Kaiser Foundation Hospital - Los Angeles

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51973 Based on interview and record review, the facility failed to provide a timely Medical Screening Examination (MSE, the process a hospital emergency department must use to determine if an individual has an emergency medical condition [EMC, a medical condition that has acute symptoms so severe that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part]) for one (1) of 22 sampled patients (Patient 1) who presented to the emergency department (ED - a specialized medical facility that provides acute care for patients with serious injuries or illnesses who arrive without a prior appointment, equipped for immediate life-threatening conditions) with chest pain rated as 7/10 on the pain scale. Patient 1 was assigned an Emergency Severity Index (ESI- is a five-level tier triage algorithm that categorizes ED patients by evaluating patient acuity [the severity, complexity, and urgency of a patient’s medical condition] and resources needs) of 3 on arrival instead of an ESI of 2. In addition, the facility did not reassess the patient’s (Patient 1) elevated blood pressure nor performed timely ongoing monitoring as required by Federal EMTALA (Emergency Medical Treatment and Labor Act, a federal law that requires Medicare-participating hospitals to provide a medical screening examination to anyone requesting it, regardless of their insurance status or ability to pay. If an emergency medical condition is found, the hospital must stabilize the patient before they can be discharged or transferred to another facility) and the facility’s policies and procedures. This deficient practice had the potential to result in patient harm and/or death due to inaccurate triaging (the process in an emergency room where a nurse quickly assesses a patient’s condition to determine the severity of their illness or injury and prioritize their treatment) and monitoring leading to a delay in MSE. Findings: During a concurrent interview and record review on 11/19/2025 at 12:06 p.m. with the Emergency Department Nurse Manager (ED NM) 2, Patient 1’s “Patient Care Timeline” record, dated 5/19/2025, was reviewed. ED NM 2 stated that the facility received Patient 1 in the emergency department (ED) via ambulance at 2:37 a.m. The Patient Care timeline also indicated the following: -At 2:39 a.m., Patient 1 was assigned an Emergency Severity Index (ESI- is a five-level tier triage algorithm that categorizes ED patients by evaluating patient acuity and resources needs) of 3. -At 2:41 a.m., Patient 1’s chief complaint indicated “not feeling well” after taking recreational drugs (substance used primarily for enjoyment). The note also indicated Patient 1 complained of chest pain. -At 2:41 a.m., Patient 1’s vital signs (VS-measurements of the body’s most basic functions) were documented as temperature (T- 98.3F), Heart rate (HR) 102, Blood Pressure (BP) 183/113, and oxygen saturation (O2 saturation - a measurement of how much oxygen the blood is carrying as a percentage) 100% on room air (RA). -At 2:41 a.m., Patient 1’s chest pain had a pain score of 7 out of 10 (severe pain), in the left chest that was a continuous ache. -At 5:41 a.m., Patient 1 was placed in an ED room. -At 6:04 a.m., Patient 1’s VS were documented as T- 98.4, HR-98, BP- 181/100, O2 sat-100% -At 6:24 a.m., Patient 1 was seen by medical doctor (MD) -At 6:46 a.m., Patient 1 had orders placed and was administered aspirin (improves blood flow to the heart and potentially reduce heart damage) 162 mg (milligram, a unit of measurement). -At 6:54 a.m., Patient 1 had labs (laboratory blood draws) collected -At 7:30 a.m., Patient 1’s Troponin (a protein found in the heart muscle and a test helps rule out heart attack) level was 57 (high). During an interview on 11/19/2025 at 11:50 a.m. with the ED Nurse Manager 2 (EDNM 2), EDNM 2 stated “If I were the triage nurse I would have assigned Patient 1 an ESI level 2 and rechecked the BP more frequently.” During an interview on 11/20/2025 between 8:10 a.m. and 8:45 a.m. with ED Charge Nurse 1 (EDCN 1), the EDCN 1 stated the following: -the triage nurse does the ESI assessment and determines what level (ESI level) the patient will be. -the triage nurse registers patients, for example if a chest pain patient walks in, patient may get upgraded to an ESI level 2 based on vital signs. -when patients arrive by ambulance, the Emergency Medical Technician (EMT) will register patient with the Patient Facility Coordinator (PFC), the PFC will take report, takes VS and assign an ESI 2 if vitals were abnormal and get patient in a room right away. -the expectations for the nurses when patients with chest pain arrived, would be that VS were taken and if the BP was high, then patient was placed in a room right away. -the clinical impression of seeing a BP of 183/113 would warrant an ESI level 2 to be assigned. -A BP of 183/113 was abnormal. -the standard practice for how often vital signs were checked for patients with chest pain, should be every two hours or more if BP and troponin were elevated. -the practice for monitoring patients whose initial BP was severely elevated was to notify the MD and ask for medications to administer and recheck the BP 15-30 minutes after administration. -Patient 1 did not receive appropriate care, and the triage nurse should have assigned Patient 1 an ESI level 2 after the initial VS. -it was not acceptable for Patient 1 to have a BP of 183/113 and go 3 hours and 23 minutes without a repeat BP check. EDCN 1 stated that as a charge nurse “we track patients waiting for re-assessments or monitoring through our track board, the track board lets us know when BPs are abnormal.” -charge nurses are always looking at track board and always have access to the track board. -the consequences of leaving a BP unmonitored for so long especially if patients have taken recreational drugs, was “they (referring to the patients) can have a stroke (occurs when blood flow to part of the brain is interrupted) or bleed which is a very common thing we see especially in the ED when the patient has an elevated troponin.” During an interview on 11/20/2025 between 12 p.m. and 12:45 p.m. with the Chief of Emergency Medicine (CEM), the CEM stated the following: -stabilizing interventions that were expected for a chest pain patient included Electrocardiogram (EKG-a test that checks your heart’s electrical activity), VS, and reassessment of VS if they were abnormal. -the expectations for nurses and qualified EMTs were to take a complete set of VS every two hours at minimum, which included Temperature, HR, BP, and O2 sat. -a 3-hour and 23-minute delay in VS reassessment was not appropriate for Patient 1. -there was a delay in the VS re-assessment and a lack of monitoring for Patient 1. -CEM stated that VS monitoring were very important, and MDs rely on the VS documentation for review -the risks associated with delaying reassessment for Patient 1 could be Myocardial Infarction (MI- blood flow to heart stops). During a review of the facility’s policy and procedure (P&P) titled, “Triage and Patient Flow in the ED”, dated 11/2024, the P&P indicated: B. Patients who present to the ED by Paramedics/BLS/ALS Ambulance: ... b) Assign the patient to a treatment bed and notify the primary nurse and physician of the patient’s arrival, chief complaint, condition, and immediate needs. ESI 3- Vital Signs Including Pain Score, every 2 hours or more often if the condition warrants. During a review of the facility’s policy and procedure (P&P) titled, Triage and Patient Flow in the Emergency Department (ED), dated 11/2024, the P&P indicated the following: 1. Patients arriving by way of emergency medical services (EMS - paramedics or transport ambulance services) shall be triaged in the main ED by the Triage registered nurse (RN) and assigned an Emergency Severity Index (ESI - a 5-level triage algorithm used in the ED to sort patients based on the acuity of their condition and the resources they will need) level using the ESI algorithm version 4. 2. The Triage RN will enter the chief complaint, assigned ESI level, place the patient in the treatment area. 3. Patients with ESI level 2 will have vital signs with pain score evaluated every two (2) hours or more often and assessments every 2 hours or more often. During a review of the facility’s policy and procedure (P&P) titled, Standing Order - ED Nurse Initiated Condition-Based Orders, dated 12/2024, the P&P indicated the following: 1. Patients with an ESI 2 (emergent, high-risk situation) will require physician notification of ESI priority, saline lock by way of a vein (IV - a type of access that keeps a vein open for fluids including medications and blood products), cardiac monitor (medical device that tracks the heart’s electrical activity, including heart rate), 12-lead electrocardiogram (EKG - a medical test that measures the electrical activity of the heart), and laboratory tests (samples of body fluids, including blood, to provide information about the health of a person). 2. Patients with chest pain will require a patient to be placed in a bed with cardiac monitoring as soon as possible, will need an EKG with results provided to any ED physician, for review, laboratory tests, and chest x-ray, and medication for chest pain. 3. Patients with an ESI 3 (urgent situation) will require a saline lock, cardiac monitor and/or EKG, laboratory tests. During a review of the facility’s policy and procedure (P&P) titled, “Standing Order: ED Nurse Initiated Condition-Based Orders,” dated 11/2024, the P&P indicated: D. Chest Pain .... (Rule Out Myocardial-Infarction) .... 1) If the nurse suspects that the pain is cardiac in origin .... (has history of cardiac disease, or recreational drug use) place the patient in a monitored bed as soon as possible. During a review of the facility’s guidelines titled, “Emergency Severity Index Handbook Fifth Edition,” dated 2023, the guidelines indicated: Unrecognized or unmanaged abnormalities of these vital signs (i.e. .... blood pressure, heart rate, respiratory rate, and oxygen saturation) is significantly associated with higher mortality rates, highlighting the importance of monitoring a wide range of vital signs to identify deterioration in the patient’s health status.”

“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: 51973 Based on interview and record review, the facility failed to provide a timely Medical Screening Examination (MSE, the process a hospital emergency department must use to determine if an individual has an emergency medical condition [EMC, a medical condition that has acute symptoms so severe that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part]) for one (1) of 22 sampled patients (Patient 1) who presented to the emergency department (ED - a specialized medical facility that provides acute care for patients with serious injuries or illnesses who arrive without a prior appointment, equipped for immediate life-threatening conditions) with chest pain rated as 7/10 on the pain scale. Patient 1 was assigned an Emergency Severity Index (ESI- is a five-level tier triage algorithm that categorizes ED patients by evaluating patient acuity [the severity, complexity, and urgency of a patient’s medical condition] and resources needs) of 3 on arrival instead of an ESI of 2. In addition, the facility did not reassess the patient’s (Patient 1) elevated blood pressure nor performed timely ongoing monitoring as required by Federal EMTALA (Emergency Medical Treatment and Labor Act, a federal law that requires Medicare-participating hospitals to provide a medical screening examination to anyone requesting it, regardless of their insurance status or ability to pay. If an emergency medical condition is found, the hospital must stabilize the patient before they can be discharged or transferred to another facility) and the facility’s policies and procedures. This deficient practice had the potential to result in patient harm and/or death due to inaccurate triaging (the process in an emergency room where a nurse quickly assesses a patient’s condition to determine the severity of their illness or injury and prioritize their treatment) and monitoring leading to a delay in MSE. Findings: During a concurrent interview and record review on 11/19/2025 at 12:06 p.m. with the Emergency Department Nurse Manager (ED NM) 2, Patient 1’s “Patient Care Timeline” record, dated 5/19/2025, was reviewed. ED NM 2 stated that the facility received Patient 1 in the emergency department (ED) via ambulance at 2:37 a.m. The Patient Care timeline also indicated the following: -At 2:39 a.m., Patient 1 was assigned an Emergency Severity Index (ESI- is a five-level tier triage algorithm that categorizes ED patients by evaluating patient acuity and resources needs) of 3. -At 2:41 a.m., Patient 1’s chief complaint indicated “not feeling well” after taking recreational drugs (substance used primarily for enjoyment). The note also indicated Patient 1 complained of chest pain. -At 2:41 a.m., Patient 1’s vital signs (VS-measurements of the body’s most basic functions) were documented as temperature (T- 98.3F), Heart rate (HR) 102, Blood Pressure (BP) 183/113, and oxygen saturation (O2 saturation - a measurement of how much oxygen the blood is carrying as a percentage) 100% on room air (RA). -At 2:41 a.m., Patient 1’s chest pain had a pain score of 7 out of 10 (severe pain), in the left chest that was a continuous ache. -At 5:41 a.m., Patient 1 was placed in an ED room. -At 6:04 a.m., Patient 1’s VS were documented as T- 98.4, HR-98, BP- 181/100, O2 sat-100% -At 6:24 a.m., Patient 1 was seen by medical doctor (MD) -At 6:46 a.m., Patient 1 had orders placed and was administered aspirin (improves blood flow to the heart and potentially reduce heart damage) 162 mg (milligram, a unit of measurement). -At 6:54 a.m., Patient 1 had labs (laboratory blood draws) collected -At 7:30 a.m., Patient 1’s Troponin (a protein found in the heart muscle and a test helps rule out heart attack) level was 57 (high). During an interview on 11/19/2025 at 11:50 a.m. with the ED Nurse Manager 2 (EDNM 2), EDNM 2 stated “If I were the triage nurse I would have assigned Patient 1 an ESI level 2, and rechecked BP more frequently.” During an interview on 11/20/2025 between 8:10 a.m. and 8:45 a.m. with ED Charge Nurse 1 (EDCN 1), the EDCN 1 stated the following: -the triage nurse does the ESI assessment and determines what level (ESI level) the patient will be. -the triage nurse registers patients, for example if a chest pain patient walks in, patient may get upgraded to an ESI level 2 based on vital signs. -when patients arrive by ambulance, the Emergency Medical Technician (EMT) will register patient with the Patient Facility Coordinator (PFC), the PFC will take report, takes VS and assigns an ESI 2 if vitals were abnormal and get patient in a room right away. -the expectations for the nurses when patients with chest pain arrived, would be that VS were taken and if the BP was high, then patient was placed in a room right away. -the clinical impression of seeing a BP of 183/113 would warrant an ESI level 2 to be assigned. -A BP of 183/113 was abnormal. -the standard practice for how often vital signs were checked for patient with chest pain, should be every two hours or more if BP and troponin were elevated. -the practice for monitoring patients whose initial BP was severely elevated was to notify the MD and ask for medications to administer and recheck the BP 15-30 minutes after administration. -Patient 1 did not receive appropriate care, and the triage nurse should have assigned Patient 1 an ESI level 2 after the initial VS. -it was not acceptable for Patient 1 to have a BP of 183/113 and go 3 hours and 23 minutes without a repeat BP check. EDCN 1 stated that as a charge nurse “we track patients waiting for re-assessments or monitoring through our track board, the track board lets us know when BPs are abnormal.” -charge nurses are always looking at track board and always have access to the track board. -the consequences of leaving a BP unmonitored for so long especially if patients have taken recreational drugs, was “they can have a stroke (occurs when blood flow to part of the brain is interrupted) or bleed which is a very common thing we see especially in the ED when the patient has an elevated troponin.” During an interview on 11/20/2025 between 12 p.m. and 12:45 p.m. with the Chief of Emergency Medicine (CEM), the CEM stated the following: -stabilizing interventions that were expected for a chest pain patient included Electrocardiogram (EKG-a test that checks your heart’s electrical activity), VS, and reassessment of VS if they were abnormal. -the expectations for nurses and qualified EMTs were to take a complete set of VS every two hours at minimum, which included Temperature, HR, BP, and O2 sat. -a 3-hour and 23-minute delay in VS reassessment was not appropriate for Patient 1. -there was a delay in the VS re-assessment and a lack of monitoring for Patient 1. -CEM stated that VS monitoring was very important, and MDs rely on the VS documentation for review -the risks associated with delaying reassessment for Patient 1 could be Myocardial Infarction (MI- blood flow to heart stops). During a review of the facility’s policy and procedure (P&P) titled, “Triage and Patient Flow in the ED,” dated 11/2024, the P&P indicated: B. Patients who present to the ED by Paramedics/BLS/ALS Ambulance: ... b) Assign the patient to a treatment bed and notify the primary nurse and physician of the patient’s arrival, chief complaint, condition, and immediate needs. ESI 3- Vital Signs Including Pain Score, every 2 hours or more often if the condition warrants. During a review of the facility’s policy and procedure (P&P) titled, Triage and Patient Flow in the Emergency Department (ED), dated 11/2024, the P&P indicated the following: -Patients arriving by way of emergency medical services (EMS - paramedics or transport ambulance services) shall be triaged in the main ED by the Triage registered nurse (RN) and assigned an Emergency Severity Index (ESI - a 5-level triage algorithm used in the ED to sort patients based on the acuity of their condition and the resources they will need) level using the ESI algorithm version 4. -The Triage RN will enter the chief complaint, assigned ESI level, place the patient in the treatment area. -Patients with ESI level 2 will have vital signs with pain score evaluated every two (2) hours or more often and assessments every 2 hours or more often. During a review of the facility’s policy and procedure (P&P) titled, Standing Order - ED Nurse Initiated Condition-Based Orders, dated 12/2024, the P&P indicated the following: -Patients with an ESI 2 (emergent, high-risk situation) will require physician notification of ESI priority, saline lock by way of a vein (IV - a type of access that keeps a vein open for fluids including medications and blood products), cardiac monitor (medical device that tracks the heart’s electrical activity, including heart rate), 12-lead electrocardiogram (EKG - a medical test that measures the electrical activity of the heart), and laboratory tests (samples of body fluids, including blood, to provide information about the health of a person). -Patients with chest pain will require a patient to be placed in a bed with cardiac monitoring as soon as possible, will need an EKG with results provided to any ED physician, for review, laboratory tests, and chest x-ray, and medication for chest pain. -Patients with an ESI 3 (urgent situation) will require a saline lock, cardiac monitor and/or EKG, laboratory tests. During a review of the facility’s policy and procedure (P&P) titled, “Standing Order: ED Nurse Initiated Condition-Based Orders,” dated 11/2024, the P&P indicated: D. Chest Pain .... (Rule Out Myocardial-Infarction) .... 1) If the nurse suspects that the pain is cardiac in origin .... (has history of cardiac disease, or recreational drug use) place the patient in a monitored bed as soon as possible. During a review of the facility’s guidelines titled, “Emergency Severity Index Handbook Fifth Edition,” dated 2023, the guidelines indicated: Unrecognized or unmanaged abnormalities of these vital signs (i.e. .... blood pressure, heart rate, respiratory rate, and oxygen saturation) is significantly associated with higher mortality rates, highlighting the importance of monitoring a wide range of vital signs to identify deterioration in the patient’s health status.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to complete a Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment for two of 29 randomly selected patients (Patient 9 and Patient10) and evaluate those two patients for an Emergency Medical Condition (EMC - a condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health in serious jeopardy, with serious impairment, and or with serious dysfunction of any bodily organ or part), when these patients (Patient 9 and Patient 10) presented in the emergency department with chest pain, and were not seen by a physician within 15 minutes after being assigned an ESI (Emergency Severity Index, tool for use in the ED for rapid, reproducible and clinical classification of patients from acuity level 1/most urgent, to acuity level 5/least urgent) of 2. Patient 9 left the ED without being seen/evaluated by a physician almost 3 hours after arriving in the ED, while Patient 10 left the ED without being seen/evaluated by a physician after waiting almost 7 hours from ED arrival. This deficient practice resulted in Patient 9 and Patient 10 not receiving complete MSE and evaluation for an EMC, which had the potential for the patients to not be provided treatment in a timely manner and may result in complications such as cardiac arrest (when the heart stops beating). Findings: During a record review on 11/14/2024 at 11:40 a.m. with the Assistant Director of Regulatory, Licensing and Accreditation Services (ARLCS), Patient 9’s Emergency Department (ED, provides immediate care for patients with severe illnesses and injuries) Nursing Notes - Patient Care Timeline, dated 11/12/2024, was reviewed. ARLCS stated the following: 1. Patient 9 arrived at the ED on 11/12/2024, at 6:28 p.m., with a Chief Complaint, “Someone spiked my drink. I feel jittery in my stomach and feel drunk.” 