Community Hospital of San Bernardino

“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: 51269 This Standard is not met as evidenced by: Based on interview and record review, the facility failed to ensure all licensed nurses adhered to the hospital’s policies and procedures (P&P), to provide adequate supervision and evaluation for four of 33 sampled patients (Patient 7, 10,11, and 17) when: 1. For one patient (Patient 7), the nursing staff did not document patient education regarding metformin (medication used to help lower blood sugar level in people with type 2 diabetes [high blood sugar]) as required by policy. 2. For one patient (Patient 7), the nursing staff did not provide clear shift-to-shift nursing handoff (when the nursing staff gives important information about the patient’s condition and assessment to the next shift) and failed to notify the physician of Patient 7’s worsening mental status as ordered. 3. For two patients (Patient 7 and 10), the nursing staff did not document every 4-hour (q4hr) neurological assessments (neuro check: assessments used to monitor how well a person’s brain and nervous system are working, including the alertness, orientation, pupil response, speech, strength, movement and sensation) as ordered. 4. For one patient (Patient 11), the nursing staff did not document vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR- how fast the heart is beating every minute), respiratory rate (RR- how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood) during blood transfusion (giving blood from another person in your vein) as required by policy. 5. For one patient (Patient 17), the nursing staff did not document discharge VS as required by policy. These failures had the potential to result in the hospital’s inability to provide consistent and adequate nursing services in a safe environment and potentially delayed monitoring, evaluation, treatment, deterioration of patient conditions, and unsafe patient care. Findings: 1. During a review of Patient 7’s “History and Physical” (H&P- a document containing demographic information), dated May 3, 2026, the H&P indicated Patient 7 was admitted on May 3, 2026, for a Transient Ischemic Attack (TIA- blood flow to part of the brain is temporarily blocked but tend to go away within minutes and do not cause permanent brain damage). Patient 7 had medical history including hypertension (HTN- High blood pressure) and Cerebrovascular Accident (CVA or stroke, a condition where blood flow to part of the brain is blocked or when a blood vessel in the brain bursts). A review of Patient 7’s “Orders,” dated May 3, 2026, through May 6, 2026, indicated, “metformin 500 mg [milligram-unit dosing medication], PO [by mouth], TAB, BID [twice a day] with meals ...start May 5, 2026...” During an interview on June 4, 2026, at 8:09 AM, with Registered Nurse (RN 1) and the Medical Surgical/Telemetry Director (MSTD), RN 1 stated the nursing staff are expected to document the education provided to the patients regarding new medications. RN 1 stated that the nursing staff have an icon that the nursing staff can click in the Medication Administration Record (MAR- an electronic record that shows what medications a patient is supposed to receive, when it should be given and whether it was administered) that indicated, “patient educated.” RN 1 stated it is important to document because that is when the nursing staff explain the medication and the side effects that the patient can experience. During a concurrent interview and record review on June 4, 2026, at 8:47 AM, with the MSTD, Patient 7’s MAR, dated May 3, 2026, through May 6, 2026, and the Medication Reconciliation (Med Rec- process of reviewing and comparing the patients current home medications with the new medication orders), undated, were reviewed. The MAR indicated that Patient 7 received metformin for the first time on May 5, 2026, at 12:44 PM, and there was no education on the medication noted. The Med Rec indicated that metformin was not a medication that Patient 7 was taking at home. The MSTD stated there was no nursing documentation on metformin education and there should have been. The MSTD further stated, it is important to document the education provided to the patients because the patients should know what medications are being received and the side effects the medication can cause. During a concurrent interview and record review on June 4, 2026, at 9:40 AM, with the Director of Quality and Patient Safety (DQPS), the facility’s P&P titled “Barcode Medication Administration (BCMA) and Electronic Medication Administration Record (Emar),” dated May 2011, was reviewed. The P&P indicated “ ...3.0 At the patient’s bedside ...3.2 Advise patients, or if appropriate, designated family members, about the medication’s actions, potential clinical adverse reactions [unwanted reactions to medication], and possible side effects ...3.3 log into the computer at the bedside and scan the patient’s armband and then all medications to be administered ...” The DQPS stated that the policy was not followed and should have been for patient safety. 2. During a review of Patient 7’s H&P, dated May 3, 2026, the H&P indicated Patient 7 was admitted on May 3, 2026, for a TIA. Patient 7 had medical history including HTN and CVA. A review of Patient 7’s “Orders,” dated May 3, 2026, through May 6, 2026, indicated, “Notify MD [Medical Doctor] if ... neurological status worsens ...” During a telephone interview on June 3, 2026, at 8:59 AM, with RN 2 and the Medical Surgical/ Telemetry shift Manager (MSTM), RN 2 stated the shift-to-shift hand off is done at each patient’s bedside. RN 2 stated that the nursing staff are expected to chart who provided report or who you received report from in “Events” or “Nursing Notes”. RN 2 stated it is important to document who received report to hand off the patient care and to know who was taking care of the patient. RN 2 added, if there was a change in the patient’s condition to what he got on hand off, RN 2 would notify the provider and document it in “Events” or “Nursing Notes”. RN 2 stated, he did not remember Patient 7 and what was charted is what he did while caring for Patient 7. During a follow-up concurrent telephone interview and record review on June 3, 2026, at 9:02 AM, with RN 2 and the MSTM, Patient 7’s “Neurological Assessment,” dated May 4, 2026, from 6:00 AM through 7:00 PM, “Events,” dated May 3, 2026, through May 6, 2026, and “Nursing Notes,” dated May 3, 2026, through May 6, 2026, were reviewed. The “Neurological Assessment” indicated Patient 7’s neurological assessment as follows: May 4, 2026, at 6:00 AM: “ ...Speech ...clear ...Gait ...steady ...” May 4, 2026, at 8:00 AM: “ ...Speech ...slurred ...Gait ...unsteady ...” The “Events” and “Nursing Notes” indicated there was no shift-to-shift hand off for May 4, 2026 (night shift (May 3, 2026, 7:00 PM-7:30 AM) to day shift (May 4, 2026, 7:00 AM-7:30 PM)) or any notification to provider of the Patient 7’s worsening neurological assessment. The MSTM verified that there was no documentation for the worsening neurological assessment, hand off or provider notification. RN 2 stated, “I probably did not document the hand off, I am really bad at documenting handoff”. RN 2 added he should have notified the provider as there was a change in the Patient 7’s condition during his shift. During a concurrent interview and record review on June 3, 2026, at 8:50 AM with the MSTD, the facility’s P&P titled, “Hand off/ Providing A Patient Report,” dated January 2006, and “Core Nursing Standards of Practice,” dated March 2024, were reviewed. The “Hand off/ Providing A Patient Report” indicated, “Procedure: 1.0 Upon transport or transfer of a patient, provide a report of the patient’s clinical status to the receiving clinical staff. 