completion of the face-to-face evaluation.”

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 45618 Based on a review of hospital record, it was determined the hospital failed to report a death associated with a chemical and physical restraint and seclusion, within 24 hours. This failure poses the risk of an incomplete evaluation as to contributory factors in the death due to passage of time, and an inability to identify potentially dangerous practices with the use of restraint and/or seclusion. Cross reference A-0115, A-0043, A-0057 Findings include: Hospital policy titled “Restraint or Seclusion Use,” revealed: “...Reporting Patient Deaths: All deaths of patients in restraints or seclusion must be reported to Centers for Medicare and Medicaid Services (CMS) and the Division of Mental Health and Addiction (DMHA). Patient deaths that occur while in restraints or seclusion; within 24 hour {sic} of discontinuation of restraints or seclusion and if known to the hospital that occur one week after their removal/disconnection where it is reasonable to assume that the use of restraints or placement in seclusion contributed directly or indirectly to a patient’s death must be reported to QI. Deaths must be reported by QI to CMS within one business day following knowledge of death. Documentation in medical record must include the date and time that CMS was informed. Staff nurses must inform nursing leadership of there is any knowledge of the above....” Hospital document titled “NeuroPsychiatric Hospitals Code of Conduct,” revealed: “...We expect all officers, employees, members of the System’s Governing Board, members of the System’s Medical Staff...(collectively, “System’s Representatives”) to adhere to the highest standards of conduct whenever acting on behalf of the System...Accuracy, Retention and Disposal of Records: Every System Representative is responsible for the integrity and accuracy of the System’s records. Records must not only comply with regulatory and legal requirements, but should also support our business practices and actions. Alteration or falsification of information on any record or document is strictly prohibited....” Patient #19’s medical record, dated 01/28/2024, contained a note titled “Daily Nursing Narrative,” which revealed: “...Patient began hitting BHT with balled up fist. RN notified Psych Provider obtained order for seclusion, and 2mg Ativan IM. Patient taken to seclusion room per 3 staff...Patient stayed in seclusion room after 2nd attempt with IM was successful...First attempt unsuccessful to L deltoid muscle d/t patient moving side to side and up and down with 2 staff hold. Patient was removed from seclusion at 0105 and taken to [his] room...Staff will continue performing Q15 safety supervision and Q 2 hrs. nurses round to ensure wellness of the patient. Writer checked on patient at 0255, patient resting in bed with eyes closed, snoring. Respiration unlabored, writer visualized chest rising up and down. At 0452 staff performing rounds and called on nurses to come check on patient. Upon assessment, patient had a weak pulse, sternum rub done, crackles heard, writer called for help and code was called. CPR started immediately, 911 called, medical provider called, staff and nurses continued CPR until 911 arrived. Patient was taken to Banner University Medical Hospital at 0515....” The note was signed by Employee #27, on 01/29/2024, at 05:15. Patient #19’s medical record contained a document titled “Seclusion and Restraint Individual Reporting Form,” dated 01/29/2024, which revealed Patient #19 was in a physical hold from 00:13 to 00:15, and again from 00:38, until 00:40. Patient #19 was also administered 2mg of IM Ativan, used as a chemical restraint at 00:40. Patient #19 was in seclusion from 00:15 to 01:05. Patient #19’s medical record contained a form titled “Patient Observation Rounds,” dated 01/28/2024, which revealed documentation that patient rounds were performed every 15 minutes by the BHT between 01:54 and 04:39. A review of recorded security footage, showing room number 109, in which Patients #19 was staying, dated 01/29/2024, revealed: Timestamp/Estimated actual time: 00:30/01:54 - Patient rounding performed by BHT 02:15/03:40 - Patient rounding performed by BHT 02:48/04:13 - Patient rounding performed by BHT 03:14/04:39 - Patient rounding performed; Employee #30 enters Patient #19’s room 03:16/04:41 - Employee #30 leaves Patient #19’s room 03:18/04:43 - Employee #27 and #30 enter Patient #19’s room After several minutes of activity in the hallway, a code cart and oxygen was brought to Patient #19’s room at 03:26/04:51 Hospital documentation dated 01/29/2024, revealed: “...Review of RN documentation indicates...patient was rounded on multiple times by RN afterward prior to code event...1/31 pt reported as expired per DON who contacted BUMC. COE {sic} to contact DOH and JC for reporting....” A CMS death reporting notification was requested on 02/14/2024, 02/15/2024, and 02/20/24, and was not received. Employee #1 confirmed in an interview on 02/21/2024, that the patient death was not reported to CMS because Patient #19 did not have Medicare. Employee #1 further confirmed patient rounds were not performed every 15 minutes per policy on night shift on 01/28/2024. Employee #1 also confirmed the timestamp on the video footage being watched was approximately 1 hour and 25 minutes behind the actual time. Employee #1 also confirmed the hospital was aware of the death of Patient #19 on 01/31/2024.