2. Patient 9 was triaged (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) on 11/12/2024, at 6:31 p.m., with an Emergency Severity Index (ESI - tool for use in the ED for rapid, reproducible and clinical classification of patients from acuity level 1/most urgent, to acuity level 5/least urgent) of level 2 acuity (severity of illness). 3. Vital Signs (VS - measurements of the body’s most basic functions which includes heart rate, respiratory rate, temperature, blood pressure) were Temperature (T) 97.8 degrees Fahrenheit (F, a unit of measurement- normally 97 to 99 degrees F); Pulse rate (HR) 98 beats-per-minute (BPM - normally 60 to 100); Respiration rate (RR) 18 breaths-per-minute (normally 12 to 20); Blood Pressure (BP) 131/89 (normally 120/80); Oxygen Saturation of 99% on room air (measurement of the amount of oxygen in the blood). Pain assessment was not documented and should have been assessed and documented. Concurrently, during a review of Patient 9’s ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 6:31 p.m., ARLCS stated the following: 1. Patient 9’s general appearance/distress level was moderate. 2. Patient 9’s mental status/ level of consciousness/awareness was oriented to person and place. 3. Patient 9’s mobility indicated patient had Dizziness/Generalized Weakness. During a review of Patient 9’s ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 8:13 p.m., ARLCS stated Laboratory ordered for complete blood count (CBC - a blood test that measures the number and types of cells in the blood), glucose (blood sugar), and electrolytes (a blood test that measures the levels of minerals in the blood that help the body function normally). During a review of Patient 9’s ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 8:52 p.m., ARLCS stated Patient 9 was called multiple times in the ED, lobby, and front entrance, with no answer. ED disposition indicated patient Left Without Being Seen (LWBS) by the physician. During a review of the facility’s emergency department (ED) Standing Orders for ED Nurses - Condition-based Orders, dated 1/2024, the document indicated the following: 1. ED registered nurses (RN’s) may initiate condition-based orders based on patient’s chief complaints and presenting symptoms, prior to an evaluation of the ED physician. 2. Acuity with ESI level 1 (resuscitative - requiring immediate life-saving interventions) patients require the physician to come to the patient’s bedside immediately. 3. Acuity with ESI level 2 (emergent - high risk situation) -patients shall be seen within 15 minutes. 4. Acuity with ESI level 3 patients have urgent needs. 5. Acuity with ESI level 4 are patients with non-urgent complaints. 6. Acuity with ESI level 5 are patients with minor complaints. During a review of the facility’s reference for emergency severity index (ESI), Emergency Nurses Association, dated 2023, the document indicated the ESI algorithm is intended for use by nurses with emergency nursing and triage experience, which included the following: 1. ESI is a triage acuity algorithm that is valid for evaluating patient acuity and resource needs, as determined by a trained triage nurse, upon the patient’s presentation to the ED. 2. The ESI tool was developed to categorize patients by acuity and direct stable patients to resources, upon presentation, and to differentiate between patients who are at risk for decompensation and those who are more stable. 3. For ESI level 1, patients are defined as in need of immediate lifesaving intervention(s), including a full set of vital signs (VS - measurements of the body’s basic functions, including temperature, heart rate, breathing rate, and blood pressure) and a focused assessment, prior to reaching a determination. 4. For ESI level 2, patients are determined whether they are likely to deteriorate and/or require more immediate care, based on symptoms and risk factors. These patients require a full set of VS and a focused assessment, prior to reaching a determination. 5. ESI levels 3, 4, and 5 patients are determined to be physiologically stable with low risk for deterioration. 2. During a concurrent interview and record review on 11/14/2024 at 11:54 a.m. with ARLCS, Patient 10’s Emergency Department (ED) Nursing Notes - Patient Care Timeline, dated 10/1/2024, was reviewed. ARLCS stated the following: 1. Patient 10 arrived at the ED on 10/1/2024 at 1:08 p.m. 2. At 1:09 p.m., patient’s (Patient 10) Chief Complaint was intermittent chest pain on the left-side for three days, after patient ran out of maintenance medication. 3. patient (Patient 10) was triaged at 1:11 p.m. with an ESI level 2 acuity. 4. At 1:13 pm, patient’s (Patient 10) Vital Signs (VS - measurements of the body’s most basic functions) were: Temperature 98.1 degrees Fahrenheit (normally 97 to 99); HR 70 BPM (beats per minute; normally 60 to 100); RR 18 BPM (normally 12 to 20); BP 131/91 (normally 120/80); Oxygen saturation 98% on RA. Pain Score was 3 out of 10. Pain Location was at left Chest. 5. At 2:42 p.m., VS: T 98.1 degrees F; HR 65; RR 17 BPM; BP 138/95. Oxygen saturation 98% on RA. Concurrently, during review of Patient10’s ED Nursing Notes - Patient Care Timeline, dated 10/1/2024, with ARLCS, ARLCS stated the following: 1. At 1:21 p.m., a 12-lead electrocardiogram (EKG - a medical test that measures the heart’s electrical activity that compares the strength of signals between twelve different pairs of electrodes/leads, attached to the body) was done. 2. At 2:31 p.m., labs were ordered for CBC, electrolytes, Troponin I (a heart-specific protein that is part of the constitutive heart function), glucose, and B-type natriuretic peptide (BNP - hormone produced by the heart to diagnose and monitor the heart’s condition). 3. At 4:12 p.m., indicated patient was three-hours post ESI. 4. At 6:12 p.m., indicated patient was five hours post ESI. 5. At 8 p.m., indicated patient was dismissed and the ED diagnosis was LWBS (Left Without Being Seen) During a review of facility’s emergency department (ED) Standing Orders for ED Nurses - Condition-based Orders, dated 1/2024, the document indicated the following: - ED registered nurses (RN’s) may initiate condition-based orders based on patient’s chief complaints and presenting symptoms, prior to an evaluation of the ED physician. - Acuity with ESI level 1 (resuscitative - requiring immediate life-saving interventions) patients require the physician to come to the patient’s bedside immediately. - Acuity with ESI level 2 (emergent - high risk situation) patients shall be seen within 15 minutes. - Acuity with ESI level 3 patients have urgent needs. - Acuity with ESI level 4 are patients with non-urgent complaints. - Acuity with ESI level 5 are patients with minor complaints. During A review of the facility’s reference for emergency severity index (ESI), Emergency Nurses Association, dated 2023, indicated the ESI algorithm is intended for use by nurses with emergency nursing and triage experience, which included the following: 1. ESI is a triage acuity algorithm that is valid for evaluating patient acuity and resource needs, as determined by a trained triage nurse, upon the patient’s presentation to the ED. 2. The ESI tool was developed to categorize patients by acuity and direct stable patients to resources, upon presentation, and to differentiate between patients who are at risk for decompensation and those who are more stable. 3. For ESI level 1, patients are defined as in need of immediate lifesaving intervention(s), including a full set of vital signs (VS - measurements of the body’s basic functions, including temperature, heart rate, breathing rate, and blood pressure) and a focused assessment, prior to reaching a determination. 4. For ESI level 2, patients are determined whether they are likely to deteriorate and/or require more immediate care, based on symptoms and risk factors. These patients require a full set of VS and a focused assessment, prior to reaching a determination. 5. ESI levels 3, 4, and 5 patients are determined to be physiologically stable with low risk for deterioration.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 45774 Based on observation and interview, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) requirement posting signage for informing patients of their right to receive a medical screening examination (an initial exam performed by a qualified medical professional to determine if a patient has an emergency medical condition), stabilizing treatment (to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability), and an appropriate transfer, regardless of their ability to pay, when the EMTALA signage was not posted conspicuously (attracts notice or attention, a place or places likely to be noticed by all individuals) in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma). This deficient practice had the potential for patients arriving in the ED to not be aware of their rights for a medical screening exam and necessary stabilizing treatment, which may lead to negative patient outcomes. Findings: During an observation on 11/12/2024 at 1:00 p.m.; Emergency Medical Treatment and Labor Act (EMTALA) signage was not found in a conspicuous area at the ED entrance, admitting area, or patient waiting area. During a concurrent observation and interview on 11/12/2024 at 1:05 p.m. with he Director of Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma); stated there was no signage posted in the waiting room, the EMTALA signage was posted on the wall at the entrance of treatment area which was located at the end corner of the ED waiting room, the treatment area was behind the ED waiting area. Observed the EMTALA signage was not readily visible in the sitting area. During an interview on 11/12/2024 at 1:25 p.m. with the Director of Emergency Department (ED), the Director of the ED stated the EMTALA signage should be posted in an area that was accessible to the patients, so patients can see and read the notice and be informed of their rights. They will put the EMTALA signage today (11/12/2024) at the nurse check in area. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer,” dated 1/08/2023, the P&P indicated the following: Signage: “Conspicuous signs will be posted at hospital entrances and in places likely to be noticed by all individuals who entered the Emergency Department (ED) (e.g., parking garage, entrance, admitting area, waiting room, treatment area). Signage will specify the rights of individuals to examination and treatment for emergency medical conditions regardless of the ability to pay, and the rights of women in labor for health care services, and whether the hospital participates in the Medicaid (a government program that provides health insurance for adults and children with limited income and resources) program ...””

“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: 31993 Based on interview and record review, the facility failed to complete a Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment for two of 29 randomly selected patients (Patient 9 and Patient10) and evaluate those two patients for an Emergency Medical Condition (EMC - a condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health in serious jeopardy, with serious impairment, and or with serious dysfunction of any bodily organ or part), when these patients (Patient 9 and Patient 10) presented in the emergency department with chest pain, and were not seen by a physician within 15 minutes after being assigned an ESI (Emergency Severity Index, tool for use in the ED for rapid, reproducible and clinical classification of patients from acuity level 1/most urgent, to acuity level 5/least urgent) of 2. Patient 9 left the ED without being seen/evaluated by a physician almost 3 hours after arriving in the ED, while Patient 10 left the ED without being seen/evaluated by a physician after waiting almost 7 hours from ED arrival. This deficient practice resulted in Patient 9 and Patient 10 not receiving complete MSE and evaluation for an EMC, which had the potential for the patients to not be provided treatment in a timely manner and may result in complications such as cardiac arrest (when the heart stops beating). Findings: During a record review on 11/14/2024 at 11:40 a.m. with the Assistant Director of Regulatory, Licensing and Accreditation Services (ARLCS), Patient 9’s Emergency Department (ED, provides immediate care for patients with severe illnesses and injuries) Nursing Notes - Patient Care Timeline, dated 11/12/2024, was reviewed. ARLCS stated the following: 1. Patient 9 arrived at the ED on 11/12/2024, at 6:28 p.m., with a Chief Complaint, “Someone spiked my drink. I feel jittery in my stomach and feel drunk.” 2. Patient 9 was triaged (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) on 11/12/2024, at 6:31 p.m., with an Emergency Severity Index (ESI - tool for use in the ED for rapid, reproducible and clinical classification of patients from acuity level 1/most urgent, to acuity level 5/least urgent) of level 2 acuity (severity of illness). 3. Vital Signs (VS - measurements of the body’s most basic functions which includes heart rate, respiratory rate, temperature, blood pressure) were Temperature (T) 97.8 degrees Fahrenheit (F, a unit of measurement- normally 97 to 99 degrees F); Pulse rate (HR) 98 beats-per-minute (BPM - normally 60 to 100); Respiration rate (RR) 18 breaths-per-minute (normally 12 to 20); Blood Pressure (BP) 131/89 (normally 120/80); Oxygen Saturation of 99% on room air (measurement of the amount of oxygen in the blood). Pain assessment was not documented and should have been assessed and documented. Concurrently, during a review of Patient 9’s ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 6:31 p.m., ARLCS stated the following: 1. Patient 9’s general appearance/distress level was moderate. 2. Patient 9’s mental status/ level of consciousness/awareness was oriented to person and place. 3. Patient 9’s mobility indicated patient had Dizziness/Generalized Weakness. During a review of Patient 9’s ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 8:13 p.m., ARLCS stated Laboratory ordered for complete blood count (CBC - a blood test that measures the number and types of cells in the blood), glucose (blood sugar), and electrolytes (a blood test that measures the levels of minerals in the blood that help the body function normally). During a review of Patient 9’s ED Nursing Notes - Patient Care Timeline, dated 11/12/2024, at 8:52 p.m., ARLCS stated Patient 9 was called multiple times in the ED, lobby, and front entrance, with no answer. ED disposition indicated patient Left Without Being Seen (LWBS) by the physician. During a review of the facility’s emergency department (ED) Standing Orders for ED Nurses - Condition-based Orders, dated 1/2024, the document indicated the following: 1. ED registered nurses (RN’s) may initiate condition-based orders based on patient’s chief complaints and presenting symptoms, prior to an evaluation of the ED physician. 2. Acuity with ESI level 1 (resuscitative - requiring immediate life-saving interventions) patients require the physician to come to the patient’s bedside immediately. 3. Acuity with ESI level 2 (emergent - high risk situation) -patients shall be seen within 15 minutes. 4. Acuity with ESI level 3 patients have urgent needs. 5. Acuity with ESI level 4 are patients with non-urgent complaints. 6. Acuity with ESI level 5 are patients with minor complaints. During a review of the facility’s reference for emergency severity index (ESI), Emergency Nurses Association, dated 2023, the document indicated the ESI algorithm is intended for use by nurses with emergency nursing and triage experience, which included the following: 1. ESI is a triage acuity algorithm that is valid for evaluating patient acuity and resource needs, as determined by a trained triage nurse, upon the patient’s presentation to the ED. 2. The ESI tool was developed to categorize patients by acuity and direct stable patients to resources, upon presentation, and to differentiate between patients who are at risk for decompensation and those who are more stable. 3. For ESI level 1, patients are defined as in need of immediate lifesaving intervention(s), including a full set of vital signs (VS - measurements of the body’s basic functions, including temperature, heart rate, breathing rate, and blood pressure) and a focused assessment, prior to reaching a determination. 4. For ESI level 2, patients are determined whether they are likely to deteriorate and/or require more immediate care, based on symptoms and risk factors. These patients require a full set of VS and a focused assessment, prior to reaching a determination. 5. ESI levels 3, 4, and 5 patients are determined to be physiologically stable with low risk for deterioration. 2. During a concurrent interview and record review on 11/14/2024 at 11:54 a.m. with ARLCS, Patient 10’s Emergency Department (ED) Nursing Notes - Patient Care Timeline, dated 10/1/2024, was reviewed. ARLCS stated the following: 1. Patient 10 arrived at the ED on 10/1/2024 at 1:08 p.m. 2. At 1:09 p.m., patient’s (Patient 10) Chief Complaint was intermittent chest pain on the left-side for three days, after patient ran out of maintenance medication. 3. patient (Patient 10) was triaged at 1:11 p.m. with an ESI level 2 acuity. 4. At 1:13 pm, patient’s (Patient 10) Vital Signs (VS - measurements of the body’s most basic functions) were: Temperature 98.1 degrees Fahrenheit (normally 97 to 99); HR 70 BPM (beats per minute; normally 60 to 100); RR 18 BPM (normally 12 to 20); BP 131/91 (normally 120/80); Oxygen saturation 98% on RA. Pain Score was 3 out of 10. Pain Location was at left Chest. 5. At 2:42 p.m., VS: T 98.1 degrees F; HR 65; RR 17 BPM; BP 138/95. Oxygen saturation 98% on RA. Concurrently, during review of Patient10’s ED Nursing Notes - Patient Care Timeline, dated 10/1/2024, with ARLCS, ARLCS stated the following: 1. At 1:21 p.m., a 12-lead electrocardiogram (EKG - a medical test that measures the heart’s electrical activity that compares the strength of signals between twelve different pairs of electrodes/leads, attached to the body) was done. 2. At 2:31 p.m., labs were ordered for CBC, electrolytes, Troponin I (a heart-specific protein that is part of the constitutive heart function), glucose, and B-type natriuretic peptide (BNP - hormone produced by the heart to diagnose and monitor the heart’s condition). 3. At 4:12 p.m., indicated patient was three-hours post ESI. 4. At 6:12 p.m., indicated patient was five hours post ESI. 5. At 8 p.m., indicated patient was dismissed and the ED diagnosis was LWBS (Left Without Being Seen) During a review of facility’s emergency department (ED) Standing Orders for ED Nurses - Condition-based Orders, dated 1/2024, the document indicated the following: - ED registered nurses (RN’s) may initiate condition-based orders based on patient’s chief complaints and presenting symptoms, prior to an evaluation of the ED physician. - Acuity with ESI level 1 (resuscitative - requiring immediate life-saving interventions) patients require the physician to come to the patient’s bedside immediately. - Acuity with ESI level 2 (emergent - high risk situation) patients shall be seen within 15 minutes. - Acuity with ESI level 3 patients have urgent needs. - Acuity with ESI level 4 are patients with non-urgent complaints. - Acuity with ESI level 5 are patients with minor complaints. During A review of the facility’s reference for emergency severity index (ESI), Emergency Nurses Association, dated 2023, indicated the ESI algorithm is intended for use by nurses with emergency nursing and triage experience, which included the following: 1. ESI is a triage acuity algorithm that is valid for evaluating patient acuity and resource needs, as determined by a trained triage nurse, upon the patient’s presentation to the ED. 2. The ESI tool was developed to categorize patients by acuity and direct stable patients to resources, upon presentation, and to differentiate between patients who are at risk for decompensation and those who are more stable. 3. For ESI level 1, patients are defined as in need of immediate lifesaving intervention(s), including a full set of vital signs (VS - measurements of the body’s basic functions, including temperature, heart rate, breathing rate, and blood pressure) and a focused assessment, prior to reaching a determination. 4. For ESI level 2, patients are determined whether they are likely to deteriorate and/or require more immediate care, based on symptoms and risk factors. These patients require a full set of VS and a focused assessment, prior to reaching a determination. 5. ESI levels 3, 4, and 5 patients are determined to be physiologically stable with low risk for deterioration.”