2.0 Obtain the name of the healthcare provider you received report from ...hand off ...nursing change of shift from nurse to nurse ...documentation... face-to-face/verbal report ...” The “Core Nursing Standards of Practice” indicated, “ ...c. Care Delivery- the registered nurse performs and/or oversees delivers care according to the patient’s need, LIP [licensed independent practitioner- a provider who is licensed to assess patient, diagnose, and order treatment] orders, and the plan of care to achieve identified outcomes ... 3 ...in the event of an unexpected outcome, a note should be entered by the nursing providing detail and summarization, A. Nursing notes are entered for the following instances ...vi. LIP notification ...” The MSTD stated that the nursing staff did not follow the facility’s policies when the nursing staff did not document the handoff or the notification of worsening neurological status. The MSTD stated that the nursing staff have been instructed to document who the nursing staff handed off/received the patient from. The MSTD stated it is important for the nursing staff to notify the LIP if there is a change/worsening in the patient’s condition to get new orders. 3a. During a review of Patient 7’s H&P, dated May 3, 2026, the H&P indicated Patient 7 was admitted on May 3, 2026, for a TIA. Patient 7 had medical history including HTN and CVA. A review of Patient 7’s “Orders,” dated May 3, 2026, through May 6, 2026, indicated, “Neurological check ...q4hr ...” During an interview on June 4, 2026, at 8:12 AM, with RN 1 and the MSTD, RN 1 stated, if a patient has neuro checks, the nursing staff are expected to complete them to identify if there are any changes from the previous assessment. RN 1 added if there are any changes, the nursing staff should notify the provider to get new orders and document it. During a concurrent interview and record review on June 4, 2026, at 8:54 AM, with the MSTD, Patient 7’s “Neurological Assessment,” dated May 3, 2026, through May 6, 2026, were reviewed. The “Neurological Assessment” was completed as follows: May 4, 2026, 8:00 AM: neurological assessment completed May 4, 2026, 7:00 PM: neurological assessment completed (11 hours without a neuro check) May 5, 2026, 8:20 AM: neurological assessment completed (13 hours and 20 minutes without a neuro check) May 5, 2026, 8:00 PM: neurological assessment completed (11 hours and 40 minutes without a neuro check) May 6, 2026, 9:00 AM: neurological assessment completed (13 hours without a neuro check) May 6, 2026, 6:52 PM: patient discharged. The MSTD stated that the nursing staff did not complete and document a neurological assessment every 4 hours and should have. The MSTD stated it is important to complete the neuro checks as ordered by the physician to identify any changes and follow up with the physician. 3b. During a review of Patient 10’s H&P, dated May 31, 2026, the H&P indicated Patient 10 was admitted on May 31, 2026, for left sided facial droop, rule out CVA. Patient 10 had medical history including hypothyroidism (the thyroid gland (organ in your neck that controls the body’s energy and speed) is slow and not making enough hormones). A review of Patient 10’s “Orders,” dated May 31, 2026, through June 2, 2026, indicated, “Neurological check ...q4hr ...” During an interview on June 4, 2026, at 8:12 AM, with RN 1 and the MSTD, RN 1 stated, if a patient has neuro checks, the nursing staff are expected to complete them to identify if there are any changes from the previous assessment. RN 1 added if there are any changes, the nursing staff should notify the provider to get new orders and document it. During a concurrent interview and record review on June 4, 2026, at 8:56 AM, with the MSTD, Patient 10’s “Neurological Assessment,” dated May 31, 2026, through June 1, 2026, were reviewed. The “Neurological Assessment” was completed as follows: May 31, 2026, 2:00 PM: neurological assessment completed May 31, 2026, 8:00 PM: neurological assessment completed (6 hours without a neuro check) June 1, 2026, 8:00 AM: neurological assessment completed (12 hours without a neuro check) June 1, 2026, 2:11 PM: patient discharged. The MSTD stated that the nursing staff did not complete and document a neurological assessment every 4 hours and should have. The MSTD stated it is important to complete the neuro checks as ordered by the physician to identify any changes and follow up with the physician. During a concurrent interview and record review on June 4, 2026, at 9:20 AM, with the DQPS, the facility’s P&P titled, “Core Nursing Standards of Practice,” dated March 2024, was reviewed. The P&P indicated, “ ...c. Care Delivery- the registered nurse performs and/or oversees delivers care according to the patient’s need, LIP [licensed independent practitioner- a provider who is licensed to assess patient, diagnose, and order treatment] orders, and the plan of care to achieve identified outcomes ...” The DQPS stated that the policy was not followed for Patient 7 or Patient 10 as the nursing staff did not document q4hr neurological assessment as ordered by the provider. The DQPS stated it is important to follow the policy to provide adequate quality of care to the patients. 4. During a review of Patient 11’s H&P, dated May 28, 2026, the H&P indicated Patient 11 was admitted on May 28, 2026, for a chronic (long-lasting) anemia (not enough health red blood cells or hemoglobin (carries oxygen through the body) in your blood. Patient 11 had medical history of diabetes (DM- high blood sugar) and HTN. A review of Patient 11’s “Orders,” dated May 28, 2026, at 7:42 PM, indicated, “PRBC [Packed red blood cells- blood transfusion] ...number of units 4 ...” During an interview on June 4, 2026, at 8:15 AM, with RN 1 and the MSTD, RN 1 stated the nursing staff are required to document VS before the blood administration, every 15 minutes for the first hour of administration, then every hour after until the blood is administered, and the last one is immediately after the transfusion is completed. During a concurrent interview and record review on June 4, 2026, at 9:00 AM, with the MSTD, Patient 11’s “Blood Transfusion Flowsheet,” dated May 29, 2026, “Blood Start Time,” dated May 29, 2026, and “Vital section,” dated May 29, 2026, was reviewed. The “Blood Transfusion Flowsheet” indicated, “Unit #3 [3rd blood transfusion] ...vital signs ...pre transfusion: time: 0330 [3:30 AM] ... 36.8 [temp], 61 [HR], 18 [RR], 126/60 [BP] ...” the rest of the VS were crossed off indicating “see EMAR [Electronic Medication Administration Record]”. The “Blood Start/End Time” indicated the transfusion was started on May 29, 2026, at 4:07 AM and ended on May 29, 2026, at 7:28 AM. The “Vital Section” indicated the VS were completed as follows: May 29, 2026, 4:00AM to 4:14 AM: VS documented (Prior to blood transfusion) May 29, 2026, 5:00 AM to 5:15 AM: VS documented (approximately 53 minutes after initiation of blood transfusion) May 29, 2026, 7:00 AM to 7:14 AM: VS documented (approximately 1 hour and 45 minutes from previous VS) May 29, 2026, 11:00 AM to 11:14 AM: VS documented (approximately 3 hours and 32 minutes after completion of blood transfusion) The MSTD stated that she was unable to provide documentation that the VS was completed as required. The MSTD stated that the nursing staff did not document VS as required and should have because it is important to identify if there is a blood transfusion reaction (unsafe response to donated blood including, fever, back/chest pain, shortness of breath, low blood pressure, or allergic reactions). During a concurrent interview and record review on June 4, 2026, at 9:24 AM, with the DQPS, the facility’s P&P titled, “Blood and Blood Product Administration,” dated March 2024, was reviewed. The P&P indicated “ ...8.0 see attached table for Blood/Blood Product Administration ...inform patients of rationale for frequent vital signs and monitoring ... Blood Transfusion Flowsheet ...Vital Signs ...Pre transfusion ...15 min [minutes] post [after] start ...30 min post start ...45 min post start ...1 hour post start ... 