Zuckerberg San Francisco General Hosp & Trauma Ctr

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 49264 Based on interview and record review, the facility failed to ensure two out of 27 sampled patients (Patient 17 and Patient 1) were not free from all forms of abuse when: 1. Patient 17 was pushed by RN 1 and fell to the floor and 2. Patient 1’s breast was touched by Pharmacist 1 outside of clinical necessity (an appropriate reason to do something based off of clinician judgement) and a practitioner’s clinical scope (the defined procedures, actions, and processes that a licensed healthcare professional is legally permitted to undertake, based on their specific education, training, and competency). These findings have the potential for patients to have physical harm, pain, or mental anguish. Findings: 1. A review of Patient 17’s Psychiatric Emergency Services (PES, specialized unit providing immediate evaluation, crisis intervention, and stabilization for individuals experiencing acute mental health crises ) Intake Evaluation (a clinical record of a patient’s first session upon being admitted to PES), dated 11/28/25, indicated Patient 17 was “presenting with psychosis [a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not] and SUD/OUD [Substance Use Disorder/Opiate Use Disorder, mental health condition where someone’s uncontrolled use of a substance (e.g. alcohol, drugs, nicotine) continues despite harmful physical, social, and functional consequences].” The intake evaluation further indicated Patient 17 was brought to PES as “it was reported that 911 calls were made because patient was running in and out of traffic ...believing that people were following him and trying to kill him.” A review PES Progress note for Patient 17 titled “Restraint / Seclusion Face to Face Assessment”, dated 11/28/25, indicated Patient 17 was continued in seclusion (involuntary confinement of a person alone in a room or area from which they are physically prevented from leaving) as Patient 17 was “loud yelling, threatening, requiring increased staff presence” even after “Less Restrictive Alternatives” were attempted by staff. During a concurrent interview and record review on 04/30/26 at 9:31 AM with PES Nurse Manager (NM) 1, an Emergency Department (ED) Note written by Registered Nurse (RN) 1, dated 11/28/25, was reviewed. The note indicated Patient 17 “became agitated while using the restroom at approx. [approximately] 1620 [4:20 PM] ...” and while Patient 17 “stood in the doorway he continued to yell that he would not go into the room, that he wanted more hand gel and made verbal threats of what he would do to PES staff if forced into the room. This RN [RN 1] pushed Pt. [patient] ...into the room as another RN closed the door to room A and locked it ...[Patient 17] fell to the floor form the push and began yelling and swearing ...Staff continued to visually monitor the Pt. for injury as well as offer medication ....[Patient 17] was eventually able to walk to the room window ...Pt was provided dinner and eventually layed [sic] calmly on his bed.” NM 1 stated, “we keep hands off [patients] unless there isn’t any other option ...this was a miss for this employee”. NM 1 was asked I Patient 17 was actively harming staff or themselves, NM 1 stated “No”. NM 1 further stated, “there was no justification for the nurse to do what he did”. A review of hospital P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES”, dated as last approved 06/2023, indicated, “1. Patients have the right to: ...Receive care in a safe setting, free from neglect, exploitation, verbal, mental, physical, or sexual abuse, and harassment ...” A review of hospital Policy and Procedure (P&P) titled, “ABUSE PREVENTION/PROHIBITION PROGRAM”, dated as last approved 11/2025, indicated, “It is facility policy to prohibit any actions that will harm our patients, visitors or staff. Each patient shall be treated with dignity and respect and shall not be subjected to verbal or physical abuse”. The P&P defined physical abuse as “hitting slapping, pinching, spitting and kicking. It also includes controlling behavior through corporal punishment. Except when it is determined by an appointed medical professional, or when staff have reasonable cause to believe that a patient presents a danger to themselves and/or other, the contract security provider may be called to maintain the safety of the patient, staff and/or visitors, and may use reasonable and necessary force ... in conformance with federal and state law.” The P&P further indicated prevention measures included “staff supervision to identify inappropriate actions i.e., use of derogatory and inappropriate language, rough handling ...” 