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the Director of Nursing (DON) failed to manage the overall nursing services of the facility. This deficient practice poses a risk to the health and safety of patients if there is a lack of continuous nursing supervision in the provision of quality patient care to meet the needs of patients, nursing staff adherence to policies and procedures, and surveillance of patient care delivery to support the patient’s physical and mental well-being. Cross reference A-0385, A-0043, A-0057 Findings include: Document titled, “NeuroPsychiatric Hospitals Job Description”, revealed: “ ...Job Title ...Director of Nursing ...Position Summary ...Performs administrative duties of supervision within assigned clinical departments. Responsible for assigned departmental performance improvement and quality initiatives consistent with organizational policies and procedures ....Job Functions ...Ensures patient care needs are met. Responsible for appropriate staffing levels throughout areas of responsibility including staffing patient care unit when appropriate or needed. Responsible for policy and procedures that reflect standards of professional care in accordance with standards of care/practice. Ensures accreditation requirements and regulatory standards are met on an ongoing basis. Analyzes and when necessary, restructures the activities and processes of nursing and other personnel. Reviews charts for documentation compliance on a daily basis. Responsible for patient safety, efficiency and suitability of the environment of care. Ensures incident reports, chart audits, and all other assigned quality indicators are monitored, and nursing peer review are accomplished through the organizational Quality Improvement Plan ....Verifies that the nursing department and other areas of responsibility meet mandated State and Federal regulations ...Facilitates and gives oversight to the development, revision, and implementation of policies and procedures It was determined the DON failed to perform the core functions of the position as demonstrated by the following: Cross reference A-0131: Failure to ensure consent for treatment was obtained from the representative of a patient, who was deemed incompetent. Cross reference A-0144: Failure to ensure patients safety: 1. By not having appropriate monitoring of patients after restraint and seclusion episode. 2. By lack of fall evaluation after they occurred, and included fall precaution in the patient’s treatment plan. Cross reference A-0145: Failure to ensure a patient was free from harassment and not secluded in the bedroom. Cross reference A-0160: Failure to ensure chemical restraints were recognized and documented as restraints. Cross reference A-0162: Failure to ensure a patient timeout did not occur in a seclusion room. Cross reference A-0168: Failure to ensure patients had a physician order before receiving a restraint and/or seclusion. Cross reference A-0176: Failure to ensure providers writing restraints and seclusion, had working knowledge of restraint and seclusion rules and facility policies. Cross reference A-0178: Failure to ensure registered nurses performing face-to-face evaluations received training on face-to-face evaluations after use of restraint/seclusion. Cross reference A-0179: Failure to ensure patients placed in restraints received a face-to-face evaluation within one hour of initiation of the restraint. Cross reference A-0182: Failure to ensure registered nurses performing face-to-face evaluations consulted with the attending physician. Cross reference A-0395: Failure to ensure registered nurses supervised the care behavioral health technician (BHT) provide to psychiatric patients. Cross reference A-0396: Failure to ensure high fall risk patient had fall prevention care plan in place. Cross reference A-0398: Failure to ensure the nursing staff monitored and reacted in a timely manner to a patient requiring cardiopulmonary resuscitation. Cross reference A-0438: Failure to ensure patient’s medical record were properly filed and accessible to surveyors. Cross reference A-0450: Failure to ensure contents of medical record were accurately dated, timed and authenticated, and had proper patient identifying information. Cross reference A-0467: Failure to ensure: 1. Medical records contained all laboratory results and reports. 2. Patient’s weight was documented in the medical record per facility’s policies and procedures.”