2 hours post start ...3 hours post start ...immediate post transfusion ...” The DQPS stated that the nursing staff did not follow the policy for Patient 11’s blood transfusion and should have. The DQPS stated it is important to follow the policy for patient safety. 5. During a review of Patient 17’s H&P, dated June 1, 2026, the H&P indicated Patient 17 was admitted on June 1, 2026, for asthma (airway in the lungs become tight, swollen and clogged with mucus). Patient 17 had medical history including DM and HTN. A review of Patient 17’s “Orders,” dated June 1, 2026, indicated “discharge .... disposition: home ...” During an interview on June 4, 2026, at 8:18 AM, with RN 1 and the MSTD, RN 1 stated the nursing staff should be documenting discharge VS within an hour of the patient being discharged. RN 1 stated it was important to document the VS to ensure that it is safe for the patient to go home and there has not been a change in the patient’s condition. During a concurrent interview and record review on June 4, 2026, at 9:07 AM, with the MSTD, Patient 17’s “Vital Section,” dated June 1, 2026, and “Nursing Discharge Summary,” dated June 1, 2026, were reviewed. The “Vital Section” indicated, the last VS were documented on June 1, 2026, 7:00 AM. The “Nursing Discharge Summary” indicated Patient 17 was discharged on June 1, 2026, at 5:04 PM (10 hours after the last set of VS). The MSTD verified and confirmed that Patient 17 did not have discharge VS. The MSTD stated the expectation is for the nursing staff to take VS at least one hour before the patient is discharged to ensure that the discharge is safe and if there is an unexpected change, the nursing staff should notify the provider and hold the discharge until further instruction. During a concurrent interview and record review on June 4, 2026, at 9:34 AM, with the DQPS, the facility’s P&P titled, “Core Nursing Standards of Practice,” dated March 2024, was reviewed. The P&P indicated “ ...iii. Vital signs should be obtained within 1 hour prior to patient transfer or discharge ...” The DQPS stated that the policy was not followed for Patient 17 and should have been for patient safety.”

“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: 51099 Based on interview and record review, the Governing Body (GB - a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure safe and effective quality of care for a universe of 33 sampled patients, when the GB failed to ensure an effective Quality Assurance and Performance Improvement (QAPI- is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) program and provide effective oversight of patient safety related to nursing fall risk assessment (assessment tool to assess risk for falls with scoring as 1-5 is low risk, 6-13 is moderate risk, 14 and up is high risk) processes and Columbia Suicide Severity Risk Scale (C-SSRS - screening tool used to assess a person’s risk for suicide) risk assessment (evaluation to determine how likely a patient is to harm or kill themselves) including every 15 minute (Q 15 min) observation, direct observation (when staff personally and visually watch a patient to ensure safety in real time), and suicide risk care planning (plan that outlines a patient’s problems, goals, and the care needed to treat them) for behavioral health patients (patients receiving care for mental health or substance use issues that affect their thoughts, mood, or behavior). (Refer to A-0049) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of safe and appropriate care in a high-risk behavioral health setting, which placed patients at risk for harm.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 51099 Based on interview and record review, the facility failed to ensure an effective ongoing, hospital-wide, data-driven Quality Improvement and Performance Improvement (QAPI- is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) program for a universe of 33 sampled patients, as evidenced by: The facility failed to maintain an effective, ongoing, hospital-wide, data-driven QAPI program to identify opportunities for improvement and implement effective corrective actions based on identified issues related to nursing fall risk assessment (assessment tool to assess risk for falls with scoring as 1-5 is low risk, 6-13 is moderate risk, 14 and up is high risk) processes and Columbia Suicide Severity Rating Scale (C-SSRS - screening tool used to assess a person’s risk for suicide) risk assessment (evaluation to determine how likely a patient is to harm or kill themselves) including every 15 minute (Q 15 min) observation, direct observation (when staff personally and visually watch a patient to ensure safety in real time), suicide risk care planning (plan that outlines a patient’s problems, goals, and the care needed to treat them) for behavioral health patients (patients receiving care for mental health or substance use issues that affect their thoughts, mood, or behavior). (Refer to A-0283). The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem-prone areas, implement effective performance improvement activities, and ensure the provision of safe and appropriate care for high-risk behavioral health patients, which placed patients at risk for harm.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 51099 Based on observation, interview, and record review, the facility failed to maintain an effective and organized nursing services for six of 33 sampled patients (Patient 1, 12, 22, 23, 32, and 33), as evidenced by: 1. For one patient (Patient 22), the suicidal care plan (plan that outlines a patient’s problems, goals, and the care needed to treat them) was not initiated upon admission. (Refer to A-0396) 2. For one patient (Patient 12), the fall risk assessment (tool to assess risk for falls with given score as 1-5 is low risk, 6-13 is moderate risk, 14 and up is high risk) documentation was not documented and completed appropriately and accurately. (Refer to A-0398) 3. For one patient (Patient 1), the facility staff did not follow the facility’s policies and procedures (P&P) appropriately for the Columbia Suicide Severity Rating Scale (C-SSRS - screening tool used to assess a person’s risk for suicide) Risk Assessment (also known as Lifetime - section of the C-SSRS that looks at a person’s entire history of suicidal thoughts and behaviors) for Patient 1, who was deemed as high-risk (a result on the C-SSRS, indicating the individual has expressed active suicidal ideation with a specific plan, intent, or recent preparatory behaviors and needs immediate crisis intervention and safety planning). (Refer to A-0398) 4. For two patients (Patient 32 and 33), the facility staff did not document and observe patients every 15 minutes appropriately. 5. For three patients (Patient 22, 23, and 33), the C-SSRS assessment was not completed accurately according to policy. (Refer to A-0398) The cumulative effects of these systemic problems resulted in the facility’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed supervision, monitoring, reassessment, and delayed intervention, which jeopardized the health and safety of the patients.”