39792 2. During a review of Patient 1’s, “Patient Care Coordination Note”, dated 08/14/24 at 10:30 AM, the note indicated Care Manager 1 called Patient 1 to inform Patient 1of a mammogram screening ( a low dose x-ray [electromagnetic radiation to produce images of soft tissue of breast and or bones] used to detect early breast cancer [is a disease where cells in the breast grow out of control, forming tumors] before symptoms would appear) which was due. The note further indicated Patient 1 reported experiencing pain in the left breast area around the nipple. Care Manager 1 documented that Patient 1 was reminded about the appointment with Pharmacist 1 on the following day (08/15/24). During a review of Patient 1’s, “Pharmacy (Medication Management Clinic) Note” dated 08/15/24, the note indicated Patient 1 met with Pharmacist 1 to review the prescribed medications for a complex medical history which included Diabetes Mellitus (a chronic metabolic condition where the body develops insulin [a hormone that removes excess sugar from the blood , can be produced by the body or given artificially via medication] resistance and inadequate insulin production, leading to high blood sugar). During a review of Patient 1’s, “Complex Care Management: Care Coordination Note” written by RN 4, dated 01/22/2025, the note indicated Patient 1 asked to cancel the upcoming appointment with the Pharmacist 1 on 01/23/25. The noted indicated Patient 1 requested to discuss medications with the primary care physician. During an interview on 04/27/26 at 1:26 PM with Risk Management Director (RMD), the RMD stated that the risk team was initially notified of the Pharmacist 1’s conduct when RN 4 reported that Patient 1 wanted to cancel an upcoming appointment with Pharmacist 1 after Patient 1 received a breast exam during a medication management visit with Pharmacist 1 on 08/15/24 and Pharmacist 1 requested to do another breast exam on 01/02/25 but Patient 1 refused. RMD stated there was no documentation of any physical exam for the encounters dated 08/15/24 or 01/02/25 with Pharmacist 1. RMD stated Pharmacist 1 was asked if a breast exam was the standard of care for a medication review visit and Pharmacist 1 would not answer the question which RMD found alarming. In the course of RMD’s investigation, the RMD was able to identify another similar patient case with Pharmacist 1. During a virtual interview on 05/01/26 at 9:56 AM with RN 4, RN 4 stated they work at the Complex Care Management Clinic and were quite familiar with Patient 1. RN 4 stated on 01/22/25, they called Patient 1 regarding a missed pharmacy appointment. RN 4 stated it was their job to follow up on missed appointments and reschedule them. RN 4 stated Patient 1 did not wish to have further appointments with Pharmacist 1 and wanted to cancel the next scheduled appointment with Pharmacist 1 on 01/23/25 due to a concern about a breast exam. RN 4 stated she detailed the concerns in an email to the Complex Care Management (CCM) Clinic supervisor. During a record review on 05/01/26 at 8:45 AM of a facility provided email dated 01/22/25, the email indicated it was sent by RN 4 to the supervisor of the Complex Care Management (CCM) Clinic with the title “Secure: [Patient 1’s initials]”. The email indicated, “I am documenting via this email a conversation I had this morning w/ [with] one of my CCM patients ...during a visit w/ PharmD [Pharmacist 1], 8/15/24 ...the pharmacist asked her about pain in her breast ...He asked her to lift up her blouse and pt [patient] covered her nipple while he palpated her breast. He then moved her fingers and touched her nipple to examine her ... She returned on 1/2/25 for another appt [appointment] and he asked her again about the breast pain and if he could exam her again, she said no this time ...The patient told me she ...thought it was strange that he asked to examine her. She also was not sure if he was also an MD [medical doctor] as well as pharmacist, so she had not mentioned to me thinking he had the ability to do this exam. She asked me to cancel the appt she had schedule [sic] w/ him tomorrow. I reviewed the chart and did not see any notes in either visit mentioning pt had been asked about breast pain.””