“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: 45618 Based on a review of hospital record and staff interview, it was determined the administrator failed to ensure the care given by behavioral health technicians (BHT’s) to psychiatric patients was supervised by a registered nurse. This failure poses the risk of a patient being secluded inappropriately, a patient suffering a health event that BHT’s are not trained to detect, and patients going prolonged periods of time without being assessed by a licensed or registered nurse. Cross reference A-0385, A-0043, A-0057 Findings include: Policy titled, “Restraint or Seclusion Use”, revealed: “...Patients at the Hospital have the right to be free from restraints of any form that are not medically necessary...Restraint and Seclusion are never used as a means of coercion, discipline, convenience, or retaliation by staff...The hospital is committed to...limiting the use of restraints and/or seclusion through the assessment of risk potential by determining and addressing underlying causes of behavior, triggers, and by promoting preventive strategies and use of safe, effective and least restrictive alternatives to the use of restraints; maintaining restrained and/or secluded patient’s rights and dignity...Assuring staff are competent in the safe and effective use of Handle With Care, restraints and/or seclusion...Seclusion- the confinement of a person alone in a room or an area where the person is physically prevented from leaving...Restraint/Seclusion Orders: Restraints/seclusion may only be utilized upon the written or telephone order of a Licensed Independent Practitioner, Nurse Practitioner or Physician’s Assistant permitted by the hospital and state law to write orders or through emergency application. The LIP, Nurse Practitioner or Registered Nurse must have a working knowledge of the restraint/seclusion policy....” Document titled “Job Title Registered Nurse; Department Name Nursing,” revealed: “...Directs non-professional personnel in implementing nursing care plans, and provides guidance and demonstrates appropriate methods, as necessary, to correct deviations from established standards... Maintains the standards of accurate and complete recording and reporting. Reports patient’s condition, medications given and treatments administered to nursing administration and the following shift...Makes regular rounds of assigned patients independently and with physicians. Observes and evaluates patient’s symptoms, progress and reactions to treatments and mediations {sic}, Takes corrective actions as indicated...Observes and supports hospital policy, mission statement, and vision....” Hospital policy titled “Patient Observation,” revealed: “...All patients will be admitted to the patient care unit with a minimum of “every 15 minutes” observation level...Level 1 - General Observation a. All patients on this level are on every 15 minute observation, at a minimum. B. This is the minimum acceptable level for all patients....” Hospital document titled “NeuroPsychiatric Hospitals Code of Conduct,” revealed: “...We expect all officers, employees, members of the System’s Governing Board, members of the System’s Medical Staff...(collectively, “System’s Representatives”) to adhere to the highest standards of conduct whenever acting on behalf of the System...Accuracy, Retention and Disposal of Records: Every System Representative is responsible for the integrity and accuracy of the System’s records. Records must not only comply with regulatory and legal requirements, but should also support our business practices and actions. Alteration or falsification of information on any record or document is strictly prohibited....” Hospital documentation dated 02/04/2024, concerning an event with Patient #20, revealed: “...Morning BHT’s and CNA’s began doing new shift rounds when the CNA heard a patient crying In {sic} room 113. This room has two doors and a short hallway to get Into {sic} the room. The Second door to the patient room which opens outward was blocked shut with a heavy weighted chair. The patient was not able to exit [his] room and was found Inside {sic} the room on the floor In {sic} the fetal position In {sic} distress crying. This Is a Dementia oatient who Is AOx1{sic}... (Employee #33) stated [he] placed a weighted chair at the door approximately about 10:15 PM....” Documentation further revealed that Employees #34, #35, #36, and #37, all night shift BHA’s on the unit on 02/03/2024, were interviewed, and Employees #33 and #36 were terminated based on this event. Patient #20’s medical record contained a form titled “Patient Observation Rounds,” dated 02/03/2024, which revealed documentation that rounds were performed every 15 minutes on Patient #20 by the BHT, and was signed by Employee #34 in the space “Night Nurse Signature,” on the