“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: 51099 Based on interview and record review, the Governing Body (GB - a group of people responsible for the overall direction and management of an organization) failed to ensure patient safety and quality of care for a universe of 33 sampled patients, when the GB did not have effective oversight of clinical processes related to nursing fall risk assessment (assessment tool to assess risk for falls with scoring as 1-5 is low risk, 6-13 is moderate risk, 14 and up is high risk) processes and Columbia Suicide Severity Risk Scale (C-SSRS - screening tool used to assess a person’s risk for suicide) risk assessment (evaluation to determine how likely a patient is to harm or kill themselves) including every 15 minute (Q 15 min) observation, direct observation (when staff personally and visually watch a patient to ensure safety in real time), and suicide risk care planning (plan that outlines a patient’s problems, goals, and the care needed to treat them) for behavioral health patients (patients receiving care for mental health or substance use issues that affect their thoughts, mood, or behavior) These failures resulted in the facility’s inability to identify problem-prone areas and deliver care with the GB oversight, and to provide safe patient care environment with adequate supervision, which could jeopardize the health and safety of the patients. Findings: During a review of the facility’s document titled, “Executive Committee Meeting [Name] Meeting Minutes” [Meeting minutes], dated January 28, 2026, through March 30, 2026, the meeting minutes indicated quality care outcomes and identified safety concerns discussed at Quality Assurance and Performance Improvement (QAPI- is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) meetings. The meeting minutes did not include any documented data of Q15 minute monitoring observations, compliance with completion of C-SSRS assessments and reassessments, direct observation monitoring for high-risk behavioral patients, and tracking for fall risk assessments in the Behavioral Health Unit (BHU) or care plan initiation for patients at high risk for suicide. During an interview on April 8, 2026, at 3:40 PM, with a member of the GB: Chief Medical Officer (CMO), the survey team’s brief summary of findings were discussed including incomplete suicide risk assessments, inaccurate document of Q15 min observations, not provided direct observation for a high-risk behavioral health patient, not initiated suicide care plan, and inconsistency of fall risk assessment scores. The CMO stated the GB was not aware of issues with C-SSRS risk assessment, fall risk assessment inaccuracies, direct observations with high-risk behavioral health patients, or Q15min observations. The CMO further stated, the GB was reconstructed in December 2025, and only the previous members of the old GB were aware of concerns pertaining to suicide risk assessments, care plan initiation, Q15min observations, but it is new information for the current GB members. The CMO stated the GB has overall responsibility for the facility and for overall patient safety. During a review of the facility’s document titled, “Bylaws of the [name] Board of Community Advisors” dated October 1, 2025, indicated, “ ...2.2.2 Quality, Safety, Patient Experience ...the Board of Community Advisors’ duties and responsibilities with respect to quality, safety, and patient experience at each Market Hospital shall include (a) assuring that health care services provided are of high quality, safe, effective, efficient, and consistent with community standards; (b) approving ongoing quality assessment, performance improvement, patient safety, and utilization management activities; (c ) assuring that quality and patient safety issues are addressed and resolved timely and appropriately ...””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 51099 Based on interview and record review, the facility did not maintain an effective and ongoing hospital-wide Quality Assurance and Performance Improvement (QAPI- is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) program for a universe of 33 sampled patients, when the facility failed to identify opportunities for improvement and implement changes with the collected data related to nursing fall risk assessment (assessment tool to assess risk for falls with scoring as 1-5 is low risk, 6-13 is moderate risk, 14 and up is high risk) processes and Columbia Suicide Severity Rating Scale (C-SSRS - screening tool used to assess a person’s risk for suicide) risk assessment (evaluation to determine how likely a patient is to harm or kill themselves) including every 15 minute (Q 15 min) observation, direct observation (when staff personally and visually watch a patient to ensure safety in real time), suicide risk care planning (plan that outlines a patient’s problems, goals, and the care needed to treat them) for behavioral health patients (patients receiving care for mental health or substance use issues that affect their thoughts, mood, or behavior). These failures resulted in the facility’s inability to implement sustained improvements and ensure safe care for behavioral health patients, placing patients at risk for harm. Findings: During an interview on April 8, 2026, at 1:54 PM, with members of the facility’s QAPI program: the Director of Quality and Patient Safety (DQPS), Chief Nursing Officer (CNO), and the Director of Behavioral Health Unit (DBHU), the facility’s QAPI program was discussed. The DQPS stated the facility’s QAPI program includes a multi-level data collection process in which unit-based departments conduct audits and performance improvement activities, which are then reported to the Clinical Quality Committee (CQC), and subsequently to the Quality Improvement Council (QIC) and Governing