“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: 38310 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Governing Body was met as evidenced by: 1. The Governing Body failed to ensure that its contracted messenger service department transported important patient documents (such as signed documents regarding receipt of Patient Rights [ethical principles that apply to patient care] and discussion of treatment plan [a documented guide or outline of a patient’s therapeutic treatment] with Patient 9) to the scanning department (responsible for making digital copies of a patient’s paper version of documents), for one of 30 sampled patients (Patient 9), so that the documents will be scanned and properly filed in Patient 9’s medical record in accordance with the facility’s policies regarding contract oversight and record keeping. This deficient practice resulted in the loss of Patient 9’s paper documents and having an incomplete medical record, which may impact Patient 9’s treatment plan. In addition, this deficient practice had the potential for a Health Insurance Portability and Accountability Act (HIPAA - federal law that sets a national standard to protect medical records and other personal health information) violation from Patient 9’s lost facility paper documents. (Refer to A-0083) 2. The Governing Body failed to ensure the contracted security service department ensure that four of four contracted security guards (SG 1, 2, 3, and 4), who worked in the Mental Health Center (MHC, provides care and treatment for mentally ill patients), had documented evidence of training on how to handle aggressive patients in the MHC. In addition, three of four security guards (SG 2, 3, and 4) failed to have an annual performance evaluation (means to identify and discuss areas where performance could be improved). This deficient practice had the potential for security guards (SG 1, 2, 3, and 4) to be untrained on how to handle aggressive patients in the MHC and not evaluated to ensure security guards were meeting performance expectations. This deficient practice also had the potential for patient harm due to lack of security personnel training in managing patients with mental health issues. (Refer to A-0083) 3. The Governing Body failed to ensure its contracted security services abode with the standards of practice on patient safety to assure a one to one (1:1 - consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) security observation was provided for one of four sampled patients (Patient 6), when Patients 6 was allowed to stay inside his (Patient 6) patient room with the door closed, while the security guard was outside the patient’s room with no direct line of sight (a level of observation wherein the patient remains in staff view at all times) on Patients 6. This deficient practice had the potential for Patients 6, who was put on 1:1 security observation for violent behavior, to inflict self-harm or harm others. (Refer to A-0084) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of eloping, harm themselves or harm others.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39503 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to provide two of 30 sampled patients (Patient 16 and Patient 11) the information regarding patient rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.). This deficient practice resulted in Patient 16 and Patient 11 to not be informed of their rights as a patient, which may also result in Patients 16’s and Patient 11’s inability to effectively make decisions regarding their care or treatment. (Refer to A-0117) 2. The facility failed to provide a correct contact address and phone number of the Department in the facility’s admission booklet (Patient Handbook- a patient welcome guide designed to assist patients with simple questions on key care topics and explains patient rights and responsibilities) for two of 30 sampled patients (Patient 16 and Patient 11), in order for patients (Patient 16 and Patient 11) to know who to contact when filing a grievance (written or oral expression of dissatisfaction regarding the quality of care provided to a patient) with the Department. This deficient practice had the potential to inhibit patients from contacting the Department to file grievance or complaints, which may result in a delay of investigation of a potential patient safety issue that can cause patient harm or death. (Refer to A-0118) 3. The facility failed to ensure that keys to open one of one sampled fire exit door were kept secured by staff and that three staff members were available in the patient care area at all times to assure a safe environment, was provided for one of 30 sampled patients (Patient 1) to prevent Patient 1 from eloping (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) from the facility. This deficient practice had the potential for serious harm to Patient 1, who left the facility, via the fire exit door, into the street, where there are pedestrians and vehicles, and the potential for danger to others, who encounter Patient 1 in the street. (Refer to A-0144) 4. The facility failed to ensure a one to one (1:1 - consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) security observation was provided for one of four sampled patients (Patient 6), when Patients 6 was allowed to stay inside his (Patient 6) patient room with the door closed, while the security guard was outside the patient’s room with no direct line of sight (a level of observation wherein the patient remains in staff view at all times) on Patients 6. This deficient practice had the potential for Patient 6, who was put on 1:1 security observation for violent behavior, to inflict self-harm or harm others. (Refer to A-0144) 5. The facility failed to ensure one of four sampled patients (Patient 22) had a physician order for restraints (devices that limit a patient’s movement) on 12/12/2023. This deficient practice resulted in the violation of Patient 22’s patient rights regarding restraints use as Patient 22 was restrained with bilateral (both) wrist restraints, bilateral mittens and a vest restraint on 12/12/2023 without a physician’s order. This deficient practice also had the potential to result in patient harm such as skin tear, strangulation, etc. when there’s no physician order to use restraints and patient is not properly monitored. (Refer to A-0168) 6. The facility failed to ensure one of two sampled patients (Patients 6) was assessed and monitored after chemical restraints (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) were administered. Patient 6 was given the medications: Benadryl (a medication that has a calming effect and puts a patient to sleep), Haldol (used to treat mental/mood disorders), and Ativan (used to treat anxiety). This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) and had the potential to violate the patients’ rights regarding restraints use. (Refer to A-0175) 7. The facility failed to ensure two of two sampled patients (Patients 6 and Patient 9) had a face-to-face assessment (an evaluation required to be done and documented for each episode requiring the use of violent/self-destructive (behavioral) restraint) within one hour, after the initiation of a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) to manage violent or self-destructive behavior was conducted. This deficient practice resulted in Patients 6 and Patient 9 to not have an in-person evaluation and assessment for any changes or deterioration of the patients’ physical and psychological condition after restraints (emergency medication/chemical restraint [a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient]) were applied. This deficient practice also had the potential to result in patient harm due to the failure to assess a potential change of condition that may require immediate medical intervention. (Refer to A-0179) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality care in a safe environment and potentially putting 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: 39503 Based on interview and record review, the facility failed to: 1. Ensure one of four sampled staff (Charge Nurse 1) assigned at the Mental Health Care Unit 1 (a unit that provides care to patients admitted with mental, emotional and behavioral disorders), was readily available to respond in an emergency situation when, there was only one Licensed Vocational Nurse (LVN) 1, and one Certified Nursing Assistant (CNA 1) left in Unit 1’s patient care area during one of 30 sampled patients (Patient 1’s) attempt to elope (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) from the unit (Unit 1) on 12/15/2023. This deficient practice resulted in Patient 1’s elopement from the facility on 12/15/2023. In addition, this deficient practice had the potential for serious harm to Patient 1, who left the facility, via the fire exit door, into the street, where there were pedestrians and vehicles, and the potential for danger to others, who would encounter Patient 1 in the street. (Refer to A-0392) 2. Ensure one of five sampled patient’s (Patient 7) high blood pressure (BP) reading of 189/94 millimeters of mercury (mmHg, a unit of measurement; a reading of 140/90 or higher is considered a high BP) was evaluated and treated. In addition, the physician was not notified of Patient 7’s high BP. This deficient practice had the potential to delay treatment and necessary adjustments in Patient 7’s treatment plan in order to lower Patient 7’s high blood pressure, which had the potential to result in complications such as stroke (when a blood vessel that carries blood to the brain gets blocked by a clot or if it ruptures leading to paralysis [inability to move some or parts of the body]) if left untreated. (Refer to A-0395) 3. Ensure one of five sampled patients’ (Patient 7) comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and implemented upon admission in order to address Patient 7’s Hypertension (high blood pressure [BP] - a reading of 140/90 or higher is considered a high BP). This deficient practice had the potential to result in the delay of treatment by not identifying the patient’s (Patient 7) needs and risks and had the potential for Patient 7’s hypertension to worsen which may result in complications such as stroke (when a blood vessel that carries blood to the brain gets blocked by a clot or if it ruptures leading to paralysis [inability to move some or parts of the body]) if left untreated. (Refer to A-0396) 4. Ensure one of four sampled staff (Registered Nurse [RN] 1), who worked in the facility’s Mental Health Center (MHC, provides care and treatment for mentally ill patients), completed the required annual skills validation training (process of assessing, verifying, and documenting an individual’s competencies in a specific area), in accordance with the facility’s policies and procedures regarding staff training. This deficient practice had the potential for RN 1 to be unprepared to handle emergency situations such as a code gray (a call for security personnel indicating there is a dangerous person in a public area of the hospital, there is a missing person, or there is criminal activity somewhere in the hospital), face to face evaluation (patient assessment and immediate situation, body system assessment, pre-existing condition identification, use of behavioral criteria, and smart phase), and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) placement. This deficient practice also had the potential to result in patient harm due to lack of staff training in the management of patients with mental and behavioral issues. (Refer to A-0397) 5. The facility failed to check tube feeding residuals (the volume of fluid remaining in the stomach at a point in time during tube feeding) for one of 30 sampled patients (Patient 13), who was receiving nutrition via nasal gastric tube (NGT, a tube inserted through the nose and into the stomach), in accordance with the physician’s orders and the facility’s policies and procedures regarding tube feeding. This deficient practice had the potential for aspiration (fluid or liquid is breathed into airways or lungs) for Patient 1. (Refer to A-0398) 6. The facility failed to ensure one of 30 sampled patients (Patient 20) was accurately assessed for suicide risk (thoughts of killing oneself) upon arriving at the Emergency Department (ED- responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), in accordance with the facility’s policies and procedures regarding suicide risk screening (a quick way to detect someone that needs further evaluation) and assessment. This deficient practice had the potential for incorrect suicide screening (a quick way to identify someone that needs further evaluation) and inappropriate precautions for Patient 20, which may result in patient harm or death. (Refer to A-0398) 7. The facility failed to Ensure one of five sampled patient’s (Patient 6) suicide risk (thoughts of killing oneself) reassessment was completed in accordance with the facility’s policy and procedure (P&P) regarding Suicide risk assessment and precautions. This deficient practice had the potential to result in Patient 6’s inaccurate suicide risk assessment and inappropriate precautions that may lead to patient harm or death. (Refer to A-0398) 8. The facility failed to ensure one of five sampled patient’s (Patient 7) multidisciplinary (interactions between a patient and all other healthcare professionals involved in the patient care such as physicians, nurses, etc.) treatment plan (a documented guide or outline of a patient’s therapeutic treatment) was completed every 7 days from the time of admission in accordance with the facility’s policy and procedure regarding completing/updating a multidisciplinary treatment plan. This deficient practice had the potential for Patient 7 to not have an individualized treatment plan that will help achieve treatment goals, which may result in delay of Patient 7’s recovery from illness. (Refer to A-0398) 9. The facility failed to ensure one of 30 sampled patient’s (Patient 7) blood pressure medication (hydralazine, medication used to treat high blood pressure [high BP - a reading of 140/90 millimeters of mercury (mmHg, a unit of measurement) or higher]) was administered to Patient 7 as ordered by the physician. This deficient practice had the potential to negatively affect the patient’s health and safety due to not receiving medication to lower his (Patient 7) blood pressure, which may lead to prolonged hospitalization and/or death. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality care in a safe environment and potentially putting patients at risk for harm.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 39503 Based on interview and record review, the Governing Body failed to: 1. Ensure that its contracted messenger service department transported important patient documents (such as signed documents regarding receipt of Patient Rights [ethical principles that apply to patient care] and discussion of treatment plan [a documented guide or outline of a patient’s therapeutic treatment] with Patient 9) to the scanning department (responsible for making digital copies of a patient’s paper version of documents), for one of 30 sampled patients (Patient 9), so that the documents will be scanned and properly filed in Patient 9’s medical record in accordance with the facility’s policies regarding contract oversight and record keeping. This deficient practice resulted in the loss of Patient 9’s paper documents and having an incomplete medical record, which may impact Patient 9’s treatment plan. In addition, this deficient practice had the potential for a Health Insurance Portability and Accountability Act (HIPAA - federal law that sets a national standard to protect medical records and other personal health information) violation from Patient 9’s lost facility paper documents. 2. Ensure the contracted security service department assure that four of four contracted security guards (SG 1, 2, 3, and 4), who worked in the Mental Health Center (MHC, provides care and treatment for mentally ill patients), had documented evidence of training on how to handle aggressive patients in the MHC. In addition, three of four security guards (SG 2, 3, and 4) failed to have an annual performance evaluation (means to identify and discuss areas where performance could be improved). This deficient practice had the potential for security guards (SG 1, 2, 3, and 4) to be untrained on how to handle aggressive patients in the MHC and not evaluated to ensure security guards were meeting performance expectations. This deficient practice also had the potential for patient harm due to lack of security personnel training in managing patients with mental health issues. Findings: 1. During a record review on 12/29/2023 at 11:30 a.m., Patient 9’s medical record was reviewed. The “Hospital Admission Note,” dated 11/18/2023, indicated Patient 9 was transferred from another hospital (Hospital 1) and was admitted to the facility (Hospital 2) on 11/17/2023 for agitation (a feeling of irritability or severe restlessness). During an interview on 12/29/2023 at 11:45 a.m. with the Department Administrator of Mental Health Center (DAMHC), the DAMHC stated Patient 9 was admitted to the facility on 11/17/2023 and was discharged on 11/22/2023. The DAMHC stated in the Mental Health Center, the patients’ record was electronic except for the Hospital Conditions of Admission (constitutes a contract between the hospital and the patient that outlines the patient’s obligations with respect to the hospital services received), Patient’s Rights (ethical principles that apply to patient care), consents, and signature sheet for the multidisciplinary treatment plan (a documented guide or outline of a patient’s therapeutic treatment) meeting. The DAMHC said the facility paper documents would be scanned into the patient’s electronic medical record (EMR- electronic version of a patient’s medical history) after the patient was discharged from the facility. In the same interview, the DAMHC stated there were no scanned facility paper documents on Patient 9’s EMR during the patient’s admission to facility from 11/17/2023 to 11/22/2023. The DAMHC stated it had been a month since the patient was discharged and she (DAMHC) was not sure if there was a delay in scanning the documents. The DAMHC also said the contracted messenger service picks up all the facility paper documents needed to be scanned into the patient’s EMR. The facility paper documents were being picked up once a week and transported to the facility’s scanning department (responsible for making digital copies of a patient’s paper version of documents). During an interview on 12/29/2023 at 4 :17 p.m. with the Supervisor for Health Informatic Services (SHIM), the SHIM stated once the facility paper documents were picked up from the facility and received by the facility scanning department, it should only take 72 hours to be scanned and be readily available in the patient’s EMR. In the same interview, the SHIM stated at this time, Patient 9’s facility paper documents for the patient’s admission on 11/17/2023 were not found. The SHIM said he (SHIM) was not sure if Patient 9’s documents were transported and received in the facility’s scanning department because there was no log of what Patient 9’s record was picked up and there was no log of what the scanning department had received. The SHIM stated they were not able to locate where Patient 9’s facility paper documents were. The SHIM further stated it was the facility’s responsibility to ensure the patient’s (Patient 9) EMR were complete during the patient’s (Patient 9) admission to the facility. During an interview on 12/29/2023 at 3:45 p.m. with the Senior Vice President (SVP), the SVP stated the Governing Body (GB) has the ultimate responsibility in ensuring the contractual services were performing and providing a safe, effective and quality care to the patients. During a review of the facility’s policy and procedure (P&P) titled, “Hospital Clinical Contracts Quality Oversight,” dated 11/1/2019, the P&P indicated, “...Patient care services, and all other services, provided under contract are subject to the same hospital-wide Quality Assessment and Performance Improvement (QAPI- a process used to ensure services are meeting quality standards and assuring patient care reaches a certain level) oversight as other services provided directly by the hospital...Through established oversight structures and reporting, contracted services are ultimately accountable to the Executive Committee...” During a review of the facility’s policy and procedure (P&P) titled, “Medical Record Document Scanning Process and Scanned Document Turnaround Time Policy,” dated 9/25/2015, the P&P indicated the following: - A complete and legible medical record shall be maintained for each individual who is evaluated by or receives clinical treatment from a (name of the facility). - To ensure that medical records staff is collecting all the documents for scanning and indexing each day, the departments and units will collaborate with the Central Scanning Center to define procedures that ensures all documents are collected or sent for scanning and indexing every day. 2. During a concurrent interview and record review on 12/28/2023 at 2:17 p.m. with the Area Director for Security Services (ADSS), the ADSS stated the following: Security Guards (SG) 1, 2, 3, and 4 worked in the Mental Health Center (MHC, provides care and treatment for mentally ill patients). Starting in 4/20/2021, all security guards or officers who worked in the MHC received a training. The training was titled, “Interactions with Aggressive Patients - Guidelines for Mental Health Patients.” The training was started due to the increase in workplace violence. The training included how to handle mental health patients, observation, and communication techniques. The training was meant to decrease workplace injuries. The ADSS reviewed SG, 1, 2, 3, and 4’s employee files and stated the facility had no evidence that SG 1, 2, 3, and 4 received the training. In addition, ADSS verified that SG 2, 3, and 4’s annual performance evaluations were overdue. The ADSS stated the performance evaluations were a means to identify and discuss areas where performance could be improved. During a review of SG 1, 2, 3, and 4’s employee files, on 12/28/2023, the files indicated the following: SG 1 was hired on 3/30/2023. There was no documented evidence of completion of the training titled, “Interactions with Aggressive Patients - Guidelines for the Mental Health Patients.” SG 2 was hired on 7/5/2012. There was no documented evidence of completion of the training titled, “Interactions with Aggressive Patients - Guidelines for the Mental Health Patients.” SG 2’s last performance evaluation was dated 8/10/2022. SG 3’s date of hire was undocumented. The ADSS did not know the date of hire. There was no documented evidence of completion of the training titled, “Interactions with Aggressive Patients - Guidelines for the Mental Health Patients.” SG 3’s last performance evaluation was dated 6/21/2021. SG 4 was hired on 11/20/2018. There was no documented evidence of completion of the training titled, “Interactions with Aggressive Patients - Guidelines for the Mental Health Patients.” SG 4’s last performance evaluation was dated 8/3/2022. During a review of the facility’s service agreement titled, “Master Services Agreement for Managed Service Provider and Security Services,” dated 3/30/2018, the service agreement indicated the following: Exhibit D: (Name of Facility) Additional Requirements and Guidelines ...3. Training. If Supplier provides services at a Customer facility on a regular basis, Supplier agrees that its personnel performing services at Customer facilities shall undergo the same training that the Customer imposes on its own employees and supervisors in similar positions to ensure full compliance with all applicable laws, regulations and (name of facility) policies. Failure of a Supplier to timely complete any mandatory training course shall result in Customer removing the employee from his/her assignment. Schedule 1: Security Officer Services 1.1. General Services. Subject to oversite by Supplier, unless self-performed by Supplier ... Supplier and Sub-contractor will provide, manage, train, supervise, and maintain Security Officers at the Customer facilities or designated locations covered under this Agreement ...