morning of 02/04/2024. A review of recorded security footage, showing room number 113, the room Patient #20 was in, revealed patient rounding performed by Employees #33, 35, and 37, identified as BHT’s. There were no employees identified as RN’s making rounds on Patient #20. A review of “Patient Observation Rounds” forms, dated 01/28/2024, for Patients #19, #25, #26, #27, and #29, revealed Employees #29 and #39 documented every 15 minute rounds from 01:55 until 04:35. Employee #30 documented every 15 minute patient rounds on Patient #28 in the same time frame. All patients were documented as a location of P (Patient Room), and a behavior code of 1 (Resting/Eyes Closed), during this time frame. Patients #26 and #27’s observation rounds were signed by Employee #28 in the space “Night Nurse Signature,” on the morning of 01/29/2024. Patients #25 and #29’s observation rounds were signed by Employee #40, in the space “Night Nurse Signature,” on the morning of 01/29/2024. Patients #19 and #28’s observation rounds were signed by Employee #41 in the space “Night Nurse Signature,” on the morning of 01/29/2024. Patient #19’s medical record contained a note titled “Daily Nursing Narrative,” which revealed: “...Patient was removed from seclusion at 0105 and taken to [his] room...Staff will continue performing Q15 safety supervision and Q 2 hrs. nurses round to ensure wellness of the patient. Writer checked on patient at 0255, patient resting in bed with eyes closed, snoring. Respiration unlabored, writer visualized chest rising up and down. At 0452 staff performing rounds and called on nurses to come check on patient. Upon assessment, patient had a weak pulse, sternum rub done, crackles heard, writer called for help and code was called. CPR started immediately, 911 called....” The note was signed by Employee #27 with a time and date of 05:15 on 01/29/2024. Hospital documentation dated 01/29/2024, revealed: “...Review of RN documentation indicates...patient was rounded on multiple times by RN afterward prior to code event....” A review of recorded security footage, showing room numbers 108 through 111, in which Patients #19, 25, 26, 27, 28, and 29, were staying, dated 01/29/2024, revealed: (Video Timestamp/Estimated actual time) 00:30/01:54 - Patient rounding performed 01:46/03:11 - Patient #28 left room #108 02:02/03:27 - Patient #28 returned to room #108 02:15/03:40 - Patient rounding performed 02:48/04:13 - Patient rounding performed 03:14/04:39 - Patient rounding performed; Employee #30 enters Patient #19’s room 03:16/04:41 - Employee #30 leaves Patient #19’s room 03:18/04:43 - Employee #27 and #30 enter Patient #19’s room There were several times the timestamp of the recording skipped to different times including jumps from: 00:30/01:55 to 01:46/03:11 (1 hour, 16 minutes skipped) 01:51/03:15 to 02:01/03:26 (10 minutes skipped) 02:16/03:41 to 02:27/03:52 (11 minutes skipped) 02:25/03:53 to 02:48/04:13 (23 minutes skipped) Employee #2 confirmed in an interview on 02/22/2024, that the two night shift RN’s on duty 02/03/2024, Employees #33 and #38, were interviewed, however there is no documentation for it. Employee #2 further confirmed that the Patient #20 was confined to the room for approximately nine hours, from 22:15 on 02/03/2024, until 07:15 on 02/04/2024, and Employees #33 and #38 had no knowledge of the incident. Employee #2 also confirmed there is no time requirement for nurse rounding in the unit. Employee #1 and Employee #5 confirmed in separate interviews, conducted on 02/22/2024, patient rounds were not performed every 15 minutes per policy on night shift on 01/28/2024. Employee #1 further confirmed, the department in charge of the security cameras has said, if no activity is detected by the video cameras, then that footage is not recorded. The recording is triggered by movement detected by the cameras. Employee #1 also confirmed the timestamp on the video footage being watched was approximately 1 hour and 25 minutes behind the actual time.”

“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: 45618 Based on a review of hospital records and interview, it was determined the hospital failed to ensure a patient (Patient #17) who was a high fall risk, had a care plan in place for fall prevention. This failure poses the risk of increased falls for the patient and increases the risk of patient harm and serious injury due to a fall. Cross reference A-0385, A-0043, A-0057 Findings include: Policy titled, “Fall Prevention Program”, revealed: “ ...Policy: ...A Fall Prevention Program will be implemented and maintained to assure the safety of all patients admitted to the facility ....All falls occurring during hospitalization will be evaluated to determine the potential causative factors and discern appropriate interventions ....Procedure: Risk Identification/Precaution/Prevention: 1. All patients presenting for admission to the hospital will be assessed and identified for the level of fall risk during the nursing admission assessment using the Morse Fall Scale ...2. All patients will be placed on a low, moderate, or high fall risk. 3. Patients who score a low risk for falls (scoring <24 on the Morse Fall Scale) will be monitored ....4. Patients who score a moderate risk for falls (scoring 25-44 on the Morse Fall Scale) and high risk for falls (scoring 45 and higher on the Morse Fall Scale) will receive red colored non-skid socks, as well as any other potential interventions ....Procedure: Post Fall Evaluation: 1. Each time a patient falls, the patient will be assessed by the nurse directly after the fall and the nurse will notify the provider to obtain any necessary orders. 