Body (GB - a group of people responsible for the overall direction and management of an organization). The CNO stated that the facility’s QAPI structure involved unit-level data being reported quarterly (every three months) to the CQC, and bi-annually (two times a year) to the QIC. During a follow-up interview on April 8, 2026, at 2:13 PM, with the DQPS, CNO, and DBHU, the CNO stated the facility was tracking falls, but it was hospital-wide and random, not specifically in the Behavioral Health Unit (BHU). The CNO further stated that the facility was tracking compliance with documentation for C-SRRS, Q 15 min observations, and confirmed the facility did not audit verification of actual patient monitoring or tracking of patients placed under direct observation. During a follow-up concurrent interview and record review on April 8, 2026, at 2:49 PM, with the DQPS, CNO, and DBHU, the facility’s “Clinical Quality Improvement Report” (Report), dated October 30, 2025, through January 2026, was reviewed. The Report indicated that the facility monitored data for Q 15 min observation and patient assessment/re-assessments of C-SSRS risk assessment. The DBHU verified and stated that the BHU audits 40 charts each month, which include review of documentation for C-SSRS, observation checks, and care planning. The DBHU further stated, audits primarily focused on documentation, timeliness, and accuracy of documents rather than verifying of actual patient required monitoring. During a follow-up interview on April 8, 2026, at 3:12 PM, with the DQPS, CNO, and DBHU, the survey team brought up brief summary of the issues identified during survey as follows: incomplete suicide risk assessments, inaccurate document of Q15 min observations, not provided direct observation for a high suicide risk of behavioral health patient, not initiated suicide risk care plan, and inconsistency of fall risk assessment scores. The CNO stated that the facility was aware there were issues with compliance for Q15 min observations, including staff failing to visualize patients and falsely documenting times, and confirmed the facility’s audits failed to catch those issues. The CNO further stated the facility does random audits for falls and care plan initiation, but there were no specific indicators for behavior health patients nor any tracking for patients who were placed on direct observation. The DBHU stated all components of C-SSRS should be reviewed, including real-time demonstration of staff intervention and observation. The DBHU confirmed the collected data is not a true reflection of the current concerns in BHU and the facility was not able to use the data to analyze and implement performance improvements. A record review of the facility’s policies and procedures (P&P) titled, “Quality Assurance and Performance Improvement Plan,” dated January 2026, indicated, “ ...The scope of the organization’s QAPI Program, established by the medical staff and an interdisciplinary Quality/Patient Safety Committee with the support and approval of the Community Governing Board, encompasses organization-wide activities related to performance measurement, assessment, improvement, and control of patient care and support services and processes, including contracted services ...Governing Body: The Governing Body authorizes the establishment of this performance improvement program. The Governing Body: Has the overall responsibility of governance for the safety, quality, and performance improvement activities within the organization ...””

“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: 46917 Based on observation, interview, and record review, the facility failed to ensure nursing staff developed and maintained an individual plan of care (documented, organized, guide that outlines a patient’s healthcare needs, identifies nursing diagnoses, sets patient-centered goals, and specifies the nursing interventions and evaluations required to achieve these goals) per the facility’s policy and procedure (P&P) for one of 33 sampled patients (Patient 22) who presented with suicidal ideation (having thoughts of ending own life). This failure had the potential to result in missed safety interventions (specific actions taken to keep a person safe when there is a risk of harm) which places Patient 22 at increased risk for self-harm. Findings: During a review of Patient 22’s “History and Physical” (H&P-document to show patient’s health assessment), dated March 24, 2026, the H&P indicated Patient 22 was “brought in by EMS [Emergency Medical Services- emergency care and transportation] for overdose w/ [with] reported [suicidal ideation] ...” During an observation on April 6, 2026, at 9:37 AM, Patient 22 was sleeping in bed. Patient 22 had a sitter or constant observer at the bedside watching him. During a concurrent interview and record review on April 6, 2026, at 3:20 PM, with Registered Nurse (RN 1), Patient 22’s plan of care, undated, was reviewed. There was no documented behavioral plan of care for suicidal ideation for Patient 22. RN 1 verified and confirmed there was no documented plan of care and stated there should have been a plan of care to keep Patient 22 safe. During an interview on April 7, 2026, at 8:41 AM, with (RN 2), RN 2 stated plan of care must be updated daily to reflect the patient’s status. During a concurrent interview and record review on April 8, 2026, at 10:13 AM, with the Director of Medical Surgical Unit (DMSU), the facility’s P&P titled, “Interdisciplinary Plan of Care”, dated March 2024, was reviewed. The P&P indicated, “ ... an individualized plan of care will be completed for all patients presenting to [name of hospital] ... 1.0 Patient’s needs will be identified and prioritized and an interdisciplinary plan of care will be initiated ...” The DMSU stated the policy was not followed for Patient 22.”