(t) Rules and Regulations. Whenever this Agreement requires compliance with the rules, regulations and/or policies of a Customer or a particular facility, the obligation of the Supplier to comply with such rules, regulations, and/or policies is subject to Supplier or Sub-contractor first having been provided with such rules, regulations and /or polices in writing or with links thereto.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 39503 Based on interview and record review, the Governing Body failed to ensure its contracted security services abode with the standards of practice regarding patient safety to assure a one to one (1:1 - consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) security observation was provided for one of four sampled patients (Patient 6), when Patients 6 was allowed to stay inside his (Patient 6) patient room with the door closed, while the security guard was outside the patient’s room with no direct line of sight (a level of observation wherein the patient remains in staff view at all times) on Patients 6. This deficient practice had the potential for Patients 6, who was put on 1:1 security observation for violent behavior, to inflict self-harm or harm others. Findings: During a review on 12/28/2023, Patient 6’s medical record was reviewed. The “Psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) Admission Note,” dated 12/15/2023, indicated Patient 6 came from another hospital and while at the other hospital, Patient 6 attempted to elope (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) three times, was periodically disorganized, angry and agitated (a feeling of irritability or severe restlessness). Patient 6 was then transferred and admitted to the facility on 12/15/2023 for a 72-hour hold (5150 hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others, or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his basic personal needs such as hygiene, food, etc.]). During a review of Patient 6’s “Psychiatrist Progress Note,” dated 12/16/2023 at 10:19 a.m., the Psychiatrist Progress Note indicated, “...Per RN (Registered Nurse), patient (Patient 6) got agitated, started throwing chairs on the unit because he (Patient 6) was demanding to be discharged. On evaluation, patient (Patient 6) presents with labile mood and affect (abrupt change in mood or emotional state), alternating between being angry and crying...quickly escalating, not responding to verbal de-escalation (techniques to use to help calm down a person who was upset or angry) ...” During a review of Patient 6’s “Multi-Discipline Progress Note (contains all the interactions between a patient and all other healthcare professionals involved in the patient care such as physicians, nurses, etc.),” dated 12/16/2023 at 9:37 p.m., authored by Registered Nurse (RN 3) 3, the note indicated, “...One to one security observation done to ensure patient safety and monitor patient for signs of aggressive behavior ...” During a review of Patient 6’s “Security Standby Form (outlines what the security personnel has to do when assigned to conduct a 1:1 observation),” the form indicated Patient 6 was on 1:1 security observation (1:1 - consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) from 12/15/2023 at 1:30 p.m. through 12/19/2023 at 7:30 a.m. During an interview on 12/28/2023 at 8:31 a.m. with Security Guard (SG) 1, SG 1 stated he (SG 1) was the assigned SG to do 1:1 security observation on Patient 6 (the roommate of Patient 1, who could be harmed by Patient 6 if there was no continuous line-of-sight monitoring [a level of observation wherein the patient remains in staff view]) of Patient 6) when Patient 1 eloped on 12/15/2023. SG 1 stated Patient 6 was on 1:1 security observation for danger to self (DTS) and danger to others (DTO). SG 1 stated during the 1:1 security observation, he (SG 1) ensured Patient 6 followed the facility rules, that Patient 6 was safe and everyone who was around Patient 6 was safe. SG 1 said when Patient 6 was out from the patient’s room and walking around the unit, SG 1 followed Patient 6 at arm’s length, at all times. In the same interview, SG 1 stated when Patient 6 goes inside the patient’s (Patient 6) room, he (SG 1) stayed outside the room and does not follow Patient 6 inside the room. SG 1 stated it is the discretion of Patient 6 if he (Patient 6) wanted to close the door while inside the patient’s room and SG 1 would stay outside Patient 6’s room with the door closed. SG 1 stated he (SG 1) does not go inside Patient 6’s room unless a staff goes into the room, then he (SG 1) will accompany the staff to ensure safety. SG 1 stated that was how he (SG 1) did his observation when he (SG 1) was assigned to do a 1:1 security observation on a patient in the Mental Health Center. Furthermore, SG 1 stated he (SG 1) recalled that when Patient 6 was inside his (Patient 6) room with his roommate (Patient 1), the room door (the room shared by Patient 6 and Patient 1) was closed, and he (SG 1) was outside the patients’ (Patient 6 and Patient 1) room. SG 1 stated he (SG 1) heard an unusual loud noise, but he (SG 1) was not sure if it came inside Patient 6 and 1’s room. SG 1 stated he (SG 1) was concerned of Patient 6’s and Patient 1’s safety from the unusual loud noise. SG 1 stated he (SG 1) quickly peeked inside the patients’ (Patient 6 and Patient 1) room door and saw Patient 6 was asleep in his (Patient 6) bed, he (SG 1) then closed the door. SG 1 stated he (SG 1) did not see Patient 1 (the roommate of Patient 6) because he (SG 1) just took a quick peek and did not check the entire perimeter of the room. In addition, SG 1 said he (SG 1) did not report to the nursing staff about what he (SG 1) heard and his concern for Patient 6 and Patient 1’s safety inside the patients’ room with the door closed, because he (SG 1) did not want to make any allegations. SG 1 stated he waited until a nursing staff went inside Patient 6’s room and he entered with the staff. SG 1 stated when he entered Patient 6’s room, he found Patient 6’s walker was broken. SG 1 said he (SG 1) was aware that 1:1 observation should have a continuous visual monitoring of the patient. SG 1 stated he did not have a direct line of sight (a level of observation wherein the patient remains in staff view) on Patient 6 when the patient was inside the room with the roommate (Patient 1) and the door of the room was closed, and he (SG 1) stayed outside the patient’s room. During an interview on 12/28/2023 at 11:16 a.m. with the Department Administrator of Mental Health Center (DAMHC), the Director of Quality, Risk and Patient Safety (DQRPS), and the Area Director for Security Services (ADSS), the DQRPS stated Patient 6’s walker in the patient’s room could be used as a weapon to hurt self or others. The DQRPS stated a 1:1 security observation was in place to ensure Patient 6’s safety and everyone that was around the patient. The ADSS also stated Patient 6’s aggressive behavior was a danger to others (DTO) and there should be continuous monitoring with line of sight on Patient 6 to ensure safety. However, the SG 1 failed to ensure line of sight monitoring because he (SG 1) remained outside the patient room. The ADSS said when Patient 6 was inside the patient’s room with his roommate (Patient 1) there should be a continuous visual monitoring and the patient’s room door should not be closed at all. In the same interview, the ADSS stated he (ADSS) was not aware the Security Guards (SG) were allowing the patients to close the patients’ room door and the SG would be outside the patients’ room with no direct visual observation of the patient. During an interview on 12/28/2023 at 2:26 p.m. with the Informatics Practice Specialist (IPS), the IPS stated upon checking the census in Unit 1, Patient 6 had a roommate on 12/16/2023 and 12/17/2023. During an interview on 12/29/2023 at 3:45 p.m. with the Senior Vice President (SVP), the SVP stated the facility’s Security Services was a contractual service. The SVP stated the Governing Body (GB) has the ultimate responsibility in ensuring the contractual services were performing and providing a safe, effective and quality care to the patients. In the same interview, the SVP stated after learning the issues and concerns from security services, he (SVP) concurred there would be room for improvement in providing a safe care to the patients. During a review of the facility’s policy and procedure (P&P) titled, “Hospital Clinical Contracts Quality Oversight,” dated 11/1/2019, the P&P indicated, “...Patient care services, and all other services, provided under contract are subject to the same hospital-wide Quality Assessment and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring patient care reaches a certain level) oversight as other services provided directly by the hospital...Through established oversight structures and reporting, contracted services are ultimately accountable to the Executive Committee...” During a review of the facility’s document titled, “Security Standby Form,” revised in June 2020, the document indicated the following: - Security Officers will maintain continuous, direct observation of the patient without distractions, at a range that allows for immediate intervention. - Protect the patient and the staff from any harm. - Only leave the patient when relieved by another security officer or a member of the clinical staff, and a hand-off (transfer of care between two members of the healthcare team in which the sharing of information regarding the patient’s care is conducted in the presence of the patient) is completed. - Report all suspicious activity between the patient and visitor(s) to the assigned nurse immediately.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to provide Patient 16 and Patient 11 the information regarding patient rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.). This deficient practice resulted in Patient 16 and Patient 11 to not be informed of their rights as a patient, which may also result in Patient 16’s and Patient 11’s inability to effectively make decisions regarding their care or treatment. Findings: 1. During a concurrent observation and interview on 12/27/2023 at 3:27 p.m., with Patient 16, Patient 16 was awake and alert, sitting on the bed. Patient 16 stated that he (Patient 16) was provided with information regarding Medicare Rights and Conditions of Admission (COA, a document that include provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits] for treatment and may also require the patient’s confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility) upon admission and signed in acknowledgment of receiving that information. Patient 16 stated he (Patient 16) was not provided with any information regarding patient rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.). During an interview on 12/29/2023 at 11:42 a.m. with the Admitting Manager (AM), the AM stated the following: When patients are admitted to the hospital the patients are given an admission booklet titled “During Your Stay,” which includes information regarding patient rights and the contact information of the state agency for patient to report any complaints. The facility documented the date the admission booklet was issued to the patient in the patient’s medical record. Patients were also given information regarding Medicare Rights and Conditions of Admission, which were signed by patients, acknowledging that the patients received the information. During a review of Patient 16’s “History and Physical,” (H&P, formal and complete assessment of the patient and the problem) dated 10/22/2023 at 9:41 a.m., the H&P indicated Patient 16 was admitted for persistent diarrhea (loose stools). During a concurrent interview and review of Patient 16’s medical record on 12/29/2023 at 12:10 p.m. with the AM. The AM verified that there was no documented evidence that Patient 16 was issued an admission handbook and stated the patient (Patient 16) may not be aware of his (Patient 16) patient rights. During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights,” revised 3/2023, the P&P indicated the following: - PURPOSE: To ensure patients are informed of their legal rights. - PROCEDURE: Patient must be informed upon admission in understandable language of their rights while in the hospital and given a patient’s rights handbook. Patient must sign form stating they are informed of their hospital rights. 2. During a review of Patient 11’s “History and Physical (H&P, a complete and formal assessment of the patient and the problem),” dated 12/20/2023 at 10:15 a.m., the H&P indicated Patient 11 was admitted for pain to the lower back and abdomen for four (4) days. During a concurrent interview and record review of Patient 11’s medical record, on 12/29/2023 at 12:37 p.m., with the Admitting Manager (AM). The AM verified that there was no documented evidence that Patient 11 was issued an admission handbook and stated the patient (Patient 11) may not be aware of his patient rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.). During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights,” revised 3/2023, the P&P indicated the following: - PURPOSE: To ensure patients are informed of their legal rights. - PROCEDURE: Patient must be informed upon admission in understandable language of their rights while in the hospital and given a patient’s rights handbook. Patient must sign form stating they are informed of their hospital rights.”

“PATIENT RIGHTS: 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. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to provide a correct contact address and phone number of the Department in the facility’s admission booklet (Patient Handbook- a patient welcome guide designed to assist patients with simple questions on key care topics and explains patient rights and responsibilities) for two of 30 sampled patients (Patient 16 and Patient 11), in order for patients (Patient 16 and Patient 11) to know who to contact when filing a grievance (written or oral expression of dissatisfaction regarding the quality of care provided to a patient) with the Department. This deficient practice had the potential to inhibit patients from contacting the Department to file grievance or complaints, which may result in a delay of investigation of a potential patient safety issue that can cause patient harm or death. Findings: During a review of Patient 16’s “History and Physical (H&P, formal and complete assessment of the patient and the problem),” dated 10/22/2023 at 9:41 a.m., the H&P indicated Patient 16 was admitted for persistent diarrhea (loose stools). During a review of Patient 11’s “History and Physical (H&P, a complete and formal assessment of the patient and the problem),” dated 12/20/2023 at 10:15 a.m., the H&P indicated Patient 11 was admitted for pain to the lower back and abdomen for four (4) days. During an interview, on 12/29/2023 at 11:42 a.m. with the Admitting Manager (AM), the AM stated when patients are admitted to the hospital, the patients are given an admission booklet, which included information regarding patient rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.) and the contact information of the Department for patients to report any complaints/grievances (written or oral expression of dissatisfaction regarding the quality of care provided to a patient). During a review of the facility’s admission booklet titled, “Patient handbook (a patient welcome guide designed to assist patients with simple questions on key care topics and explains patient rights and responsibilities) ‘During Your Stay’ ([Name of Facility] patient handbook),” page 20, the handbook indicated, “You may also file a grievance and/or file a complaint with the California Department of Public Health - regardless of whether or not you use the hospital grievance process. The patient handbook indicated a phone number and an address for patients to contact. During a concurrent observation and interview on 12/29/2023 at 4:46 p.m. with the Director of Quality, Risk and Safety (DQRS) at the facility’s conference room, surveyor called the phone number listed by the facility in the patient handbook and heard a message of “you have reached the number that has been disconnected or no longer in service.” DQRS stated that the address and phone number on the patient handbook were incorrect and, therefore, if the patient were to call the number listed in the patient handbook, the call will not go through. During an interview on 12/29/2023 at 5:20 p.m. with Senior Regional Director of Accreditation, Regulatory and Licensing (SDRARL), the SDRARL stated the correct Department contact information including address and phone number was on the facility’s patients’ rights poster but not in the patient handbook (which is individually handed out to each patient on admission). During a review of the facility’s policy and procedure (P&P) titled, “Hospital Patient Grievance Policy,” dated 07/07/2022, the P&P indicated, “The patient has the right to be informed of the patient grievance process. The process is published in the “Patient Handbook.””