2. Interventions necessary to stabilize the patient will be completed in a timely manner....5. The Incident Report will be submitted through Wellsky...Individualized fall prevention interventions will be developed in the Interdisciplinary Treatment Plan for all fall risk patients. Fall prevention interventions specific to the patient’s needs will be implemented as needed ....” Patient #17’s medical record contained a note titled “Nursing Admission Assessment,” dated 07/29/2023, which revealed a Morse Fall Scale Score of 70, and a check in the box for High Risk (>45 points). Patient #17’s medical record contained a note titled “Admission Orders,” dated 07/29/2023, which revealed the patient was not placed on fall precautions on admission. Patient #17’s medical record contained an “Interdisciplinary Treatment Plan,” dated 07/29/2023, which did not identify falls on the problem list. Patient #17’s medical record contained a note titled “Daily Nursing Narrative,” dated 08/01/2023, which revealed: “...Patient was ambulating to the bathroom when [she] tried to get up from [her] wheelchair to go to the bathroom [she] fell and hit the side of [her] head on the floor; fall was unwitnessed. V/S were taken, patient was examined by the medical provide on the unit and neuro checks put in place...Patient came out complaining of blurry vision and a headache. Called the medical provider, obtained an order to send pt out via AMR to [Valleywise] for post fall CT scan d/t patient being on anticoagulants....” The Post Fall Huddle Form was requested for the fall Patient #17 sustained on [08/01/2023]. None was provided. Falls were not added to the Interdisciplinary Treatment Plan as a problem after the 08/01/2023 fall. Patient #17’s medical record contained a note titled “Daily Nursing Narrative,” dated 08/07/2023, which revealed: “...Roommate came to nurses’ station and reported “Patient got up from bed to go to bathroom and [she] is on the floor”. Went to room Patient found lying across bed laying on [her] abdomen...noted small 0.4cm long cut to upper inner lip. Patient also noted to have blue bruising to left cheek bone. Patient stated “I had to go pee so I stood up when I took a step I got off balance and I tried to get next to the wall but I fell and landed on the floor.” As patient speaking noted dentures are broken to upper left side...Notified Psych provider received order for 1:1 for patient safety d/t fall....” Patient #17’s medical record contained a note titled “Interdisciplinary Care Plan,” which revealed: “...Problem: Fall Risk; As Evidenced By: Fall at Bedside; Date Initiated: 08/07/2023...” A fall log was requested for the previous 12 months. Patient #17 was not on the log. Employee #2 confirmed during an interview conducted on 02/21/2024 Patient #17 was not placed on fall precautions on admission, per policy, nor had falls identified as a problem on the Interdisciplinary Care Plan, until after two falls had occurred.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45618 Based on a review of hospital records and interview, it was determined the hospital failed to ensure hospital staff followed policies and procedures while providing nursing care to patients requiring frequent observation or experiencing cardiac arrest. This failure poses the risk of an increased chance of harm, injury, or death, due to staff not providing patient care, per policy. Cross reference A-0385, A-0043, A-0057 Findings include: Policy titled “Adult Cardiopulmonary Resuscitation,” revealed: “Charge RN or Designee: Respond to all codes as quickly as possible...Functions as the Team Leader as defied by BLS practice in the absence of the LIP...May serve as code recorder; may initiate CPR...Nurse assigned to Patient...may initiate CPR; may serve as code recorder....” Policy titled “Patient Care Management,” revealed: “...Emergency Intervention...Any adverse changes in condition will be recognized and appropriate measures taken...1. Follows established protocol for identifying and responding to a code 2. Documents the events of a Code on the appropriate record....” Document titled “Job Title Registered Nurse; Department Name Nursing,” revealed: “...Directs non-professional personnel in implementing