“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: 51099 Based on observation, interview, and record review, the facility failed to ensure nursing services were provided in accordance with accepted standards of practice and the facility’s policies and procedures (P&P) to meet the nursing care needs for six of 33 sampled patients (Patient 1, 12, 22, 23, 32, and 33) when: 1. For one patient (Patient 12), the fall risk assessment (tool to assess risk for falls with given score as 1-5 is low risk, 6-13 is moderate risk, 14 and up is high risk) documentation was not documented and completed appropriately and accurately. This failure had the potential to result in failure to identify patients at risk for falls and implement appropriate safety interventions, increasing the likelihood of falls and serious injury, including fractures, head injury, or functional decline. 2. For one patient (Patient 1), the facility staff did not follow the facility’s policies and procedures (P&P) appropriately for the Columbia Suicide Severity Rating Scale (C-SSRS - screening tool used to assess a person’s risk for suicide) Risk Assessment (also known as Lifetime - section of the C-SSRS that looks at a person’s entire history of suicidal thoughts and behaviors) for Patient 1, who was deemed as high-risk (a result on the C-SSRS, indicating the individual has expressed active suicidal ideation with a specific plan, intent, or recent preparatory behaviors and needs immediate crisis intervention and safety planning). This failure had resulted in underestimation of Patient 1’s suicide risk, failure to implement appropriate observation levels and safety interventions, which could contribute to Patient 1’s death. 3. For two patients (Patient 32 and 33), the facility staff did not document and observe patients every 15 minutes appropriately. 4. For three patients (Patient 22, 23, and 33), the C-SSRS was not completed accurately according to policy. These failures had the potential to delay and identify Patients’ change of condition or declined in health condition, which could increase the risk of self-harm, and compromised patients’ safety. Findings: 1. A review of Patient 12’s face sheet (contains medical and demographic information), indicated Patient 12 was admitted to the facility on April 2, 2026, with diagnoses including danger to self and unspecified psychosis (condition where a person is losing touch with reality, but the exact cause is not fully known yet). During a concurrent observation and interview on April 6, 2026, at 9:00 AM, in the Behavioral Health Unit (BHU), with the Director of Behavior Health Unit (DBHU), Patient 12 was observed in the bed with a mental health worker (MHW) sitting at the bedside. The DBHU confirmed and stated that Patient 12 had a constant observer or sitter (a person who always stays with patients to keep them safe) due to a high risk for falls since Patient 12 had a recent fall within the past six months. During a concurrent interview and record review on April 7, 2026, at 9:05 AM, with the DBHU, Patient 12’s “Fall Risk Scores,” dated April 2, 2026, through April 7, 2026, was reviewed as follows: On April 2, 2026, at 9:56 AM: 34 (high) On April 2, 2026, at 3:03 PM: 6 (low) On April 2, 2026, at 11:42 PM: 34 (high) On April 3, 2026, at 9:00 AM: 4 (low) On April 3, 2026, at 10:26 AM: 6 (low) On April 4. 2026, at 9:04 AM: 1 (low) On April 4, 2026. at 8:45 PM: 34 (high) On April 5, 2026, at 8:15 AM: 1 (low) On April 5, 2026, at 9:10 PM: 1 (low) On April 6, 2026, at 7:55 AM: 36 (high) On April 7, 2026, at 12:40 AM: 1 (low) On April 7, 2026, at 9:21 AM: 34 (high) The DBHU confirmed Patient 12’s fall risk scores dated April 2, 2026, through April 7, 2026, and stated the fall risk scores were not documented accurately. The DBHU further stated, Patient 12’s fall risk scores should have always been reflected as high risk. During an interview on April 7, 2026, 12:00 PM, with Registered Nurse 2 (RN 2), RN 2 stated, fall risk assessment scores had to be completed every shift and needs to accurately reflect the patient’s status. During a concurrent interview and record review on April 7, 2026, at 2:18 PM, with the DBHU, the facility’s P&P titled, “Fall Prevention and Management Policy and Procedure,” dated July 2022, was reviewed. The P&P indicated, “ ...Policy: To provide a safe environment for patients and to minimize their risk of falling ...A. Assessment and Reassessment ...2. Evidence-based fall risk interventions will be implemented based upon an age-appropriate Fall Risk Assessment Tool (FRAT). a. Adult - [Name] Fall Risk Assessment Tool (> age 18) ...D. Implementation of Interventions: Individualized application of the interventions according to the risk factors identified for the patient ...a. Implement Adult Fall Prevention Interventions based on [Name] Fall Risk Assessment Tool ...F. Documentation: Acute: a. Document fall risk score using appropriate Fall Risk Assessment Tool (FRAT) in the medical health record upon admission, every shift, upon transfer to another level of care or after a patient fall ...” The DBHU stated the facility did not follow policy. 2. A review of Patient 1’s face sheet, indicated, Patient 1 was admitted to the facility on February 10, 2026, due to danger-to-self (DTS - situation where a patient is at risk of hurting or killing themselves). A review of Patient 1’s “Progress Notes - Nursing,” dated February 10, 2026, indicated, “ ...Patient presents to BH [Behavioral Health] East on a 5150 [involuntary hold for up to 72 hours when someone is a danger to themselves, others, or gravely disabled] due to DTS for taking 4 tablets of unknown medication and writing a suicide note and text message per PES [Psychiatric Evaluation Screening - initial assessment to determine if a patient is having a mental health crisis and needs further psychiatric care] note ...Pt [patient] is positive (+) for THC [Tetrahydrocannabinol - main chemical in cannabis or marijuana] per PES note ...Pt reports having a medical history of seizure [sudden burst of abnormal electrical activity in the brain that causes changes in movement, behavior, or awareness] with the last reported seizure being in December 2025 ....Pt denies seizures being related to alcohol ...” During a concurrent interview and record review on April 6, 2026, at 1:55 PM, with the DBHU, Patient 1’s C-SSRS, dated February 10, 2026, was reviewed. The C-SSRS indicated that Patient 1 was assessed as high risk. The DBHU confirmed the C-SSRS indicated Patient 1 was a high-risk patient. A review of Patient 1’s “Progress Note - Nursing,” dated February 10, 2026, indicated, “ ... 