“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: 38310 Based on observation, interview and record review, the facility failed to: 1. Ensure that keys to open one of one sampled fire exit door were kept secured by staff and that three staff members were available in the patient care area at all times to assure a safe environment, was provided for one of 30 sampled patients (Patient 1) to prevent Patient 1 from eloping (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) from the facility. This deficient practice had the potential for serious harm to Patient 1, who left the facility, via the fire exit door, into the street, where there are pedestrians and vehicles, and the potential for danger to others, who encounter Patient 1 in the street. 2. Ensure a one to one (1:1 - consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) security observation was continuously provided for one of four sampled patients (Patient 6), when Patients 6 was allowed to stay inside his (Patient 6) patient room with the door closed, while the security guard was outside the patient’s room with no direct line of sight (a level of observation wherein the patient remains in staff view at all times) on Patients 6. This deficient practice had the potential for Patients 6, who was put on 1:1 security observation for violent behavior, to inflict self-harm or harm others. On 12/27/2023, at 4:36 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the facility’s Department Administrator for Mental Health, the Chief Nursing Executive, and the Senior Regional Director for Accreditation, Regulatory and Licensing. The facility failed to ensure a safe environment for one of 30 sampled patients (Patient 1), to prevent him from eloping (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) from the facility on 12/15/2023, at 5:50 p.m. Patient 1, who was on an involuntary 72-hour hold (5150 hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for being a danger to others, eloped from the facility via the fire exit door. This had the potential for serious harm to Patient 1, who exited out of the facility in the street, where there is pedestrian and vehicular traffic, and a potential harm to others, because Patient 1 was out in the street, where he can be dangerous to others. Likewise, there were eleven patients in the unit, who were considered high risk for elopement. The facility administrators were informed of the immediate jeopardy situation regarding the failure to provide a safe environment for Patient 1 and the failure to provide appropriate monitoring of patients, including Patient 1, who eloped from the facility. The facility needed to take immediate action to prevent other 5150 patients from eloping through the fire exit door, using a key, forcefully taken from the staff. On 12/29/2023, at 6:34 p.m., the IJ was removed in the presence of the Assistant Medical Center Administrator, Chief Nursing Executive, Senior Regional Director for Accreditation, Regulatory and Licensing, Area Administrator for Quality, Security Department Account Manager, Director of Quality/Risk/Safety, and the Acting Senior Vice President/Chief Operations Officer, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ Removal Plan indicated the following interventions: 1. Retrain staff on the policies and procedures for: Code Gray (a call for security personnel indicating there is a dangerous person in a public area of the hospital, there is a missing person, or there is criminal activity somewhere in the hospital), Patient Elopement (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave), Warm Handoff (transfer of care between two members of the healthcare team in which the sharing of information regarding the patient’s care is conducted in the presence of the patient). 2. Retrain the registered nurses on the interventions applied for risk levels associated with Violent Assessment Tool (provides a standard against which to evaluate individuals for potential violence, enabling all healthcare providers to share a common frame of reference and understanding). 3. Training staff for Conflict Management and Situational/Environmental Awareness (the ability to observe and understand the healthcare environment, recognize potential issues before they occur, and take appropriate action) to identify high/moderate environments or situations, and to ensure decision-making was aligned with safety and security. 4. Key Control Process (an access control process that a facility uses to keep track of its keys and prevent unauthorized use) to increase awareness of staff when patients are in close proximity to staff utilizing the exit door key and to minimize exposure of the exit door key to patients who want to elope. Findings: 1. During an initial tour of the facility on 12/26/2023 at 2:01 p.m. and a concurrent interview with registered nurse (RN) 3, RN 3 stated Patient 1 was re-admitted to the facility on 12/20/2023, after threatening to beat up his (Patient 1) father, and thus, Patient 1 was taken to the emergency department (ED- responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), where he (Patient 1) was placed on a 14-day involuntary hold (otherwise known as 5250 hold which is a law that allows a patient with mental, emotional and behavioral issues to be detained for 14 days involuntarily for stabilization treatment [interventions to address mental health]). RN 3 said Patient 1 will be on a hospital hold until 1/5/2024. During a concurrent interview and record review on 12/26/2023 at 2:37 p.m. with the Department Administrator of Mental Health Center (DAMHC), Patient 1’s nursing assessment (a process where a nurse gathers, sorts, and analyzes a patient’s health information) record, dated 12/14/2023, was reviewed. The DAMHC stated Patient 1 was first admitted to the facility on 12/14/2023, at 11:21 p.m., after having been transferred from another facility and placed on a 72-hour involuntary hold (5150- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others, or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his basic personal needs such as hygiene, food, etc.]). Concurrently, during review of Patient 1’s psychiatric evaluation, dated 12/15/2023, the DAMHC stated Patient 1 had audio-visual hallucinations (when someone hears voices/noises and sees things that don’t exist in reality), was kicked out of his (Patient 1) mother’s house, taken to the emergency department (ED), and was placed on a 5150 hold for being a danger to others. During an interview on 12/26/2023, at 3:42 p.m. with licensed vocational nurse (LVN) 1, LVN 1 stated the following: 1. Unit 1 was his (LVN 1) primary unit, where patients had the highest acuity (implies that the patients’ conditions are severe and imminently dangerous) and were at risk for going “AWOL” (absent from where one should be or missing) from the facility. 2. While working in Unit 1, staff must have a heightened level of awareness of patients because the patients were unpredictable and needed to be assessed for the risk of leaving the facility. 3. He (LVN 1) worked on 12/15/2023, during the evening shift, with a charge nurse (CN 1), another RN (RN 1), a certified nursing attendant (CNA1), and a security guard (SG 1) who was assigned to watch another patient one-to-one (1:1 - consist of one-to-one staff observation with a patient never farther away at arm’s length at all times), who was at risk for going AWOL (Patient 6). 4. Patient 1 was a new patient. 5. He (LVN 1) heard the CNA1 yelling, “Stop it! Stop it,” but could not see what was going on, and ran (LVN 1) to see what was going on. 6. He (LVN 1) saw Patient 1 going AWOL (eloping), while dragging CNA1 to the fire exit door and while holding something, which turned out to be CNA1’s keys (key to open the exit door), as he (LVN 1) moved closer to the struggle. 7. At that time, the one RN (RN 1) was on a meal break and the charge nurse (CN 1) was not in the milieu (patient care area) - stated he (LVN 1) did not know where CN 1 was. 8. During the struggle between Patient 1, CNA1, and himself (LVN 1), “I grabbed the patient’s arm trying to restrain him.” LVN 1 did not call a Code gray prior to grabbing Patient 1’s arm as indicated in the facility’s policy regarding calling a Code Gray (a call for security personnel indicating there is a dangerous person in a public area of the hospital, there is a missing person, or there is criminal activity somewhere in the hospital). 9. After the struggle, the CN 1 “entered into the milieu” and called a Code Gray (a call for security personnel indicating there is a dangerous person in a public area of the hospital, there is a missing person, or there is criminal activity somewhere in the hospital) then a Code Green (indicates patient already eloped), after the patient (Patient 1) left the unit. 10. For a successful take-down (when a patient is forced down and immobilized to apply restraints) of a patient, who is aggressive and trying to leave, there has to be three people to successfully take a patient down and restrain the patient in order to prevent the patient from leaving: one to call a code and call for help and two to hold a patient by both arms and prevent patient from leaving. 11. There were only two staff, at the time Patient 1 was trying to leave, on the floor - the LVN 1 and CNA 1. 12. If there were all four staff on the floor, during the struggle with Patient 1, Patient 1 would not be able to leave the floor and go AWOL. 13. CNA 1 was a new hire and Unit 1 was not the CNA1’s “home” unit. 14. In Unit 1, whenever he (LVN 1) gets his (LVN 1) keys out, he (LVN 1) has to be hyper aware of his surroundings, all the time. 15. On the floor, there should be three staff all-the-time - two licensed nurses (two RN’s or one RN and one LVN) and one CNA, for safety. During an interview on 12/26/2023 at 4:37 p.m. with Charge Nurse (CN 1) 1, CN 1 stated the following: 1. On 12/15/2023, he (CN 1) was assigned as the charge nurse because the regular charge nurse was off. 2. On 12/15/2023, he (CN 1) was assigned to Patient 1 and his roommate (Patient 6). 3. On 12/15/2023, Patient 1 was not an elopement risk, but his roommate, Patient 6, was an elopement risk and had a security guard (SG) 1 assigned to watch him one to one (1:1 observation- consist of one-to-one staff observation with a patient never farther away at arm’s length at all times). 4. On 12/15/2023, Patient 6 had a walker, which he (CN 1) found broken at the beginning of the shift and was replaced with another walker. 5. Later on, when he (CN 1) went to check Patient 1 and Patient 6, he (CN 1) noticed that Patient 6’s recently replaced walker was broken again - suspected that someone broke it because the walker was really bent, in a way like someone sat on it, but could not determine who broke it - Patient 1 or Patient 6 6. Afterwards, he (CN 1) took Patient 6’s walker into the nursing station to try to fix it because there were no more walkers to replace it. 7. Did not remember if he (CN 1) told anyone he (CN 1) was going to fix Patient 6’s walker at the nursing station. 8. While in the nursing station for about five minutes, he (CN 1) heard a commotion and went outside to see what was happening. 9. Afterwards, he (CN 1) saw two staff (CNA 1 and LVN 1) at the emergency exit door with Patient 1 pushing on the door to open it. 10. He (CN 1) did not know Patient 1 had the key to the emergency exit door and called a Code Gray. 11. At the same time, while on the cellphone calling a Code Gray, he (CN 1) saw Patient 1 leave the emergency exit door and so he (CN 1) called a Code Green, on the same call. 12. He (CN 1) stated that two staff were not enough to take Patient 1 down and prevent him (Patient 1) from leaving on 12/15/2023. During an interview on 12/27/2023 at 9:37 a.m. with security guard (SG) 4, SG 4 stated the following: 1. On 12/15/2023, he (SG 4) worked and was doing his rounds in Unit 3, when he (SG 4) got the page for a Code Green in Unit 1. 2. Afterwards, he (SG 4) returned to Unit 1 and checked the emergency exit door to the street, and noticed it was already dark outside in the street and did not see the eloped patient (Patient 1) anywhere. 3. On 12/15/2023, he (SG 4) was assigned to do rounds every 15 minutes for Units 1, 2, and 3 - checking every unit, locked doors, exit doors, double-doors, emergency exit doors. 4. On 12/15/2023, one security guard (SG 1) was assigned to Unit 1 for 1:1 monitoring of an AWOL (elopement) risk patient (Patient 6, the roommate of the eloped Patient 1). 5. On 12/15/2023, one security guard (SG 3) was assigned to the security desk, on the first floor, when the Code Green was called, and he (SG 3) paged him (SG 4). 6. Unit 1 had patients who were a higher risk, than the other two units, for going AWOL. 7. On 12/15/2023, the CNA1 who was struggling with Patient 1 (Patient who eloped) was injured with a cut, afterwards. 8. On 12/15/2023, there were three security guards on duty at the facility, plus one to do 1:1 monitoring in Unit 1 (SG 1). During a tour of the facility grounds (from the outside of Unit 1’s emergency exit door, to the gated entrance for the ambulance, to the ambulance entrance into Unit 1) on 12/27/2023 at 10:40 a.m. with the Director of Facility Services (DFS), Area Director of Security Services (ADSS), Chief Nursing Executive, the Senior Regional Director for Accreditation, Regulatory and Licensing, the Department Administrator of Mental Health Center (DAMHC), and the security guard (SG 2), the DFS stated there were two entrance/exit doors to Unit 1 - one double-door from the ambulance entrance and one into the hospital hallway - used by staff regularly, including one emergency exit door (used only for emergency fire escape or other emergencies). During a tour of Unit 1’s double-door from the ambulance entrance and Unit 1’s emergency exit door on 12/27/2023 at 10:58 a.m., there was a yellow line observed, on the floor. Concurrently, the DAMHC stated that patients were not allowed to cross or go near the yellow lines and would have to be redirected by staff to stay away from those two yellow lines because they were near the exit doors of Unit 1. During an interview on 12/27/2023 at 3:16 p.m. with certified nursing attendant (CNA 1), CNA 1 stated the following: 1. She (CNA 1) started working at the facility in March 2023, without previous experience working in mental health. 2. She (CNA 1) worked 12/15/2023 at Unit 1. 3. On 12/15/2023, at around 5 p.m., she (CNA 1) was near the nursing station, getting toiletries out of the cabinet for a patient who needed a shampoo. CNA 1 did not check her surroundings to see if a patient was nearby prior to using her keys that can open not only the cabinet for supplies but also has keys to open the fire exit door that leads out to the street where a patient can escape. 4. While she (CNA 1) was opening the cabinet, Patient 1 came out of nowhere from behind her (CNA 1) and tried to grab her (CNA 1) keys (the keys can open not only the cabinet supplies but also includes a key that can open the fire exit door that leads out to the street where a patient can escape) from her (CNA 1). 5. She (CNA 1) yelled out loud at Patient 1 to stop, and LVN 1 came to assist her (CNA 1). 6. LVN 1 tried to stop Patient 1 and grabbed his (Patient 1) arm and waist as she (CNA 1) was struggling to get her (CNA 1) keys from Patient 1. 7. Charge nurse (CN 1) came out into the floor and didn’t know Patient 1 took her (CNA 1) keys. 8. Afterwards, CN 1 told them, “Don’t get hurt.” 9. At the same time, Patient 1 left from the emergency door. 10. Patient 1 was fast and strong. 11. Afterwards, additional staff came to Unit 1 to assist with Code Gray/Green. 12. Working in Unit 1 is a high-risk unit, and you always need to keep your guard very high. 13. She (CNA 1) was trained in all the codes, including Code Gray, and trained to always keep her (CNA 1) keys with her (CNA 1). 14. During her (CNA 1) struggle with Patient 1, there were only the two of them on the floor - her (CNA 1) and the LVN 1, because one nurse (RN 2) was on a meal break, and charge nurse (CN 1) was at the nursing station. During an interview on 12/28/2023 at 8:31 a.m. with security guard (SG 1), SG 1 stated the following: 1. He (SG 1) had de-escalation training (techniques to use to help calm down a person who was upset or angry). 2. On 12/15/2023, he (SG 1) was assigned to work in Unit 1 to monitor Patient 6 as a 1:1 observation, because Patient 6 was a high-risk for going AWOL (elopement). 3. On 12/15/2023, whenever Patient 6 left his (Patient 6) room, he (SG 1) had to stay close to him (Patient 6) at 2-3 feet. 4. On 12/15/2023, whenever Patient 6 was in his (Patient 6) room, the door was closed, and he (SG 1) could not see Patient 6. 5. He (SG 1) was not allowed to enter the patients’ room (shared room for Patient 1 [patient who eloped] and Patient 6) without staff to accompany him (SG 1) inside. 6. On 12/15/2023, Patient 6 had a walker that was found broken, twice that day. 7. Patient 6 had a roommate (Patient 1 who eventually eloped) 8. On 12/15/2023, he (SG 1) heard disturbing noises with the shower on, coming from Patient 6’s room (room shared by Patient 1 and patient 6), but did not report hearing the noises to the patient’s (Patient 6) nurse. 9. He (SG 1) did not know where the noises were coming from and did not want to make allegations against any patients, so he (SG 1) did not report it to any staff. 10. It was a disturbing noise - thought it was strange because there was no furniture in the patient’s (Room shared by Patient 1 and Patient 6) room. 11. He (SG 1) peeked inside the door, to look, after hearing the noises, and saw Patient 6 asleep in bed, and did not see Patient 1, because he (SG 1) was at a blind spot, in the room. 12. He (S 1) heard disturbing noises twice around dinner time but cannot remember. 13. There was a female CNA in unit 1. 14. Later, he (SG 1) heard noises in the other hallway of Unit 1 but did not know what was happening because he (SG 1) could not leave Patient 6, to see what was happening. During a concurrent interview and record review on 12/28/2023 at 2:25 p.m. with the Director of Quality/Risk/Safety (DQRS), Patient 1’s medical records, dated 12/14/2023 to 12/15/2023, were reviewed. DQRS stated the following: 1. Face sheet (a document that gives a patient’s information at a quick glance), dated 12/14/2023, indicated patient (Patient 1) was admitted at 9:43 p.m. from another facility, and placed in Unit 1 (Patient 1 was considered a high-risk patient and placed on a 5150-hold due to threats to beat up his (Patient 1) father. Patient 1 was also paranoid (thinking or feeling that you are being threatened in some way). 2. Nursing assessment, dated 12/14/2023, indicated Patient (Patient 1) was ambulatory (able to walk), and reported hearing voices 3. Nursing note, dated 12/14/2023, indicated patient was cooperative, well-groomed and behavior was calm and predictable. 4. Patient’s (Patient 1) assault and violence assessment tool (provides a standard against which to evaluate individuals for potential violence, enabling all healthcare providers to share a common frame of reference and understanding), dated 12/14/2023, at 11:15 p.m., indicated Patient 1 had a score of two which was a low risk for violence, with no precautions. 5. Patient’s (Patient 1) inpatient psychiatric admission note, dated 12/14/2023, indicated patient (Patient 1) had no suicidal ideation (thoughts of harming one’s self), no homicidal ideation (thoughts of harming or kill another person), no psychotic thoughts (a mental condition in which thought, and emotions are so affected that contact is lost with reality), but had impaired judgement (not being able to make good decisions) and was paranoid (thinking or feeling that you are being threatened in some way). Patient 1 stated he (Patient 1) felt that people were breaking into his (Patient 1) parent’s house, which resulted in his (Patient 1) parents taking him to the emergency department. 6. Nursing note, dated 12/15/2023, indicated patient’s (Patient 1) behavior was predictable and patient was internally preoccupied. Patient complained of having tactile hallucinations (sensations of touch without a physical stimulus) that felt like bugs. 7. Patient’s (Patient 1) assault and violence assessment tool, dated 12/15/2023, at 6:34 a.m., indicated a change in behavior, score of three which was at a moderate risk for violence, with moderate risk precautions needs. There was no increased frequency of line-of-sight monitoring (a level of monitoring wherein the patient remains in staff view) documented in Patient 1’s medical record. 8. A review of patient’s (Patient 1) initial group assessment, dated 12/15/2023, indicated Patient 1 was very paranoid and not good to interview. 9. A review of patient’s (Patient 1) treatment plan (a documented guide or outline of a patient’s therapeutic treatment) with psychiatrist (physician who specializes in mental health), dated 12/15/2023, indicated psychotic problems of paranoid untrue beliefs, plan for daily one-to-one interviews, and medication management throughout hospital stay. 10. History and physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/15/2023, indicated patient (Patient 1) had a psychotic disorder and was brought to the emergency department with auditory hallucinations (the sensory perception of hearing voices without an external stimulus), with a plan to admit to inpatient psychiatric unit. 11. Social Worker notes, dated 12/15/2023, indicated patient (Patient 1) lived with mother, had psychosis issues requiring medication treatment, patient (Patient 1) was agreeable to continue medications until discharge, and plan to discharge patient (patient 1) home with follow up at a clinic closest to patient’s (Patient 1) discharge destination. 12. Assault and Violence Assessment tool, dated 12/15/2023, at 9:31 a.m., indicated a score of 3, which was a moderate risk for violence, with moderate risk precautions needs. 13. Nursing note for care planning (provides a framework for evaluating and providing patient care needs related to the nursing process), dated 12/15/2023, at 2:15 p.m., indicated patient’s (Patient 1) behavior was moderately unpredictable due to symptoms of illness, including impulsivity (tendency to act without thinking), agitation (a feeling of irritability or severe restlessness), and over-reaction to stressors (a situation or event that causes someone to feel stressed). Plan to continue observing patient (Patient 1) for safety and changes in behavior. 14. Multi-discipline (members of the healthcare team from different specialties involved in a patient’s care such as physicians, nurses, etc.) notes, dated 12/15/2023, at 3:30 p.m., indicated patient (Patient 1) on a 14-day (otherwise known as 5250 hold which is a law that allows a patient with mental, emotional and behavioral issues to be detained for 14 days involuntarily for stabilization treatment [interventions to address mental health]) hold, which was explained to patient (Patient 1), with patient’s rights explained to patient (Patient 1), and questions answered. Patient (Patient 1) was receptive with no aggressive behavior noted. 15. Rehabilitation treatment plan, dated 12/15/2023, at 3:55 p.m., indicated plan for patient to attend group sessions twice daily and interact with others. 16. Nursing Note, dated 12/15/2023, at 6:36 p.m., indicated patient (Patient 1) physically removed keys from CNA 1, was able to reach emergency exit door, and use the keys to elope from the facility. Patient (Patient 1) was unable to follow verbal commands for redirection and was physically able to get past two staff members. Code gray/green were called. Patient (Patient 1) was able to unlock security door and eloped before backup arrived. Patient (Patient 1) left key in the door. Attending physician, DAMHC and security were notified. Prior to AWOL incident, patient (Patient 1) damaged roommate’s walker and wrapped towels around the bottom of the legs (pf the walker). Patient (Patient 1) was instructed not to alter or touch roommate’s (Patient 6’s) equipment and to alert staff if he (Patient 1) felt his (Patient 1) roommate (Patient 6) needed assistance. During a review of Patient 1’s Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital), dated 12/15/2023, the Discharge Summary indicated the following: 1. Patient (Patient 1) was admitted involuntarily on a 72-hour hold (5150 hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) from another facility on 12/14/2023 for danger to others. 2. History of present illness - patient (Patient 1) visually hallucinated people invading his (Patient 1) parent’s house, which resulted in him (Patient 1) being brought to the emergency department by his (Patient 1) parents. Patient (Patient 1) has never seen a psychiatrist or been on meds (medications). 3. Mental status exam - patient (Patient 1) was cooperative, mellow, denied suicidal ideation and homicidal ideation, 4. Legal status - met criteria for 14-day hold (otherwise known as 5250 hold which is a law that allows a patient with mental, emotional and behavioral issues to be detained for 14 days involuntarily for stabilization treatment [interventions to address mental health]). 