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 49264 Based on interview and record review, the facility failed to assess its discharge planning process using a periodic review of a representative sample of discharge plans. This failure has the potential for there to be an ineffective discharge planning process in which avoidable hospital readmissions can reoccur. Findings: A review of the facility’s policy and procedure (P&P) titled, “Discharge Process”, last reviewed 09/2025, indicated, “The hospital must reassess its discharge planning process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs.” During an interview on 01/22/26 at 2:29 PM with the Chief Quality Officer (CQO), the CQO was asked about how the hospital discharge process was reviewed. The CQO stated that there is an identified “PIP” (Process Improvement Plan-a structured, actionable process used to identify, analyze, and enhance a certain process) currently being worked on about documentation of anticipated discharge dates. In addition, the CQO stated there is a resident-physician-lead project regarding 30-day readmissions that has been looked at for about the past three years. During an interview on 01/22/26 at 2:34 PM with the Associate Chief Medical Officer for the Department of Care Coordination (ACMO), the ACMO was asked specifically if a sample of patient discharges are reviewed to see if they follow the hospital’s discharge process. The ACMO stated, “no.” During an interview on 01/22/26 at 2:46 PM with the CQO, the CQO stated that the discharge process policy is reviewed at a minimum “every three years” and as needed if there is a noted variance in performance. The CQO was specifically asked if a representative sample of discharges are reviewed to assess if they follow the hospital’s discharge process; the CQO stated, “no.” During an interview on 01/22/26 at 3:02 PM with the ACMO, the ACMO stated that she sits on the Utilization Management Committee. In general, the ACMO stated the committee does quarterly data reviews and looks at the hospital’s overall utilization. When asked what information they look at in terms of discharge, the ACMO stated the committee looks at data like readmission in aggregate (information combined from multiple, individual sources into summarized, high-level reports to show trends).”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 49264 Based on interview and record review, the facility failed to determine the availability of post-hospital services as determined by a patient’s assessment for two out of 30 sampled patients (Patient 7 and Patient 20) when: 1. Patient 7 was assessed as needing home health physical therapy (PT a healthcare discipline that helps people restore, maintain, or improve movement and function after injury, surgery, or due to chronic conditions) but there was no in-patient PT assessment after one was ordered and there was never an order for outpatient PT prior to discharge and 2. Patient 20 had a social services consult ordered to assist with housing resources, but the consult was never completed. These failures have the potential for a patient’s assessed or voiced needs during hospitalization to not be addressed leading to inadequate post-discharge care and/or preventable hospital readmissions. Findings: 1. A review of the facility’s policy and procedure (P&P) titled, “Discharge Process”, last reviewed 09/2025, indicated, “The discharge process ... is a collaborative, multi-disciplinary work flow performed by healthcare professional sin conjunction with patient and/or patient’s families or surrogate decision makers to develop an appropriate transition for continuing care after hospitalization ...An effective discharge evaluation requires a team approach ...It incorporates the skills and knowledge of the Physician ...Social Workers and RNs [Registered Nurses] ... Rehabilitation Therapists, Pharmacists ...” The P&P further indicated, “The Primary Inpatient Provider Team ensures appropriate outpatient clinic follow-up appointments and support are in place prior to discharge to try to ensure patient safety and healing ...In order to facilitate the discharge of a patient, supplies, referrals, and appointments should be arranged in advance of the discharge time.” During a review of Patient 7’s discharge summary (summarizes a patient’s hospital stay to ensure continuity of care, safety, and effective communication between the hospital team and the patient’s primary care doctors), dated 08/04/25, indicated Patient 7 was admitted in August of 2025 after “unwitnessed falls” twice in August in the setting of “imbalance and d/t [due to] forgetting to use the FWW [front wheel walker, a type of device to assist with walking]. During a concurrent interview and record review on 01/26/25 at 11:28 AM with Social Worker (SW) 1, a SW note for Patient 7 written by SW 1, dated 08/04/25, was reviewed. The SW note indicated, “DC [discharge] rec [recommendation] for HH [home health] PT and OT [occupational therapy, a healthcare discipline that helps people develop, maintain, or regain skills for daily living and working]. UM [Utilization Management] CCRN [Care Coordinator Registered Nurse] and Trauma [hospital specialty designed to provide immediate, multidisciplinary care for patients with severe, life-threatening physical injuries] NP [Nurse Practitioner] to coordinate with pt’s [patient’s] ... care team for DC back to [assisted living facility name] with abov noted HH support.” SW 1 stated, “based on my note this was multidisciplinary participation ... the conversation was that the patient would benefit form PT/OT.” SW 1 stated that it is “not a social