nursing care plans, and provides guidance and demonstrates appropriate methods, as necessary, to correct deviations from established standards... Maintains the standards of accurate and complete recording and reporting. Reports patient’s condition, medications given and treatments administered to nursing administration and the following shift...Makes regular rounds of assigned patients independently and with physicians. Observes and evaluates patient’s symptoms, progress and reactions to treatments and mediations {sic}, Takes corrective actions as indicated...Observes and supports hospital policy, mission statement, and vision....” Hospital policy titled “Patient Observation,” revealed: “...All patients will be admitted to the patient care unit with a minimum of “every 15 minutes” observation level...Level 1 - General Observation a. All patients on this level are on every 15 minute observation, at a minimum. B. This is the minimum acceptable level for all patients....” Patient #19’s medical record contained a note titled “Daily Nursing Narrative,” which revealed: “...Patient was removed from seclusion at 0105 and taken to [his] room...Staff will continue performing Q15 safety supervision and Q 2 hrs. nurses round to ensure wellness of the patient. Writer checked on patient at 0255, patient resting in bed with eyes closed, snoring. Respiration unlabored, writer visualized chest rising up and down. At 0452 staff performing rounds and called on nurses to come check on patient. Upon assessment, patient had a weak pulse, sternum rub done, crackles heard, writer called for help and code was called. CPR started immediately, 911 called....” The note was signed by Employee #27 with a time and date of 05:15 on 01/29/2024. Hospital documentation of the event, dated 01/29/2024, revealed: “...BHT performing q 15 min check came to nurse and reported Patient not responding and mouth open. RN (Employee #27) went to room Performed Sternal rub heard crackle from throat, Felt for Pulse patient had Pulse. Attempted Vital signs and called out for help. Code blue called to room CPR began 0450...Review of RN documentation indicates...patient was rounded on multiple times by RN afterwards prior to code event....” A review of recorded security footage, showing room numbers 108 through 111, in which Patients #19, 25, 26, 27, 28, and 29, were staying, dated 01/29/2024, revealed: Timestamp/Estimated actual time: 00:30/01:54 - Patient rounding performed by BHT 01:46/03:11 - Patient #28 left room #108 02:02/03:27 - Patient #28 returned to room #108 02:15/03:40 - Patient rounding performed by BHT 02:48/04:13 - Patient rounding performed by BHT 03:14/04:39 - Patient rounding performed; Employee #30 enters Patient #19’s room 03:16/04:41 - Employee #30 leaves Patient #19’s room 03:18/04:43 - Employee #27 and #30 enter Patient #19’s room 03:20/04:45 - Vital sign machine/monitor brought to room 03:26/04:51 - Code cart and portable oxygen brought down hallway. Code cart placed outside of patient room and oxygen taken into patient room. A review of “Patient Observation Rounds” forms, dated 01/28/2024, for Patients #19, #25, #26, #27, and #29, revealed Employees #29 and #39 documented every 15 minute rounds from 01:55 until 04:35. Employee #30 documented every 15 minute patient rounds on Patient #28 in the same time frame. All patients were documented as a location of P (Patient Room), and a behavior code of 1 (Resting/Eyes Closed), during this time frame. Patients #26 and #27’s observation rounds were signed by Employee #28 in the space “Night Nurse Signature,” on the morning of 01/29/2024. Patients #25 and #29’s observation rounds were signed by Employee #40, in the space “Night Nurse Signature,” on the morning of 01/29/2024. Patients #19 and #28’s observation rounds were signed by Employee #41 in the space “Night Nurse Signature,” on the morning of 01/29/2024. Employee #11 confirmed in an interview conducted on 02/15/2024, while on a tour of the facility, a code sheet is filled out, while indicating a form titled “NeuroPsychiatric Hospitals Code Blue Summary Sheet” found in a binder on the code cart. The “NeuroPsychiatric Hospitals Code Blue Summary Sheet” was requested for Patient #19 and was not received. Employee #1 and Employee #5 confirmed in separate interviews, conducted on 02/22/2024, patient rounds were not performed every 15 minutes per policy on night shift on 01/28/2024. Employee #1 also confirmed the timestamp on the video footage being watched was approximately 1 hour and 25 minutes behind the actual time. Employee #1 and Employee #5 confirmed it was 12 minutes in between the time the BHT was seen entering Patient #19’s room and the time the code cart was brought to the patient room at 04:51. It was also confirmed there was no Code Blue Summary Sheet for Patient #19 to document life saving measures taken by the staff.