2330 [11:30 PM] Pt received in bed resting with eyes closed. Pt respirations are active even and unlabored. Pt shows no s/s [signs and symptoms] of pain or distress at this time. Will continue current POC [plan of care - plan that outlines a patient’s problems, goals, and the care needed to treat them] and Q [every] 15 min [minutes] monitoring for safety ...” During a further interview on April 6, 2026, at 1:57 PM, with the DBHU, the DBHU stated patients who are assessed as high-risk from the C-SSRS screenings are placed under direct observation, which can be done with a sitter. The DBHU stated, at the time of admission, Patient 1 did not present any signs or symptoms that warranted the need of a sitter, so staff placed Patient 1 under direct observation by placing Patient 1 in the room directly across the nurses’ station with the door open for visualization. The DBHU also stated that all the patients in the unit are placed under Q 15 min observations because everyone is at risk for safety. During a concurrent interview and record review on April 7, 2026, at 8:26 AM, with the DBHU, the facility’s P&P, titled, “Identifying and Assessing Patients at Risk of Suicide/Self-Harm,” dated March 2025, was reviewed. The P&P indicated, “Screening: All patients will be screened for the potential risk of suicide/self-harm at Triage using the Columbia Suicide Severity Rating Scale (C-SRRS) [INITIAL] screener. If a direct admission, C-SSRS [INITIAL] Screener will be done at the earliest point of contact by licensed nurse ...2. Assessment: ...d. If someone is screened as a HIGH risk, a C-SSRS Risk assessment will be completed to clarify current suicide risk level ...Attachment G: [facility name] Addendum: Identifying and Assessing Patients at Risk of Suicide/Self-Harm ...High Suicide Risk: Patients being cared for in the above areas and found to be at high risk may be monitored under direct observation ...” The DBHU stated the facility did not follow the policy, the facility staff did not monitor Patient 1 under direct and constant observation. During an interview on April 7, 2026, at 1:38 PM, with Mental Health Worker 1 (MHW 1), MHW 1 stated, staff conducts rounds on the patients every 15 minutes, and it is the expectation to document patient behavior and location in real-time on the Q 15 min rounding sheets. MHW 1 further stated, if the patient is sleeping in the room, the expectation is that staff must go inside, directly observe the patient for rise and fall of the chest to ensure patient is breathing. If that is not seen, then it is not considered an observation. During a concurrent observation and interview on April 8, 2026, at 8:09 AM, with the DBHU, Patient 1’s Q 15 min observation sheet, dated February 10, 2026, through February 11, 2026, was cross-referenced with the closed-circuit television surveillance video (CCTV- surveillance system using cameras) for the BHU, dated February 10, 2026, through February 11, 2026, as follows: On February 10, 2026, at 11:45 PM: MHW 3 not in sight, no one observed to be standing in front of Patient 1’s room On February 10, 2026, at 11:49 PM: Registered Nurse 1 (RN 1) enters Patient 1’s room On February 11, 2026, at 12:00 AM: MHW 3 not in sight, no one observed to be standing in front of Patient 1’s room On February 11, 2026, at 12:17 AM: MHW 3 stood in front of Patient 1’s room but did not enter On February 11, 2026, at 12:30 AM: MHW 3 not in sight, no one observed to be standing in front of Patient 1’s room On February 11, 2026, at 12:45 AM: MHW 3 in hall, not in front of Patient 1’s room. On February 11, 2026, at 12:49 AM: RN 4 closes Patient 1’s room door On February 11, 2026, at 12:51 AM: MHW 3 is outside of Patient 1’s room but did not enter On February 11, 2026, at 1:17 AM: MHW 3 opens Patient 1’s door and peeks inside before shutting door closed. On February 11, 2026, at 1:34 AM: MHW 3 enters Patient 1’s room The DBHU confirmed the CCTV date, time, and observation. The DBHU confirmed MHW 3 did not enter Patient 1’s room to get the direct observation of Patient 1’s status from February 10, 2026, at 11:49 PM, through February 11, 2026, at 1:34 AM (1 hour and 45 mins without staff direct observation). The DBHU stated that the Q 15 min observation sheet was documented Q 15 mins, but it did not reflect the real condition of Patient 1’s status. The DBHU further stated, MHW 3 is on leave and is unable to be interviewed. During a concurrent interview and record review on April 8, 2026, at 9:35 AM, with the DBHU, the facility’s P&P titled, “Levels of Observation and Special Precautions,” dated February 2024, was reviewed. The P&P indicated, “ ...1.4 Assigned staff documents the Q 15-minute observations as rounds are made. Staff observes the patient location and behavior ....2.2 The staff observes the patient at least every 15 minutes and documents the location and behavior at each interval ...2.3. Assigned staff makes direct visual contact with the patient and confirm they are in no danger or distress ...2.4. The staff member enters the room the patient is in to observe the condition of the patient. Any time the patient is in bed, the staff member observes respiration by watching the rise and fall of the chest to ensure the patient is not in any distress ...” The DBHU stated the facility did not follow the policy, the facility staff did not observe Patient 1 at least every 15 minutes. A review of Patient 1’s “Progress Notes - Nursing,” dated February 10, 2026, indicated, “During Q15 min completed by CNA [Certified Nurse Assistant] at 0138 [1:38 AM]. This RN [Registered Nurse] was notified that pt was unresponsive. When this RN arrived at bedside. Pt was unresponsive with no pulse [heart rate] and not breathing. CPR [Cardiopulmonary Resuscitation - lifesaving technique used when someone’s heart stops or they stop breathing] started immediately. Code blue [emergency for a patient in cardiac or respiratory arrest; no pulse and/or not breathing] called at 0140 [1:40 AM]. Crash cart [mobile emergency cart stocked with life-saving equipment and medications used during a code blue] taken to bedside AED [automated external defibrillator - a machine that can shock the heart to restart it] pads placed on patient and compression resumed. Code blue team arrived at 0145 [1:45 AM] and took over care of patient. Code blue completed at 0216 [2:16 AM]. Code blue was recorded in code blue record. House supervisor, MD [medical doctor] and chief nursing officer made aware.” 46917 3a. During a review of Patient 32’s “History and Physical” (H&P-document to show patient’s health assessment), dated February 1, 2026, the H&P indicated Patient 32 was admitted to the facility on a 5150 hold for DTS. During a review of Patient 32’s C-SSRS, dated February 11, 2026, the C-SSRS indicated Patient 32 did not have any thoughts of killing himself. During an interview on April 7, 2026, at 1:38 PM, with MHW 1, MHW 1 stated, staff conducts rounds on the patients every 15 minutes, and it is the expectation to document patient behavior and location in real-time on the Q 15 min rounding sheets. MHW 1 further stated, if the patient is sleeping in the room, the expectation is that staff must go inside, directly observe the patient for rise and fall of the chest to ensure patient is breathing. If that is not seen, then it is not considered an observation. During a concurrent observation and interview on April 8, 2026, from 8:15 AM to 8:21 AM, with the DBHU and the Quality Program Manager (QPM), the facility’s CCTV for the BHU, dated February 10, 2026, from 6:15 PM to 9:45 PM, were reviewed. The CCTV indicated as follows: On February 10, 2026, from 6:15 PM to 6:57 PM: MHW 2 was observed sitting in the “vital sign room” (a room where staff check essential measurements of patient’s basic body function such as heart rate, respiratory rate, temperature, and blood pressure) (42 minutes). On February 10, 2026, from 8:28 PM to 8:45 PM: MHW 2 was observed sitting in the hallway. (17 