5. Plan was to continue Risperdal (a medication used to treat mental/mood disorders) and start Seroquel (a medication for manic/depressive disorder [intense shifts in mood, energy levels and behavior]). 6. Patient (Patient 1) was admitted to facility under 5150, in adult care psychiatric unit with noted limited insight and judgement. 7. Patient (Patient 1) forcibly removed unit keys from the floor staff’s possession and successfully eloped from the unit. 8. Patient (Patient 1) was admitted on a 5150 because of danger to others, placed on a 14-day hold, then eloped and left the hospital. During a review of the facility’s 5150 Authorized Personnel policy, dated 5/2023, the policy indicated only 5150’s written by: “law enforcement officers, personnel of Los Angeles County Patient Evaluation Teams (PET, licensed mental health clinicians who are designated to perform evaluations for involuntary detention of individuals who are at risk of harming themselves or others), Los Angeles County Department of Mental Health authorized psychiatrists working in Los Angeles County hospitals..., psychiatrists with admitting privileges to the facility, mental health professionals in other counties who are on the Conditional LPS (Lanterman-Petris-Short Act, an act that authorizes involuntary psychiatric treatment in very limited circumstances) Designation/Authorization list, and facility inpatient RN’s will be valid.” During a review of the facility’s Warm Handoff (transfer of care between two members of the healthcare team in which the sharing of information regarding the patient’s care is conducted in the presence of the patient) policy, dated 5/2023, the Warm Handoff policy indicated the following: 1. Warm Handoff is used to provide accurate information about a patient’s care, treatment/services, current condition, any changes communicated from one caregiver to the next. 2. Done at change of shift, break relief, transfer of care and emergency relief. During a review of the facility’s Elopement/Absent without Leave (AWOL) policy, dated 4/2023, the Elopement/Absent Without Leave (AWOL) policy indicated the following: 1. Elopement/AWOL means the patient leaves the hospital without staff or physician knowledge. 2. Staff who identifies patients at risk for elopement will notify the attending psychiatrist or on-duty psychiatrist. 3. Risk factor for elopement include history of elopement, lacking capacity to make relevant decisions, testing doors, voiced desire to leave, ideation to harm others, wandering, history of substance abuse or strong desire to obtain substances. 4. Nurse may implement elopement risk precautions by alerting all staff and placing patient on AWOL precaution, on rounds board, limit patient’s presence near exit doors, encourage group activities, and encourage patient to take medications. 5. If an elopement attempt is witnessed, a code green will be called and staff will wait for additional assistance before attempting to safely return patient to the unit, using all efforts at verbal de-escalation. During a review of the facility’s Code Gray policy, dated 3/2023, the Code gray policy indicated the following: 1. Staff will page Code Gray, when a patient is combative, a threat to self or others, had immediate breakdown with no time for interventions, when all least restrictive interventions failed. 2. Available staff shall report to Code Gray location, as soon as possible. 3. Only staff trained in Non-violent Crisis Intervention shall respond and participate. 4. All nursng staff must be trained in Non-violent Crisis Intervention prior to completing orientation. 5. Code Gray procedure includes, designating one leader who oversees the code, staff to remove potential weapons (ties, scarves, jewelry, lanyards, glasses, pens/pencils/writing utensils) 6. Staff will use only Non-Violent Crisis Intervention techniques to avoid harming themselves or others. 7. Staff will not intervene with a combative patient by themselves if they are alone with the patient. 8. Staff will be assigned specific limbs to be restrained during the containment with patient’s head protected. 9. Staff will be assigned to obtain mechanical restraints (use of a mechanical device, material or equipment attached or adjacent to the person’s body that he cannot easily remove and restricts the freedom of movement of a person’s body), if needed, and to apply restraints (devices that prevents free movement of a patient) to patient’s ankles and wrists, if needed. 10. If all least restrictive measure has been attempted and rendered ineffective, seclusion (involuntary confinement of a patient alone in a room) and/or restraints may be initiated. 2. During a review on 12/28/2023, Patient 6’s medical record was reviewed. The “Psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) Admission Note,” dated 12/15/2023, indicated Patient 6 came from another hospital and while at the other hospital, Patient 6 attempted to elope (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) three times, was periodically disorganized, angry and agitated (a feeling of irritability or severe restlessness). Patient 6 was then transferred and admitted to the facility on 12/15/2023 for a 72-hour hold (5150 hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others, or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his basic personal needs such as hygiene, food, etc.]). During a review of Patient 6’s “Assault and Violence Assessment Tool (provides a standard against which to evaluate individuals for potential violence, enabling all healthcare providers to share a common frame of reference and understanding),” dated 12/6/2023 through 12/20/2023, the tool indicated Patient 6 was at moderate risk for violence (score of 0-2 is low risk; score of 3-9 is moderate risk; and score of 9 or more is high risk). During a review of Patient 6’s “Psychiatrist (physician who specializes in mental health) Progress Note,” dated 12/16/2023 at 10:19 a.m., the Psychiatrist Progress note indicated, “...Per RN (Registered Nurse), patient (Patient 6) got agitated, started throwing chairs on the unit because he (Patient 6) was demanding to be discharged. On evaluation, patient (Patient 6) presents with labile mood and affect (abrupt change in mood or emotional state), alternating between being angry and crying...quickly escalating, not responding to verbal de-escalation (techniques to use to help calm down a person who was upset or angry) ...” During a review of Patient 6’s “Multi-Discipline Progress Note (contains all the interactions between a patient and all other healthcare professionals involved in the patient care such as physicians, nurses, etc.),” dated 12/16/2023 at 9:37 p.m., authored by Registered Nurse (RN 3) 3, the note indicated, “...One to one security observation (1:1 observation- consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) done to ensure patient safety and monitor patient for signs of aggressive behavior...” During a review of Patient 6’s “Security Standby Form (outlines what the security personnel has to do when assigned to conduct a 1:1 observation),” the form indicated Patient 6 was on 1:1 security observation (1:1 - consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) from 12/15/2023 at 1:30 p.m. through 12/19/2023 at 7:30 a.m. During an interview on 12/28/2023 at 8:31 a.m., with Security Guard (SG) 1, SG 1 stated he (SG 1) was the assigned SG to do 1:1 security observation on Patient 6, when Patient 1 eloped on 12/15/2023. SG 1 stated Patient 6 was on 1:1 security observation for danger to self (DTS) and danger to others (DTO). SG 1 stated during the 1:1 security observation, he (SG 1) ensured Patient 6 followed the facility rules, that Patient 6 was safe and everyone who was around Patient 6 was safe. SG 1 said when Patient 6 was out from the patient’s room and walking around the unit, SG 1 followed Patient 6 at arm’s length, at all times. In the same interview, SG 1 stated when Patient 6 goes inside the patient’s room, he (SG 1) stayed outside the room and does not follow Patient 6 inside the room. SG 1 stated it is the discretion of Patient 6 if he (Patient 6) wanted to close the door while inside the patient’s room and SG 1 would stay outside Patient 6’s room with the door closed. SG 1 stated he (SG 1) does not go inside Patient 6’s room unless a staff goes into the room, then he (SG 1) will accompany the staff to ensure safety. SG 1 stated that was how he (SG 1) did his observation when he (SG 1) was assigned to do a 1:1 security observation on a patient in Mental Health Center. Furthermore, SG 1 stated he (SG 1) recalled that when Patient 6 was inside his (Patient 6) room with his roommate (Patient 1), the room door (the room shared by Patient 6 and Patient 1) was closed, and he (SG 1) was outside the patients’ room. SG 1 stated he (SG 1) heard an unusual loud noise, but he (SG 1) was not sure if it came inside Patient 6 and 1’s room. SG 1 stated he (SG 1) was concerned of Patient 6’s and Patient 1’s safety from the unusual loud noise. SG 1 stated he (SG 1) quickly peeked inside the patients’ (Patient 6 and Patient 1) room door and saw Patient 6 was asleep in his (Patient 6) bed, he (SG 1) then closed the door. SG 1 stated he (SG 1) did not see Patient 1 (the roommate of Patient 6) because he (SG 1) just took a quick peek and did not check the entire perimeter of the room. In addition, SG 1 said he (SG 1) did not report to the nursing staff about what he (SG 1) heard and his concern for Patient 6 and Patient 1’s safety inside the patients’ room with the door closed, because he (SG 1) did not want to make any allegations. SG 1 stated he waited until a nursing staff went inside Patient 6’s room and he entered with the staff. SG 1 stated when he entered Patient 6’s room, he (SG 1) found Patient 6’s walker was broken. SG 1 said he (SG 1) was aware that 1:1 observation should have a continuous visual monitoring of the patient. SG 1 stated he did not have a direct line of sight on Patient 6 when the patient was inside the room with the roommate (Patient 1) and the door of the room was closed, and he (SG 1) stayed outside the patient’s room. If Patient 6 attacks his (Patient 6) roommate, he (SG 1) would not be able to see and intervene on time. During an interview on 12/28/2023 at 11:16 a.m., with the Department Administrator of Mental Health Center (DAMHC), the Director of Quality, Risk and Patient Safety (DQRPS), and the Area Director for Security Services (ADSS), the DAMHC stated Patient 6’s “Assault and Violence Assessment Tool,” from 12/6/2023 through 12/20/23 was at moderate risk which meant Patient 6 had the potential to be violent to others. Concurrently, the DQRPS stated Patient 6’s walker in the patient’s room (room shared by Patient 6 and Patient 1) could be used as a weapon to hurt self or others. The DRM stated a 1:1 security observation was in place to ensure Patient 6’s safety and everyone that was around the patient. The ADSS also stated Patient 6’s aggressive behavior was a danger to others (DTO) and there should be continuous monitoring with line of sight on Patient 6 to ensure safety. The ADSS said when Patient 6 was inside the patient’s room with his roommate (Patient 1) there should be a continuous visual monitoring and the patient’s room door should not be closed at all. In the same interview, the ADSS stated he (ADSS) was not aware the Security Guards (SG) were allowing the patients to close the patients’ room door and the SG would be outside the patients’ room with no direct visual observation of the patient. During an interview on 12/28/2023 at 2:26 p.m. with the Informatics Practice Specialist (IPS), the IPS stated upon checking the census in Unit 1, Patient 6 had a roommate on 12/16/2023 and 12/17/2023. During a review of the facility’s document titled, “Mental Health Guideline,” undated, the document indicated the following: - Purpose: To provide guidelines on the treatment of patients that are identified at risk for violence. - Moderate Level Precaution (3-9) ...Monitor for aggressiveness towards others ...No one to one interaction with patient in an isolated or confined space. During a review of the facility’s document titled, “Security Standby Form,” revised 6/2020, the document indicated the following: - Security Officers will maintain continuous, direct observation of the patient without distractions, at a range that allows for immediate intervention. - Protect the patient and the staff from any harm. - Only leave the patient when relieved by another security officer or a member of the clinical staff, and a hand-off (transfer of care between two members of the healthcare team in which the sharing of information regarding the patient’s care is conducted in the presence of the patient) is completed. - Report all suspicious activity between the patient and visitor(s) to the assigned nurse immediately. During a review of the facility’s policy and procedure (P&P) titled, “Observation and Precautions,” revised 10/2022, the P&P indicated, “...One on One: The patient is assigned a constant one to one staff member at arm’s length from patient. A staff member continuously assesses the patient’s status. The staff member assigned to watch the patient shall intervene as needed...Doors shall remain open when in room with patient ...””

“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: 48212 Based on interview and record review, the facility failed to ensure one of four sampled patients (Patient 22) had a physician order for restraints (devices that limit a patient’s movement) on 12/12/2023. This deficient practice resulted in the violation of Patient 22’s patient rights (ethical principles that apply to patient care) regarding restraints use as Patient 22 was restrained with bilateral (both) wrist restraints, bilateral mittens and a vest restraint on 12/12/2023 without a physician’s order. This deficient practice also had the potential to result in patient harm such as skin tear, strangulation, etc. when there’s no physician order to use restraints and patient is not properly monitored. Findings: During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/26/2023, the H&P indicated, Patient 22 was admitted to the facility’s Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses of Fentanyl (potent synthetic opioid drug for pain relief) overdose, acute respiratory failure (impairment of gas exchange between the lungs and the blood causing decreased oxygenation), lactic acidosis (lactic acid [a chemical in the body that breaks down carbohydrates for energy] build up in the bloodstream), tachycardia (increased heart rate) and Rhabdomyolysis (occurs when damaged muscle tissues releases its proteins and electrolytes into the blood and cause damage to the heart and kidneys. It is a serious medical condition that can be fatal or result in permanent disability). During a review of Patient 22’s “Restraints, Non-Behavioral Flowsheet (Restraints flowsheet, nursing document for restraints use)” dated from 12/11/2023 to 12/13/2023, the Restraints flowsheet indicated that Patient 22 had bilateral wrists restraints, bilateral mittens and vest restraints from 12/11/2023 to 12/13/2023. During a concurrent interview and record review on 12/29/2023 at 9:38 a.m. with Assistant Department Administrator of 6 West (ADA 8), Physician orders for Patient 22 from 12/11/2023 to 12/13/2023 were reviewed. The physician orders indicated, restraint use was ordered on 12/11/2023 and 12/13/2023. ADA 8 stated there was no physician order for restraints on 12/12/2023. ADA 8 stated the physician order was required for patient on restraints each day, and the order expired 24 hours after the physician had last signed. ADA 8 further stated it was a violation of patient rights (ethical principles that apply to patient care) for restraining patient (Patient 22) without a physician order. During a review of the facility’s policy and procedure (P&P) titled, “Restraint Use,” dated 9/1/2022, the P&P indicated, “Restraints for Clinical Reasons Order, (for the non-violent/ non-self-destructive patient’s physical safety) - in addition to ordering requirements stated in section 5.5.1 - 5.5.6, see below: A physician order must meet the following criteria: order daily, not to exceed midnight of the next calendar day.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 39503 Based on interview and record review, the facility failed to ensure one of two sampled patients (Patients 6) was assessed and monitored after chemical restraints (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) were administered. Patient 6 was given the medications: Benadryl (a medication that has a calming effect and puts a patient to sleep), Haldol (used to treat mental/mood disorders), and Ativan (used to treat anxiety). This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of chemical restraints, and had the potential to violate the patients’ rights regarding restraints use. Findings: During a review on 12/28/2023, Patient 6’s medical record was reviewed. The “Psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) Admission Note,” dated 12/15/2023, indicated Patient 6 came from another hospital and while at the other hospital, Patient 6 attempted to elope (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) three times, was periodically disorganized, angry and agitated (a feeling of irritability or severe restlessness). Patient 6 was then transferred and admitted to the facility on 12/15/2023 for a 72-hour hold (5150 hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others, or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his basic personal needs such as hygiene, food, etc.]). During a review of Patient 6’s Medication Administration Record (MAR), dated 12/16/2023, the MAR indicated that on 12/16/23 at 10:35 a.m. and at 10:36 a.m., the following physician’s order were: - Benadryl (a medication that has a calming effect and puts a patient to sleep) 50 milligrams (mg- a unit of measurement) to be given intramuscular (IM - injection to the muscle) immediately (STAT); - Haldol (used to treat mental/mood disorders) 5 mg to be given IM STAT (immediately); and, - Ativan (used to treat anxiety) 2 mg to be given IM STAT. The MAR indicated Patient 6 was given the Benadryl on 12/16/2023 at 10:35 a.m. and the Haldol and Ativan on 12/16/2023 at 10:36 a.m. During a review of Patient 6’s “Psychiatrist (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) Progress Note,” dated 12/16/2023 at 10:19 a.m., the Psychiatrist Progress Note indicated, “...Per RN (Registered Nurse), patient (Patient 6) got agitated, started throwing chairs on the unit because he was demanding to be discharged. On evaluation, patient presents with labile mood and affect (abrupt change in mood or emotional state), alternating between being angry and crying...quickly escalating, not responding to verbal de-escalation (techniques to use to help calm down a person who was upset or angry) ...Ordered Haldol 5 (mg)/Ativan 2 (mg)/Benadryl 50 (mg) IM to address agitation and emotional lability (abrupt change in emotional state) ...” During a review of Patient 6’s MAR, dated 12/16/2023, the MAR indicated that on 12/16/2023 at 8:22 p.m. and at 8:23 p.m., the following physician’s order were: - Benadryl 50 mg to be given IM (STAT); - Haldol 5 mg to be given IM STAT; and, - Ativan 2 mg to be given IM STAT. The MAR indicated Patient 6 was given the Benadryl on 12/16/2023 at 8:23 p.m. and the Haldol and Ativan on 12/16/2023 at 8:22 p.m. During a review of Patient 6’s “Multi-Discipline (contains all the interactions between a patient and all other healthcare professionals involved in the patient care such as physicians, nurses, etc.) Progress Note,” dated 12/16/2023 at 9:37 p.m., authored by Registered Nurse (RN 3) 3, the Multi-Discipline Progress Note indicated, at around 8:10 p.m., Patient 6 inquired about snacks, and when he (Patient 6) was told it would be served at a later time, Patient 6 punched the door in his (Patient 6) room. Patient 6 continued to curse and approached staff in a threatening manner. The physician was notified and obtained an order for Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM. There was no documented evidence Patient 6 was monitored or assessed (evaluated) after receiving chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) on 12/16/2023 at 10:35 a.m. and at 8:22 p.m. This lack of evidence was verified by the Department Administrator for Mental Health Center (DAMHC) during an interview. During an interview on 12/28/2023 at 2:26 p.m., with the DAMHC, the DAMHC stated Patient 6 was given the medications STAT to control Patient 6’s aggressive behavior. The DAMHC also said the STAT medications given to Patient 6 were considered a chemical restraint because it was given to control the patient’s (Patient 6) behavior. In the same interview, the DAMHC stated the facility was not aware a monitoring should be conducted when the patient was on chemical restraint. The DAMHC stated the facility only monitored the patients when physical restraint (any manual method, or physical or mechanical device attached to or adjacent to the patient’s body that the patient cannot remove easily which restricts freedom of movement) was applied or the patient was put in seclusion (the involuntary confinement of a patient in a room or an area where the patient is physically prevented from leaving). The DAMHC stated Patient 6 was not monitored or evaluated for response to the medications after receiving chemical restraint on 12/16/2023 at 10:35 a.m. and 8:22 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion & (and) Restraint,” reviewed 10/2022, the P&P indicated the following: “Behavioral Health Restraint and Seclusion (Violent or self-destructive behavior) ...Monitoring of patients in restraint or seclusion is done through continuous in-person observation by a competent staff member. a. A qualified registered nurse shall assess the patient at the initiation of restraint seclusion. b. Trained staff members’ monitor patients in restraint or seclusion every 15 minutes.””