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 45618 Based on a review of hospital record and interview, it was determined the hospital failed to ensure a patient’s (Patient #8) medical record could be easily located and was accessible to surveyors for a complaint investigation. This failure poses the risk of an inability to review medical and/or psychiatric care given to patients during a hospitalization. Cross reference A-0431, A-0043, A-0057 Findings include: Policy titled “Release of Medical Records,” revealed: “...Health Information Management Department shall release medical record information in accordance with established procedure consistent with Federal and State Law....” Phoenix Medical Psychiatric Hospital was entered by surveyors at approximately 08:45 on 02/14/2024. Patients involved in complaints were identified and medical records for the patients, including Patient #8, were requested at approximately 11:00 on 02/14/2024. Patient #8 was admitted to the hospital initially on 08/08/2023, and then transferred to a higher level of care on 08/10/2023. Patient #8 returned to the facility on 08/20/2023, and was then discharged on 09/01/2023. A medical record for Patient #8 was provided for a hospitalization with an admission date of 08/20/2023, through 09/01/2023. The request was then clarified that the medical records for both admissions would be needed for the investigation. Patient #8’s medical record for the 08/08/2023, admission was requested multiple times on 02/14/2023, 02/15/2023, and 02/20/2023. Patient #8’s medical record for the 08/08/2023 admission was provided at approximately 15:30 on 02/20/2023. Employee #1 confirmed in an interview on 02/14/2024, both admissions were in one record. Employee #1 later confirmed in an interview on 02/14/2024, the staff was looking for Patient #8’s medical record for the admission date of 08/08/2023. Employee #1 confirmed in interviews on 02/15/2024, and 02/20/2024, they were still trying to locate the medical record. Employee #1 confirmed in an interview on 02/20/2024, at approximately 15:30, the record was located.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 45618 Based on a review of hospital record and interview, it was determined the hospital failed to ensure contents of the written medical record were accurately dated, timed, and authenticated, and had proper patient identifying information on each page. This failure poses the risk of an incomplete medical record due to pages with no patient identifiers on it being separated or misplaced from the original record, and provider orders being modified or changed without the proper authentication. Cross reference A-0431, A-0043, A-0057 Findings include: Document titled “Job Title Registered Nurse; Department Name Nursing,” revealed: “...Maintains the standards of accurate and complete recording and reporting....” Document titled “Rules and Regulations of the Medical Staff PMPH,” revealed: “...All medical record entries must be legible, complete, accurate, dated, timed, and authenticated promptly, in written or electronic form...All diagnostic and therapeutic orders, including telephone orders, standing orders, order sets, and protocols must be appropriately authenticated by the responsible practitioner...All telephone orders for treatment shall note the name of the practitioner giving the order and the person relaying the order, and must be signed, dated and timed by the authorized person to whom it was dictated....” Patient #24’s medical record revealed the patient was placed in seclusion on 12/20/2023 from 04:15 until 04:20. A seclusion order was written on 12/19/2023 at 21:30 with a note on the order “...ok to modify times to 0420 ’ 0450 12/20/2023 TORB (Provider #6)....” The telephone order was signed by Employee #5 and dated 12/27/2023 at 1415. The order was not authenticated by Provider #6. Patient #22’s medical record contained a telephone order from Provider #7 to Employee #8 on 12/03 at 15:55, which revealed: “...Seclusion until calm and no longer danger to self. 1:1 monitoring....” The order was amended to say “...Can use Seclusion room...” and “...may advance to seclusion if needed start 1555 to end 1655...” in different handwriting, with no additional authentication. Patient #21’s medical record contained a note titled “Physician/NP/PA Progress Note,” that was not dated. Patient #10’s medical record contained: A “COVID-19 Nursing Assessment,” dated 08/25/20223, with no patient identifiers present; A six page “Psychosocial Assessment,” with Patient #10’s first and last name only, on page one, and no patient identifiers on pages two through six. An “Interdisciplinary Treatment Plan,” dated 09/11/2023, and a “Social Services Progress Note,” dated 09/08/2024, with Patient #10’s first name and last initial as identifiers. A “Social Services Progress Note,” dated 08/27, four typewritten pages with no title, dated 08/27/2023, 08/30/2023, 09/10/2023, and 09/12/2023, with Patient #10’s first and last name only. Patient #15’s medical record contained a “Daily Nursing Narrative Note,” dated 11/15/2023, with no patient identifiers, and a “Social Services Progress Note,” dated 11/15/2023, on which Patient #15 was only identified by first and last name. Seven “Seclusion and Restraint Individual Reporting Form” documents located in Patients’ #19 #22, #23, and #24’s medical record had patient identifiers on page one only. There were no patient identifiers on pages two through seven of the form, nor on the “Monitoring” page. Employee #1 confirmed in an interview conducted on 02/22/2024, that several pages of patient medical records lacked patient identifiers. Employee #5 confirmed in an interview conducted on 02/22/2024, the orders in Patient #21’s and #22’s medical record were not written appropriately.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure: 1. The medical records for two patients (Patient #3 and Patient #21) contained all laboratory reports. This deficient practice poses a risk to the health and safety of patients if all laboratory reports are not in the medical record, and available for review to monitor the patient’s condition and make necessary interventions. 2. The patient’s weight was documented in the medical record per facility’s policies and procedures for two patients (Patient #3 and Patient #4). This deficient practice poses a potential risk to the health and safety of patients if weights are not obtained and documented, and used to monitor the patient’s physical condition, nutritional status, and accurate drug dosages. Cross reference A-0431, A-0043, A-0057 Findings include: 1. Policy titled, “Laboratory Process”, revealed: “ ...Policy: To obtain laboratory results and place them on the chart for provider review in a timely manner. Laboratory procedures are processed through local contracted laboratories ....Procedure: 1. Provider orders lab ....3. Nurses place order for laboratory tests on lab website. 1. For a STAT order, the STAT box is noted on the on-line order. 2. STAT lab pick up is requested. 4. Nurses and/or phlebotomist obtains specimen ...7. Lab courier picks up the specimen. 8. Nurse/Unit Clerks obtain laboratory results from lab website and print results ....9. Nurses/Unit Clerks place printed results in the patient’s medical record for the provider to review ....” Review of Patient #3’s medical record revealed they had labs ordered on [04/03/2023] and collected on [04/04/2023]. Further review of Patient #3’s medical record revealed no documentation of the labs results. Patient #21’s medical record revealed stat labs were ordered on 02/01/2024 and collected on 02/02/2024. The medical record did not contain the results of Patient #21’s labs. Employee #2 confirmed during an interview conducted on 02/21/2024 that labs are sent out, and lab results are printed out and placed in the patient’s medical record. Employee #2 also confirmed Patient #3 had labs drawn and performed on [04/04/2023]. Employee #2 further confirmed the lab results were not placed in Patient #3’s medical record. Employee #2 further confirmed that Patient #21’s medical record also did not contain the lab results from labs drawn on 02/02/2024. 2. Policy titled, “Vital Signs and Weight”, revealed: “ ...Purpose: To monitor patient’s physical status ....Procedure: ...Weights will be taken a minimum of once a week, unless diagnosis deems need for increased frequency weighing and the provider orders a more frequent schedule ....Staff is to report any significant changes or abnormal findings to be the Nurse. Nurses will notify the provider of findings outside patient’s normal range. Record vital signs and weekly weights in the patient’s medical record ....” Review of Patient #3’s medical record revealed they were admitted on [04/03/2023] and discharged on [05/05/2023]. Further review of Patient #3’s medical record revealed a vital signs and weights flow sheet, and the allotted section for weight measurements were blank. Review of Patient #4’s medical record revealed they were admitted on [03/30/2023] and discharged on [04/20/2023]. Further review of Patient #4’s medical record revealed a vital signs and weights flow sheet, and the allotted section for weight measurements were blank. Employee #2 confirmed during an interview conducted on 02/20/2024 that behavioral health technicians weigh all the patients once a week, and record it in a binder. Employee #2 also confirmed the nurses copy over the documented weight in the binder to the individual patient’s vital signs and weights flow sheet. Employee #2 also confirmed the documentation in the binder was not part of the patient’s medical record. Employee #2 further confirmed they could not locate the weekly weight documentation in the binder for Patient #3 and Patient #4. Employee #2 further confirmed there was no documentation in the medical records that Patient #3 and Patient #4 were weighed weekly per the facility’s policies and procedures.”