minutes). On February 10, 2026, from 9:25 PM to 9:45 PM: MHW 2 was observed sitting in the hallway. (20 minutes). The DBHU and QPM verified and confirmed the CCTV date, time, and observation. During a follow-up interview on April 8, 2026, at 8:22 AM, with the DBHU, the DBHU stated it was the expectation of the mental health workers to capture real time observations of the behavior of the patients. The DBHU further stated MHW 2 sitting in the hallway was not the expectation of the staff. During a follow-up concurrent interview and record review on April 8, 2026, at 8:24 AM, with the DBHU, Patient 32’s “Q-15 Minute Observation Record,” dated February 10, 2026, was reviewed. The “Q-15 Minute Observation Record” indicated on February 10, 2026, from 9:00 PM through 10:00 PM (60 minutes), Patient 32 was in “bed asleep with active breathing” and “lying down”. The DBHU verified and confirmed MHW 2 was not seen on video going inside Patient 32’s room, therefore the information documented was not accurate. The DBHU further stated the staff were expected to go inside the rooms to observe and assess the patients. 3b. During a review of Patient 33’s H&P, dated February 8, 2026, the H&P indicated Patient 33 was admitted to the facility on a 5150 hold for DTS by suicidal ideation (SI- thoughts or plans about ending one’s own life). During a review of Patient 33’s C-SSRS, dated February 11, 2026, the C-SSRS indicated Patient 33 did not have any thoughts of killing himself. During an interview on April 7, 2026, at 1:38 PM, with MHW 1, MHW 1 stated, staff conducts rounds on the patients every 15 minutes, and it is the expectation to document patient behavior and location in real-time on the Q 15 min rounding sheets. MHW 1 further stated, if the patient is sleeping in the room, the expectation is that staff must go inside, directly observe the patient for rise and fall of the chest to ensure patient is breathing. If that is not seen, then it is not considered an observation. During a concurrent observation and interview on April 8, 2026, from 8:15 AM to 8:21 AM, with the DBHU and the QPM, the facility’s CCTV for the BHU, dated February 10, 2026, from 6:15 PM to 9:45 PM, were reviewed. The CCTV indicated as follows: On February 10, 2026, from 6:15 PM to 6:57 PM: MHW 2 was observed sitting in the “vital sign room” (42 minutes). On February 10, 2026, from 8:28 PM to 8:45 PM: MHW 2 was observed sitting in the hallway. (17 minutes). On February 10, 2026, from 9:25 PM to 9:45 PM: MHW 2 was observed sitting in the hallway. (20 minutes). The DBHU and QPM verified and confirmed the CCTV date, time, and observation. During a follow-up interview on April 8, 2026, at 8:22 AM, with the DBHU, the DBHU stated it was the expectation of the mental health workers to capture real time observations of the behavior of the patients. The DBHU further stated MHW 2 sitting in the hallway was not the expectation of the staff. During a follow-up concurrent interview and record review on April 8, 2026, at 8:24 AM, with the DBHU, Patient 33’s “Q-15 Minute Observation Record,” dated February 10, 2026, was reviewed. The “Q-15 Minute Observation Record” indicated on February 10, 2026, from 9:00 PM through 9:15 PM, Patient 33 was “bed awake” and “lying down” and from 9:30 PM through 10:00 PM, Patient 33 was in “bed asleep with active breathing”. The DBHU verified and confirmed MHW 2 was not seen on video going inside Patient 33’s room, therefore the information documented was not accurate. The DBHU further stated the staff were expected to go inside the rooms and to observe and assess the patients. During a review of the facility’s P&P titled, “Levels of Observation and Special Precautions” dated reviewed February 19, 2024, it indicated, “ ...to provide guidelines for observation of patients by staff ... 1.4 Assigned staff documents the Q 15-minute observations as rounds are made. Staff observes the patient location and behavior ... 2.3 Assigned staff makes direct visual contact with the patient and confirm they are in no danger or distress. 2.4 The staff member enters the room the patient is in to observe the condition of the patient. Any time the patient is in bed, the staff member observes respiration by watching the rise and fall of the chest to ensure the patient is not in any distress ...” 4a. During a review of Patient 23’s H&P, dated March 31, 2026, the H&P indicated Patient 23 was admitted to the facility for suicidal ideation. Patient 23 has a chronic indwelling catheter (a tube placed inside the bladder to collect urine) and could not be admitted to the behavioral health unit. During a concurrent observation and interview on April 6, 2026, at 9:30 AM, with Certified Nursing Assistant (CNA 1) Patient 23 was lying in bed, sleeping. CNA 1 was sitting inside the room near the door. CNA 1 stated she was the constant observer for Patient 23’s safety. During a concurrent interview and record review on April 6, 2026, at 1:55 PM, with Registered Nurse 3 (RN 3), Patient 23’s C-SSRS, dated March 31, 2026, through April 5, 2026, were reviewed. RN 3 confirmed there was no documented evidence to indicate a C-SSRS was completed for Patient 23 from April 1, 2026, through April 5, 2026. During a review of Patient 23’s C-SSRS, dated April 6, 2026, the C-SSRS indicated Patient 23’s suicide severity rating was high (indicating immediate danger to self). 4b. During a review of Patient 22’s H&P, dated March 24, 2026, the H&P indicated Patient 22 was admitted to the facility for overdose (ingestion of a substance in a larger quantity than the body can safely process) with reported suicidal ideation. During an observation on April 6, 2026, at 9:37 AM, Patient 22 was sleeping in bed. Patient 22 had a constant observer at the bedside watching him. During a concurrent interview and record review on April 6, 2026, at 2:19 PM, with RN 1, Patient 22’s C-SSRS, dated March 24, 2026, was reviewed. Patient 22’s C-SSRS indicated his suicide severity rating required a reassessment. RN 1 could not find any reassessment from March 25, 2026, to April 6, 2026. RN 1 stated Patient 22’s C-SSRS should have been reassessed to protect the patient as stated on March 24, 2026. 4c. During a review of Patient 33’s H&P, dated February 8, 2026, the H&P indicated Patient 33 was admitted to the facility on an involuntary 5150 hold for DTS by SI. During a concurrent interview and record review on April 8, 2026, at 11:31 AM, with the DBHU, Patient 33’s C-SSRS, dated February 8, 2026, was reviewed. The DBHU stated she could not find any documented evidence of the C-SSRS assessment for Patient 33 for February 8, 2026. During an interview on April 7, 2026, at 8:41 AM, with RN 4, RN 4 stated the C-SSRS assessment must be done daily. During a concurrent interview and record review on April 8, 2026, at 10:11 AM, with the Director Medical Surgical Unit (DMSU), the facility’s P&P titled, “Identifying and Assessing Patients at Risk of Suicide/Self-Harm,” dated March 4, 2025, was reviewed. The P&P indicated, “ ... this procedure applies to all [name of company] general acute care hospitals ... 3. Re-screening of high-risk patients will be completed and documented each shift and PRN [as needed] by a licensed nurse for changes in suicidal ideation and behavior ...” The DMSU stated the policy was not followed.”