“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: 39503 Based on interview and record review, the facility failed to ensure two of two sampled patients (Patients 6 and Patient 9) had a face-to-face assessment (an evaluation required to be done and documented for each episode requiring the use of violent/self-destructive (behavioral) restraint) within one hour, after the initiation of a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) to manage violent or self-destructive behavior was conducted. This deficient practice resulted in Patients 6 and Patient 9 to not have an in-person evaluation and assessment for any changes or deterioration of the patients’ physical and psychological condition after restraints (emergency medication/chemical restraint [a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient]) were applied. This deficient practice also had the potential to result in patient harm due to the failure to assess a potential change of condition that may require immediate medical intervention. Findings: 1. During a record review on 12/28/2023, Patient 6’s medical record was reviewed. The “Psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) Admission Note,” dated 12/15/2023, indicated Patient 6 came from another hospital and while at the other hospital, Patient 6 attempted to elope (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) three times, was periodically disorganized, angry and agitated (a feeling of irritability or severe restlessness). Patient 6 was then transferred and admitted to the facility on 12/15/2023 for a 72-hour hold (5150 hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others, or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his basic personal needs such as hygiene, food, etc.]). During a review of Patient 6’s Medication Administration Record (MAR), dated 12/26/2023, the MAR indicated that on 12/16/2023 at 10:35 a.m. and at 10:36 a.m., the following physician’s order were: - Benadryl (a medication that has a calming effect and puts a patient to sleep) 50 milligrams (mg- a unit of measurement) to be given intramuscular (IM - injection to the muscle) immediately (STAT); - Haldol (used to treat mental/mood disorders) 5 mg to be given IM STAT (immediately); and, - Ativan (used to treat anxiety) 2 mg to be given IM STAT. The MAR indicated Patient 6 was given the Benadryl on 12/16/2023 at 10:35 a.m. and the Haldol and Ativan on 12/16/2023 at 10:36 a.m. During a review of Patient 6’s “Psychiatrist Progress Note,” dated 12/16/2023 at 10:19 a.m., the Psychiatrist Progress Note indicated, “...Per RN (Registered Nurse), patient (Patient 6) got agitated, started throwing chairs on the unit because he was demanding to be discharged. On evaluation, patient presents with labile mood and affect (abrupt change in mood or emotional state), alternating between being angry and crying...quickly escalating, not responding to verbal de-escalation (techniques to use to help calm down a person who was upset or angry) ...Ordered Haldol 5 (mg)/Ativan 2 (mg)/Benadryl 50 (mg) IM to address agitation and emotional lability (abrupt change in emotional state) ...” During a review of Patient 6’s MAR, dated 12/16/2023, the MAR indicated that on 12/16/2023 at 8:22 p.m. and at 8:23 p.m., the following physician’s order were: - Benadryl 50 mg to be given IM (STAT); - Haldol 5 mg to be given IM STAT; and, - Ativan 2 mg to be given IM STAT. The MAR indicated Patient 6 was given the Benadryl on 12/16/2023 at 8:23 p.m. and the Haldol and Ativan on 12/16/2023 at 8:22 p.m. During a review of Patient 6’s “Multi-Discipline (contains all the interactions between a patient and all other healthcare professionals involved in the patient care such as physicians, nurses, etc.) Progress Note,” dated 12/16/2023 at 9:37 p.m., authored by Registered Nurse (RN 3) 3, the Multi-Discipline Progress Note indicated, at around 8:10 p.m., Patient 6 inquired about snacks, and when he (Patient 6) was told it would be served at a later time, Patient 6 punched the door in his (Patient 6) room. Patient 6 continued to curse and approached staff in a threatening manner. The physician was notified and obtained an order for Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM. There was no documented evidence Patient 6 had a face-to-face assessment (an evaluation required to be done and documented for each episode requiring the use of violent/self-destructive [behavioral] restraint) within one hour after receiving chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) on 12/16/2023 at 10:35 a.m. and at 8:22 p.m. This lack of evidence was verified by the Department Administrator for Mental Health Center (DAMHC) during an interview. During an interview on 12/28/2023 at 2:26 p.m. with the Director of Administration for Mental Health Center (DAMHC), the DAMHC stated Patient 6 was given the medications (Benadryl, Haldol, and Ativan) STAT to control Patient 6’s aggressive behavior. The DAMHC stated the STAT medications given to Patient 6 were considered a chemical restraint because it was given to control the patient’s behavior. In the same interview, the DAMHC stated the facility was not aware a face-to-face assessment should be conducted when the patient was on chemical restraint. The DAMHC stated the facility only perform face-to face assessment on the patients when physical restraint (any manual method, or physical or mechanical device attached to or adjacent to the patient’s body that the patient cannot remove easily which restricts freedom of movement) was applied or the patient was put in seclusion (the involuntary confinement of a patient in a room or an area where the patient is physically prevented from leaving). The DAMHC stated Patient 6 did not have a face-to-face assessment after receiving chemical restraint on 12/16/2023 at 10:35 a.m. and at 8:22 p.m. During a review of the facility’s policy and procedure titled, “Seclusion & (and) Restraint,” reviewed 10/2022, the P&P indicated the following: “Behavioral Health Restraint and Seclusion (Violent or self-destructive behavior) ...One-hour face-to-face assessment: The physician, LP (licensed practitioner), or qualified registered nurse or physician’s assistant shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of the restraint. The face-to-face assessment is performed even in those situations where the person is released early (prior to one hour) ...” 2. During a record review on 12/29/2023, Patient 9’s medical record was reviewed. The “Hospital Admission Note,” dated 11/18/2023, indicated Patient 9 was transferred from another hospital, and was admitted to the facility on 11/17/2023 for agitation (feeling of irritability or severe restlessness). During a review of Patient 9’s Medication Administration Record (MAR), dated 11/17/2023, the MAR indicated that on 11/17/2023 at 10:09 p.m. and at 10:10 p.m., the following physician’s order were: - Benadryl (a medication that has a calming effect and puts a patient to sleep) 50 milligrams (mg- a unit of measurement) to be given intramuscular (IM - injection to the muscle) immediately (STAT); - Haldol (used to treat mental/mood disorders) 10 mg to be given IM STAT (immediately); and, - Ativan (used to treat anxiety) 2 mg to be given IM STAT. The MAR indicated Patient 9 was given the Benadryl on 11/17/2023 at 10:10 p.m. and the Haldol and Ativan on 11/17/2023 at 10:09 p.m. During a review of Patient 9’s “MHC (Mental Health Center) Inpatient Psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) Admission Note,” dated 11/17/2023 at 10:58 p.m., authored by Registered Nurse (RN 8) 8, the note indicated, “...patient (Patient 9) appears disheveled (untidy), malodorous (smelling very unpleasant), dirty, appears homeless, and is agitated on the gurney...” Patient 9 was cursing and trying to lunge at the staff. The physician was called and ordered for Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg to be given IM to Patient 9. During a review of Patient 9’s MAR, dated 11/19/2023, the MAR indicated that on 11/19/2023 at 10 a.m., the following physician’s order were: - Benadryl 50 mg to be given IM STAT; - Haldol 10 mg to be given IM STAT; and, - Ativan 2 mg to be given IM STAT. The MAR indicated Patient 9 was given the Benadryl, Haldol and Ativan on 11/19/2023 at 10 a.m. During a review of Patient 9’s “Multi-Discipline (contains all the interactions between a patient and all other healthcare professionals involved in the patient care such as physicians, nurses, etc.) Progress Note,” dated 11/19/2023 at 11 a.m., authored by Registered Nurse (RN 9) 9, the note indicated, “...The patient (Patient 9) kicked the staff in the abdomen. The patient was not redirectable. He (Patient 9) lacks insight and argumentative with staff...” The physician was made aware and Ativan 2 mg, Haldol 10 mg, and Benadryl 50 mg was ordered at 10 a.m. During a review of Patient 9’s MAR, dated 11/20/2023, the MAR indicated that on 11/20/2023 at 7:21 p.m., the following physician’s order were: - Benadryl 50 mg to be given IM STAT; - Haldol 10 mg to be given IM STAT; and, - Ativan 2 mg to be given IM STAT. The MAR indicated Patient 9 was given the Benadryl, Haldol and Ativan on 11/20/2023 at 7:21 p.m. During a review of Patient 9’s “Care Planning (provides a framework for evaluating and providing patient care needs related to the nursing process) Progress Note,” dated 11/20/2023 at 8:15 p.m., the note indicated Patient 9’s behavior was very unpredictable, assaultive to staff, and verbally abusive. Patient 9 was not redirectable and required an emergency IM medications to be given during the shift (evening shift 3 p.m. to 11 p.m.). During an interview on 12/29/2023 at 11:45 a.m. with the Department Administrator for Mental Health Center (DAMHC), the DAMHC stated Patient 9 was given the medications STAT to control Patient 9’s aggressive behavior. The DAMHC said the STAT medications given to Patient 9 were considered a chemical restraint because it was given to control the patient’s behavior. In the same interview, the DAMHC stated the facility was not aware a face-to-face assessment (an evaluation required to be done and documented for each episode requiring the use of violent/self-destructive (behavioral) restraint) should be conducted when the patient was on chemical restraint. The DAMHC stated the facility only performs face-to face assessment on the patients when physical restraint (any manual method, or physical or mechanical device attached to or adjacent to the patient’s body that the patient cannot remove easily which restricts freedom of movement) was applied or the patient was put in seclusion (the involuntary confinement of a patient in a room or an area where the patient is physically prevented from leaving). The DAMHC stated Patient 9 did not have a face-to-face assessment after receiving chemical restraint on the following dates: - 11/17/2023 at 10:09 p.m.; - 11/19/2023 at 10 a.m.; and, - 11/20/2023 at 7:21 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion & (and) Restraint,” reviewed 10/2022, the P&P indicated the following: “Behavioral Health Restraint and Seclusion (Violent or self-destructive behavior) ...One-hour face-to-face assessment: The physician, LP (licensed practitioner), or qualified registered nurse or physician’s assistant shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of the restraint. The face-to-face assessment is performed even in those situations where the person is released early (prior to one hour) ...””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 39503 Based on interview and record review, the facility failed to ensure one of four sampled staff (Charge Nurse 1) assigned at the Mental Health Care Unit 1 (a unit that provides care to patients admitted with mental, emotional and behavioral disorders), was readily available to respond in an emergency situation when, there was only one Licensed Vocational Nurse (LVN) 1, and one Certified Nursing Assistant (CNA 1) left in Unit 1’s patient care area during one of 30 sampled patients (Patient 1’s) attempt to elope (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) from the unit (Unit 1) on 12/15/2023. This deficient practice resulted in Patient 1’s elopement from the facility on 12/15/2023. In addition, this deficient practice had the potential for serious harm to Patient 1, who left the facility, via the fire exit door, into the street, where there were pedestrians and vehicles, and the potential for danger to others, who would encounter Patient 1 in the street. Findings: During a record review on 12/26/2023, Patient 1’s medical record was reviewed. The “Multi-Discipline (contains all the interactions between a patient and all other healthcare professionals involved in the patient care such as physicians, nurses, etc.) Progress Note,” dated 12/15/2023 at 6:36 p.m., authored by Charge Nurse (CN) 1, indicated “...Around 1750 (5:50 p.m.), Patient (Patient 1) physically removed keys from the Certified Nursing Assistant (CNA 1) on the unit (Unit 1). Patient (Patient 1) was able to reach emergency exit door and use key to elope (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave). Patient (Patient 1) was unable to follow verbal redirection and was physically able to get past 2 staff members (LVN 1 and CNA 1, who were the two staff members left in the patient care area) ...patient (Patient 1) was able to unlock security door and eloped before backup arrived ...” During a review of Patient 1’s “Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital),” dated 12/15/2023, the Discharge Summary indicated, Patient 1 was admitted to the facility on 12/14/2023 with a 72-hour hold (5150 hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for danger to others (DTO). During an interview on 12/26/2023 at 3:42 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that on 12/15/2023, he (LVN 1) was assigned at Unit 1. LVN 1 said, at the time, when Patient 1 attempted to elope from the unit (Unit 1), LVN 1 was in Hallway A (exit by the ambulance bay) monitoring the dining room, where some of the patients were staying, when he (LVN 1) heard someone scream “STOP IT STOP IT.” LVN 1 stated he (LVN 1) went to check what was happening and saw Patient 1 in Hallway B (by the fire exit door) walking towards the fire exit door holding on to the keys that was attached to CNA 1’s wrist, and CNA 1 was being dragged by Patient 1 while he (Patient 1) was walking towards the fire exit door to escape. LVN 1 said there were 4 staff assigned to Unit 1 on 12/15/2023: CN 1, RN 2, CNA 1 and him (LVN 1). LVN 1 stated at the time of Patient 1’s attempt to elope from the unit, RN 2 was on break (meal break). LVN 1 stated he (LVN 1) was not aware that CN 1 stepped out of the unit (Unit 1) and it was only him (LVN 1) and CNA 1 who were left in the Unit 1’s patient care area. In the same interview, LVN 1 said he (LVN 1) tried to stop Patient 1 from walking towards the fire exit door and opening door, by holding on to Patient 1’s one arm while the CNA (CNA 1) was focused on getting back the keys from Patient 1. LVN 1 did not call a Code Gray (a call for security personnel indicating there is a dangerous person in a public area of the hospital, there is a missing person, or there is criminal activity somewhere in the hospital) before grabbing Patient 1’s arm. LVN 1 stated when Patient 1 reached the fire door exit and was trying to use the key to open the door, LVN 1 saw CN 1 coming out of the nurse station room and when CN 1 saw them (LVN 1 and CNA 1) struggling with Patient 1, CN 1 told them “let go of him (Patient 1), don’t hurt yourself,” and CNA 1 told CN 1 that Patient 1 got her (CNA 1) keys. LVN 1 said Patient 1 was able to open the fire exit door and eloped from the facility out into the street. Furthermore, LVN 1 stated when a takedown (when a patient is forced down and immobilized to apply restraints) was needed, one staff will hold one arm of the patient and the other staff will hold the other arm, while the third staff would call for CODE GRAY (a call for security personnel indicating there is a dangerous person in a public area of the hospital, there is a missing person, or there is criminal activity somewhere in the hospital) so the other staff from the other unit can come and help out. LVN 1 stated they (LVN 1 and CNA 1) were vulnerable at the time Patient 1 attempted to elope because there were only two staff present in the patient care area of Unit 1. LVN 1 stated he (LVN 1) did not call the CODE GRAY before responding to CNA 1 struggling with Patient 1 because, he (LVN 1) was trying to stop Patient 1 from eloping and that the staff were not allowed to use the vocera (a hands-free, wearable device use to communicate quickly between staff) to call CODE GRAY. In addition, LVN 1 said it was CN 1 who called the CODE GRAY but by the time CN 1 called, Patient 1 was able to open the fire exit door and eloped. LVN 1 stated if there were more staff on the floor and not just the two of them (LVN 1 and CNA 1) it would have been a different outcome because there will be more staff who could help prevent Patient 1 from eloping. During an interview on 12/26/2023 at 4:47 p.m. with Charge Nurse (CN) 1, CN 1 stated on 12/15/2023, he (CN 1) was assigned to work on Unit 1 as Charge Nurse. CN 1 said he (CN 1) was also the RN assigned for the care of Patient 1 and his roommate, Patient 6. CN 1 stated at the time when Patient 1 attempted to elope from the unit (Unit 1), RN 2 was on break (meal break), and he (CN 1) took Patient 6’s walker to the nursing station room to fix it because it was broken. CN 1 stated he (CN 1) did not remember if he (CN 1) told anyone (LVN 1 and CNA 1 who were left in the patient care area of Unit 1) that he (CN 1) was going to the Nursing Station to fix Patient 6’s broken walker. CN 1 said when he (CN 1) was inside the nursing station room, he (CN 1) heard a commotion and when he (CN 1) went out to the unit (Unit 1) to check, CN 1 saw Patient 1 pushing on the fire exit door while CNA 1 and LVN 1 were nearby struggling with Patient 1. CN 1 stated he (CN 1) called a CODE GRAY not knowing Patient 1 took the keys from CNA 1. CN 1 stated while he (CN 1) was calling for CODE GRAY, Patient 1 was able to open the fire exit door and left. CN 1 stated he (CN 1) then called for CODE GREEN (used to report a missing/eloping patient who is determined to be a danger to themselves or has been identified as a safety risk). During an interview on 12/27/2023 at 3:15 p.m. with CNA 1, CNA 1 stated on 12/15/2023, she (CNA 1) was assigned at Unit 1. CNA 1 said a patient requested for a shampoo, so she (CNA 1) opened the supply cabinet across the nursing station room. CNA 1 stated after she (CNA 1) opened the supply cabinet, Patient 1 came suddenly from her (CNA 1) back and grabbed the keys from her (CNA 1) which were in a plastic chain attached to her (CNA 1) wrist. CNA 1 stated she (CNA 1) was trying to get her (CNA 1) keys back from Patient 1 when LVN 1 came to help. CNA 1 stated she (CNA 1) told LVN 1 to call a CODE GRAY, but she (CNA 1) was not sure if LVN 1 did it. CNA 1 stated LVN 1 was holding Patient 1’s one arm and she (CNA 1) was trying to hold the other arm while grabbing back her (CNA 1) keys from Patient 1. CNA 1 stated CN 1 came out and told them (LVN 1 and CNA 1) not to hurt themselves and so Patient 1 was able to open the fire exit door with her (CNA 1) keys and eloped. CNA 1 said there were only two staff in the unit (Unit 1) at the time of the incident, her (CNA 1) and LVN 1. CNA 1 stated RN 2 was on break and CN 1 was in and out of the unit into the nurse station room trying to fix Patient 6’s walker. CNA 1 stated if there were additional staff in the unit’s patient care area, there will be more help to stop Patient 1 from eloping. During an interview on 12/27/2023 at 2:26 p.m. with the Department Administrator of Mental Health Center (DAMHC), the DAMHC stated nursing staffing for the units were based on Title 22 (regulates health and safety standards for licensed healthcare facilities) staffing ratio (maximum number of patients that may be assigned to an RN during one shift) and the matrix (a tool to help leadership determine what levels of each staff group are needed based on the census) to cover the unit and ensure the nursing staff assigned in the unit were readily available to respond to patient care needs and emergency situation. The DAMHC stated the matrix was designed to cover the unit and allowing one staff to go on break one at a time. In the same interview, the DAMHC stated on 12/15/2023, Unit 1’s census was 12 patients. The DAMHC said based on the matrix, the staffing requirement for Unit 1 was: 1 CN, 1 RN, 1 LVN, 1 CNA. The DAMHC stated with 1 staff going on break, there should be a minimum of three staff in the unit readily available to respond to patient care needs and emergency situation. However, when RN 1 was on meal break, CN 1 was at the Nursing station and not in the patient care area thus, leaving only two staff instead of 3 in the patient care area where the patients (Patient 1 and Patient 6) were located at the time Patient 1 eloped from the facility. During a review of the facility’s policy and procedure (P&P) titled, “Staffing Policy,” revised in 3/2023, the P&P stated, “There shall be a process for ensuring adequate staffing of qualified staff in the inpatient unit ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39503 Based on interview and record review, the facility failed to ensure one of five sampled patient’s (Patient 7) high blood pressure (BP) reading of 189/94 millimeters of mercury (mmHg, a unit of measurement; a reading of 140/90 or higher is considered a high BP) was evaluated and treated. In addition, the physician was not notified of Patient 7’s high BP. This deficient practice had the potential to delay treatment and necessary adjustments in Patient 7’s treatment plan in order to lower Patient 7’s high blood pressure, which had the potential to result in complications such as stroke (when a blood vessel that carries blood to the brain gets blocked by a clot or if it ruptures leading to paralysis [inability to move some or parts of the body]) if left untreated. Findings: During a record review on 12/28/2023, Patient 7’s medical record was reviewed. The “Attending Psychiatrist (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorder) Admission Note,” indicated Patient 7 was returning from Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) and admitted to the facility on 12/7/2023 for unstable mental illness (when a person is constantly experiencing rapid fluctuating emotions, mood, and behavior very often). Patient 7’s medical history included hypertension (high BP) and hypertensive chronic kidney disease (hypertension cause by the kidney disease). During a review of Patient 7’s “Vital Signs (VS, includes temperature, blood pressure, heart rate, and respiratory rate) Flowsheet,” the Vital Signs flowsheet indicated on 12/7/2023 at 6:43 p.m., Patient 7’s BP was 189/94 millimeters of mercury (mmHg, a unit of measurement; a reading of 140/90 or higher is considered a high BP). Patient 7’s BP was taken next on 12/8/2023 at 6:41 a.m., it was 164/93 mmHg (12 hours since the last BP check). There was no documented evidence Patient 7’s BP of 189/94 was addressed, or the physician was notified. This lack of evidence was verified by the Department Administrator for Mental Health Center (DAMHC) during an interview. During an interview on 12/28/2023 at 4:09 p.m. with the Director of Administration for Mental Health Center (DAMHC), the DAMHC stated Patient 7’s BP was high, and the Registered Nurse should have notified the physician to see if any orders can be given for the patient’s high BP. The DAMHC said the RN should have rechecked the BP to see if it had worsened or improved, and if an intervention was needed. In a follow-up interview on 12/29/2023 at 12:30 p.m., The DAMHC stated there was no written P&P regarding physician notification for the patient’s change of condition although it is the process of the facility to notify physician of any patient change of condition. Patient 7’s high BP was considered a change of condition and RN should have notified the physician.”

“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: 39503 Based on interview and record review, the facility failed to ensure one of five sampled patients’ (Patient 7) comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and implemented upon admission in order to address Patient 7’s Hypertension (high blood pressure [BP] - a reading of 140/90 or higher is considered a high BP). This deficient practice had the potential to result in the delay of treatment by not identifying the patient’s (Patient 7) needs and risks and had the potential for Patient 7’s hypertension to worsen which may result in complications such as stroke (when a blood vessel that carries blood to the brain gets blocked by a clot or if it ruptures leading to paralysis [inability to move some or parts of the body]) if left untreated. Findings: During a record review on 12/28/2023, Patient 7’s record was reviewed. The “Attending Psychiatrist (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorder) Admission Note,” indicated Patient 7 was returning from the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) and admitted to the facility on 12/7/23 for unstable mental illness (when a person is constantly experiencing rapid fluctuating emotions, mood, and behavior very often). Patient 7’s medical history included hypertension (high blood pressure [BP] - a reading of 140/90 or higher is considered a high BP) and hypertensive chronic kidney disease (hypertension cause by the kidney disease). During a review of Patient 7’s “Vital Signs (VS, includes temperature, blood pressure, heart rate, and respiratory rate) Flowsheet,” the flowsheet indicated on 12/7/23 at 6:43 p.m., Patient 7’s BP was 189/94 millimeters of mercury (mmHg, a unit of measurement; a reading of 140/90 or higher is considered a high BP). Patient 7’s BP was taken next on 12/8/2023 at 6:41 a.m., it was 164/93 mmHg (12 hours since the last BP check). There was no documented evidence Patient 7 had a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) developed addressing Patient 7’s hypertension. This lack of evidence was verified by the Department Administrator for Mental Health Center (DAMHC) during an interview. During an interview on 12/28/2023 at 4:09 p.m., with the DAMHC, the DAMHC stated Patient 7 should have a care plan addressing the patient’s (Patient 7) hypertension. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning and Care Plan Documentation,” revised 4/2022, the P&P indicated the following: - Assess - Information from the Patient Profile, Shift Assessment, Learning Assessment, and other assessments is used to individualize the plan of care. - Diagnose (Nursing) - Based on assessment, determine which problem templates should be on the Patient Plan. A problem template is applied within 8 hours of admission. - Plan - Based on the diagnosis/templates applied, plan of care in collaboration with the patient and/or family whenever possible, including goals and interventions.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure one of four sampled staff (Registered Nurse [RN] 1), who worked in the facility’s Mental Health Center (MHC, provides care and treatment for mentally ill patients), completed the required annual skills validation training (process of assessing, verifying, and documenting an individual’s competencies in a specific area), in accordance with the facility’s policies and procedures regarding staff training. This deficient practice had the potential for RN 1 to be unprepared to handle emergency situations such as a code gray (a call for security personnel indicating there is a dangerous person in a public area of the hospital, there is a missing person, or there is criminal activity somewhere in the hospital), face to face evaluation (patient assessment and immediate situation, body system assessment, pre-existing condition identification, use of behavioral criteria, and smart phase), and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) placement. This deficient practice also had the potential to result in patient harm due to lack of staff training in the management of patients with mental and behavioral issues. Findings: During a concurrent interview and record review on 12/29/2023 at 6:03 p.m. with Staff Educator for the Mental Health Center (SEDMHC) and the Director of Professional Development & Education (DPDED), Registered Nurse (RN) 1’s personnel file was reviewed. The SEDMHC stated the following: Every year the staff working in the Mental Health Center (MHC, (MHC, provides care and treatment for mentally ill patients) were required to complete a skills validation (process of assessing, verifying, and documenting an individual’s competencies in a specific area) checklist via computer-based training. The SEDMHC ensure staff completed the training and documents the completion by writing her (SEDMHC) initials next to the trainings on the “2022 Annual Skills Validation Checklist.” The SEDMHC verified that RN 1 was missing a verifier’s initial on for the following trainings: 1 Hour Face to Face Assessment (patient assessment and immediate situation, body system assessment, pre-existing condition identification, use of behavioral criteria, and smart phase), Code Blue (used to indicate a patient requiring resuscitation [methods used to restart the heart and lungs when they stop working]) & Code Gray (a call for security personnel indicating there is a dangerous person in a public area of the hospital, there is a missing person, or there is criminal activity somewhere in the hospital), Restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) & Seclusion (the involuntary confinement of a patient in a room or an area where the patient is physically prevented from leaving). During a review of RN 1’s employee file, the file indicated the following: A document titled, “2022 Annual Skill Validation Checklist,” dated 5/16/2023 indicated it was missing Verifier’s initials for the following: “QRN (qualified registered nurse) 1 HR Face to Face Assessment (patient assessment and immediate situation, body system assessment, pre-existing condition identification, use of behavioral criteria, and smart phase).” “Code Blue and Code Gray (training included calling a code, code blue patient scenario, post code mandatory debrief [process of dissecting an event, breaking down what worked and what needs improvement], nursing management best practices of roles, warm handoff [transfer of care between two members of the healthcare team in which the sharing of information regarding the patient’s care is conducted in the presence of the patient], and communication & leadership).” “Restraints & Seclusion (training included Qualified Registered Nurse [QRN], face to face evaluation of seclusion and restraints computer-based training and return demonstration).” During a review of the facility’s policy and procedure (P&P) titled, “Code Gray/Paging for Staff Assistance,” dated 3/2023, the P&P indicated, MHC (Mental Health Center) staff are trained how to recognize early signs of patient escalation (sick or deteriorating patient), and effectively communicate potential dangers to others in the workplace. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion & Restraint,” dated 10/2022, the P&P indicated all clinical staff are required to complete restraint and seclusion training and competency protocols to patient intervention ...””

“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: 36206 Based on interview and record review, the facility failed to: 1. Check tube feeding residuals (the volume of fluid remaining in the stomach at a point in time during tube feeding) for one of 30 sampled patients (Patient 13), who was receiving nutrition via nasal gastric tube (NGT, a tube inserted through the nose and into the stomach), in accordance with the physician’s orders and the facility’s policies and procedures regarding tube feeding. This deficient practice had the potential for aspiration (fluid or liquid is breathed into airways or lungs) for Patient 13. 2. Ensure one of 30 sampled patients (Patient 20) was accurately assessed for suicide risk (thoughts of killing oneself) upon arriving at the Emergency Department (ED- responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), in accordance with the facility’s policies and procedures regarding suicide risk screening (a quick way to detect someone that needs further evaluation) and assessment. This deficient practice had the potential for incorrect suicide screening and inappropriate precautions for Patient 20, which may result in patient harm or death. 3. Ensure one of five sampled patient’s (Patient 6) suicide risk (thoughts of killing oneself) reassessment was completed in accordance with the facility’s policy and procedure (P&P) regarding Suicide risk assessment and precautions. This deficient practice had the potential to result in Patient 6’s inaccurate suicide risk assessment and inappropriate precautions that may lead to patient harm or death. 4. Ensure one of five sampled patient’s (Patient 7) multidisciplinary (interactions between a patient and all other healthcare professionals involved in the patient care such as physicians, nurses, etc.) treatment plan (a documented guide or outline of a patient’s therapeutic treatment) was completed every 7 days from the time of admission in accordance with the facility’s policy and procedure regarding completing/updating a multidisciplinary treatment plan. This deficient practice had the potential for Patient 7 to not have an individualized treatment plan that will help achieve treatment goals, which may result in delay of Patient 7’s recovery from illness. Findings: 1. During a review of Patient 13’s Physicians Progress Note, dated 12/27/2023 at 9:29 a.m., the Physician’s Progress Note indicated the following: Patient 13 presented from a skilled nursing facility (SNF, a place where non-critical patients can continue to receive medical care) on 12/13/2023 due to “decreased oral intake and inability to take medications ...Assessment & Plan: ...Severe Protein Calorie Malnutrition (a nutritional status in which a reduced availability of nutrients in body composition and function): Declining oral (PO) intake due to worsening encephalopathy (disturbance in the brain’s function) ...Tube feeding (TF, a therapy where a feeding tube supplies nutrients) via nasal gastric tube (NGT, a tube inserted through the nose and into the stomach).” During a review of Patient 13’s “Physician’s Order,” dated 12/21/2023 at 7:15 a.m., the order indicated the following: “Tube feeding ...product: (Name of product) Glucose Support 1.2 Vanilla ...Route: NG tube ...continuous ... goal rate 55 Milliliter per hour (ml/hour, a unit of measurement) ...Acceptable Residual (the volume of fluid remaining in the stomach at a point in time during tube feeding) Amount: 350 ml (milliliter, a unit of measurement). Frequency of Residual Check: Every 8 hours. During a review of a nurses note titled “Tube Feeding Nasogastric # 1 Right Nare (opening of the nose),” the nurses note indicated the NGT was placed on 12/22/2023. The nurses note further indicated the following: Tube feeding was started on 12/22/2023 at 1 p.m., residual amount was 0 ml. There was no residual amount checked on 12/22/2023 at 8 p.m., nor on 12/23/2023 at 4 a.m. On 12/23/2023 at 8 a.m., residual amount was 0 ml. On 12/24/2023 at 4 p.m., residual was 0 ml. On 12/24/2023 at 11 p.m., residual was 0 ml. There was no residual check documented at 7 a.m. No residual checks were documented between 12/25/2023 at 10 pm to 12/27/2023 at 4 a.m. During a concurrent interview and record review on 12/28/2023 at 3:30 p.m. with the Quality Coordinator (QC 1) and the Clinical Nurse Specialist (CNS 1), the QC1 and CNS 1 stated the following: Patient 13’s tube feeding residuals were not checked every eight hours, as ordered by the physician and in accordance with the facility’s policies and procedures. Tube feeding residual amounts should have been checked every 8 hours, not to exceed 350 ml. The CNS 1 said it was important to check residuals to make sure Patient 13 was digesting the feedings, and Patient 13’s stomach was not getting too full, which could increase the risk of aspiration (fluid or liquid is breathed into airways or lungs). During a review of the facility’s policy and procedure (P&P) titled, “Continuous Closed Enteral Tube Feeding for Adults,” dated 1/2022, the P&P indicated the following: “Nursing: Monitors for signs of intolerance to TF such as nausea (feeling of uneasiness in the stomach), vomiting, abdominal discomfort, and excess gastric residual ... Documents residuals and notifies the physician if the residual volume exceeds physician’s parameter on residual volume.” 2. During a review of Patient 20’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 12/27/2023, the Face Sheet indicated Patient 20 arrived at the Emergency Department (ED- responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) on 12/27/2023 at 8:37 p.m. During a review of Patient 20’s “Emergency Visit Note,” dated 12/27/2023 at 9:09 p.m., the Emergency Visit Note indicated the following: Patient 20 was “brought by police smart team on 5150-hold (72-hour, involuntary hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others).” Patient (Patient 20) with “underlying psychosis (a mental condition in which thought, and emotions are so affected that contact is lost with reality), has not been taking his (Patient 20) medication, has been acting inappropriate per mother (mother of Patient 20), no compliant with self-care of his (Patient 20) mental health treatment. Responding to lots of internal stimuli (changes, experiences, or feelings that occur within someone), disorganized thought patterns ...” During a review of Patient 20’s “Columbia Suicide Severity Rating Scale (C-SSRS, a tool used for suicide risk screening [a quick way to detect someone that needs further evaluation] and assessment),” the C-SSRS indicated the C-SSRS screening was checked on 12/28/2023 at 4:35 a.m. and indicated the following questions and answers for the past month: 1. Have you wished you were dead or wished you could go to sleep and not wake up? Patient 20 answered “Yes.” 2. Have you actually had any thoughts of killing yourself? No response was documented. If Yes to 2, ask questions 3, 4, 5, 6. If No to 2, go directly to question 6. 3. Have you been thinking about how you might do this? No response was documented. 4. Have you had these thoughts and had some intention of acting on them? No response was documented. 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? No response was documented. 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? No response was documented. CSSRS Total Score: 1 CSSRS Risk Level: Low Suicide Risk. During a concurrent interview and record review on 12/29/2023 at 10:35 a.m. with the charge nurse (CN 3) from the Emergency Department (ED) and the Assistant Clinical Director (ACD 1), Patient 20’s C-SSRS record was reviewed. CN 3 and ACD 1 said the following: Patient 20 arrived at the ED on 12/27/2023 at 8:31 p.m. Patient 20 was brought by the police department and was on a 72-hour involuntary hold for being a danger to self. Patient 20 had unorganized thoughts and was rambling. CN 3 and ACD 1 stated that Patient 20’s C-SSRS was not conducted upon arrival to the ED, it was conducted on 12/28/2023 at 4:35 a.m., eight (8) hours after arriving to the ED. In addition, the C-SSRS was incomplete because there was no response documented to questions 2 and 6. CN 3 and ACD 1 stated that at minimum, the nurse should ask questions 1, 2, and 6 to be able to determine Patient 20’s suicide (thoughts of killing oneself) risk and to implement the appropriate precautions. During a review of the facility’s policy and procedure (P&P) titled, “Management of Patients Who Are a Danger to Self or Others or Are Gravely Disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his basic personal needs such as hygiene, food, etc.),” dated 7/26/2023, the P&P indicated the following: “Initial Suicide Risk Screen: During the triage (a process used by hospitals to sort out patients according to their need for emergency medical attention to determine who gets care fist) and/or admitting process, the registered nurse (RN) shall complete a suicide risk screening using the C-SSRS (Columbia Suicide Severity Rating Scale, a tool used for suicide risk screening and assessment) on any of the following patients aged ten (10) years and older ...Patients who present with a behavioral health related primary complaint. Patients exhibiting signs/symptoms of self-harm ...” 3. During a record review on 12/28/2023, Patient 6’s medical record was reviewed. The “Psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) Admission Note,” dated 12/15/2023, indicated Patient 6 came from another hospital and while at the other hospital, Patient 6 attempted to elope (patient who leaves the hospital when doing so may present an imminent threat to the patient’s health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave) three times, was periodically disorganized, angry and agitated (a feeling of irritability or severe restlessness). Patient 6 was then transferred and admitted to the facility on 12/15/2023 for a 72-hour hold (5150 hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others, or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his basic personal needs such as hygiene, food, etc.]). During a review of Patient 6’s “Columbia Suicide Severity Rating Scale (C-SSRS, a tool used for suicide risk screening [a quick way to detect someone that needs further evaluation] and assessment),” dated 12/15/2023 at 2 p.m., the C-SSRS indicated Patient 6 had a score of 6 and the risk level was a high suicide risk (thoughts of killing one’s self). During a review of Patient 6’s “Suicide Risk Assessment,” the Suicide Risk Assessment form indicated Patient 6’s suicide risk assessment was conducted on 12/16/2023 at 5 p.m. (27 hours after the initial C-SRRS was completed). During an interview on 12/28/2023 at 2:26 p.m. with the Department Administrator of Mental Health Center (DAMHC), the DAMHC stated when a patient’s C-SSRS indicated a high suicide risk such as for Patient 6, a suicide risk reassessment should be done every shift to ensure appropriate precautions were implemented for patient safety. The DAMHC also said Patient 6’s suicide risk assessment should have been done every shift and not after 27 hours from the initial suicide risk assessment. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment & (and) Precautions (continuous interventions aimed at providing a safe environment for patients identified as exhibiting suicidal behavior and/or ideations [thoughts]),” revised 10/2020, the P&P indicated the following: - Reassessment of suicidality will occur once per shift for any patient that is assessed as being positive for suicide risk and for any patient on suicide precautions or who exhibits a sudden or significant change in mental status. - Patients who continue or begin to present at high-risk for suicidality are to continue or be evaluated for heightened observations or precautions as outlined below. - Heightened Observations: All patients will be monitored at least every 15 minutes. Patients who are assessed to be at moderate or high risk for suicidality may be placed on a one to one (1:1 observation- consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) observation status. 4. During a record review on 12/28/2023, Patient 7’s medical record was reviewed. The “Attending Psychiatrist (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorder) Admission Note,” indicated Patient 7 was returning from the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) and admitted to the facility on 12/7/23 for unstable mental illness (when a person is constantly experiencing rapid fluctuating emotions, mood, and behavior very often). During a concurrent interview and record review on 12/26/2023 at 1:31 p.m., with Charge Nurse (CN) 2, CN 2 stated Patient 7’s treatment plan (a documented guide or outline of a patient’s therapeutic treatment) was initiated on 12/8/2023. CN 2 stated a follow-up treatment plan was conducted on 12/27/2023 (19 days after the initial treatment plan). In the same interview, CN 2 said when a patient was admitted to the facility, a treatment plan would be initiated within 72-hours of admission and a follow-up would be conducted every 7 days and not after 19 days. CN 2 stated Patient 7 had 2 missing treatment follow-ups. CN 2 stated there should have been a treatment follow-up on 12/15/2023 and on 12/22/2023. During a review of the facility’s policy and procedure (P&P) titled, “Multidisciplinary Treatment Plan,” revised 12/2021, the P&P indicated the following: - The Multidisciplinary Treatment Plan should be completed by all disciplines within 72 hours of admission to the program. - A multidisciplinary treatment plan is initiated on 2nd day of program, 6th day and 10th day of program. If patient extends program, then multidisciplinary treatment plan occurs every fifth day thereafter. The team identifies the patient’s psychiatric, medical, substance abuse (excessive use of a drug in a way that is detrimental to self, society, or both), and/or discharge planning (process of identifying and preparing for a patient’s anticipated health care needs after they leave the hospital/facility) problems; notes needed resources, sets specific treatment goals; and interventions.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 39503 Based on interview and record review, the facility failed to ensure one of 30 sampled patient’s (Patient 7) blood pressure medication (hydralazine, medication used to treat high blood pressure [high BP - a reading of 140/90 millimeters of mercury (mmHg, a unit of measurement) or higher]) was administered to Patient 7 as ordered by the physician. This deficient practice had the potential to negatively affect the patient’s health and safety due to not receiving medication to lower his (Patient 7) blood pressure, which may lead to prolonged hospitalization and/or death. Findings: During a record review on 12/28/2023, Patient 7’s medical record was reviewed. The “Attending Psychiatrist (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorder) Admission Note,” indicated Patient 7 was returning from Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) and admitted to the facility on 12/7/23 for unstable mental illness (when a person is constantly experiencing rapid fluctuating emotions, mood, and behavior very often). Patient 7’s medical history included hypertension (high blood pressure [BP] - a reading of 140/90 millimeters of mercury [mmHg, a unit of measurement] or higher is considered a high BP) and hypertensive chronic kidney disease (hypertension cause by the kidney disease). During a review of Patient 7’s “Vital Signs (VS, includes temperature, blood pressure, heart rate, and respiratory rate) Flowsheet,” dated 12/7/2023, the flowsheet indicated that on 12/7/2023 at 6:43 p.m., Patient 7’s BP was 189/94 mmHg. During a review of Patient 7’s Medication Administration Record (MAR), the MAR indicated a physician’s order of hydralazine (medication to lower blood pressure) 10 milligrams (mg, a unit of measurement) to be given by mouth every six hours as needed for systolic BP (upper number of the BP, measures the pressure of the arteries [the blood vessels that carry oxygen-rich blood from the heart to the rest of the body] when the heart beats) above 180 or diastolic BP (lower number of the BP, measures the pressure in the arteries when the heart rests between beats) above 110 with a start date of 12/7/2023 at 7:49 p.m. During an interview on 12/28/2023 at 4:09 p.m. with the Department Administrator of Mental Health Center (DAMHC), the DAMHC stated Patient 7’s MAR did not indicate hydralazine was given to Patient 7 on 12/7/2023. The DAMHC said Patient 7 should have been given hydralazine when the patient’s (Patient 7) BP was 189/94 mmHg as ordered by the physician. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” revised 11/2020, the P&P indicated the following: - Licensed personnel are responsible for the following related to medication administration...Verifying the medication is being administered at the proper time, at the prescribed dose, and by the correct route. - Procedure...Administer the medication as ordered.”