work role” to set up home health referrals for PT or OT; SW 1 stated it is often the provider that would write the order and a utilization management RN that would ensure it was set up. A review of a list of Patient 7’s in-patient consult orders (requests by a medical provider for a specialist or service to see a patient for a specific reason), dated from 08/03/25 to 08/04/25 indicated that there was a total of four orders on 08/02/25 which included orders for “inpatient consult to social work/social services”, “Inpatient consult to ...occupation therapy - Eval [evaluate] and treat”, and “Inpatient consult to ...physical therapy - Eval and treat”. A review of Patient 7’s OT consult note, dated 08/04/25, indicated an OT assessed Patient 7 and recommended “Pt [patient] would benefit from skilled in-house ... OT to decr [decrease] cgv [caregiver] burden ...Plan ...OT Frequency: 3 times per week Duration: Other (Comment) (1 wk [week]” A review of Patient 7’s physical therapy order titled, “Inpatient consult to [Hospital Name] physical therapy - Eval and treat”, dated 08/02/25 indicated the order was placed on 09/02/25 at 4:15 PM. The order further indicated that the order was canceled with a listed reason of cancellation as “Patient Discharge”. A review of Patient 7’s discharge orders [orders placed by a provider prior to someone leaving a hospital], dated 08/04/25, indicated Patient 7’s only discharge orders were for losartan (a blood pressure medication). During a concurrent interview and record review on 01/26/26 at 12:02 PM with Nurse Practitioner (NP) 1, Patient 7’s discharge summary written by NP 1, dated 08/04/25, was reviewed. The discharge summary indicated, “Plan by problem: #Unwitnessed falls, recurrent ... this is the 4th fall in 1 year, 3rd fall in the last 30 days ... -PT/OT ...” NP 1 stated they were the discharging provided for Patient 7 but they did not order the in-patient PT consult. NP 1 stated the OT that saw Patient 7 recommended in-home OT from their assisted living. NP 1 was asked how they would know what level of PT Patient 7 would need and how often the patient would benefit from PT; NP 1 stated “it’s hard to know because there is no PT note.” NP 1 further stated she understood that the facility that Patient 7 was discharged to has its own physical therapists and it would therefore be like a resumption of those services. NP 1 was also asked if they believed an in-patient PT assessment would be helpful in guiding the decision on out-patient PT services; NP 1 stated, “certainly. She [Patient 7] fell ... so she should definitely see PT/OT.” 38612 2. Review of the facility’s P&P titled, “Discharge Process,” last reviewed on 9/2025, indicated “Discharge Process Procedure...b. If referred to Social Services, the Social Worker will conduct a psychosocial assessment within 24 hours of the referral. Reason for Social Services Psychosocial Referral include ...vi. Supportive Housing...Reason for Social Services Discharge Planning Referral: i. Shelter ...” Review of Patient 20’s face sheet indicated Patient 20 was admitted on 11/2/25 and was diagnosed with altered mental status. During a concurrent interview and record review on 1/21/26 at 1:46 PM with the Nursing Workforce Development Manager (NWDM) and the Director of Social Services (DSS), Patient 20’s “Internal Medicine-Progress Note,” dated 11/4/25 at 7:24 PM was reviewed. The note indicated “States he (Patient 20) was staying on the street before but he would like to speak with SW regarding drop in shelter resources.” Review of Patient 20’s physician’s order for an “Inpatient consult to social work/social services,” dated 11/4/25 at 11:31 AM, indicated “Reason for SW Referral: Supportive Housing; Shelter information, patient is currently unhoused.” When asked about expectations for a social work referral, the DSS stated, “The expectation is to see the patient, contact the patient for follow up on the referral.” The DSS also stated, “They (SW) are to document their assessment of the patient in terms of their wants and needs, resources that was offered to the patient, and any efforts they made to facilitate linkage to resources.” During further review of Patient 20’s medical record, the NWDM and the DSS confirmed there was no documentation the SW consult was completed. The DSS stated, “It shows no SW consult happened.””

“DISCHARGE PLANNING-D/C PLANNING LIST CFR(s): [The hospital must] include the discharge planning a list of HHA’s, SNF’s, IRF’s, or LTCH’s that are available to the patient, that are participating in the Medicare program, and that serve the geographic area(as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available. (i) The list must only be presented to patients for whom home health care post hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation. (ii) For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the network of the patient’s managed care organization, it must share this with the patient or the patient’s representative. (iii) [The hospital must] document in the patient’s medical record that the list was presented to the patient or to the patient’s representative.…. This Standard is not met as evidenced by: 38612 Based on interview and record review, the facility failed to ensure one of five sampled patients (Patient 26) discharged to a skilled nursing facility (SNF) was given a list of SNFs that included the facility they were sent to. Additionally, there was no documentation showing the list was provided to the patient or their representative. This failure could have prevented the patient or their representative from receiving complete information about available SNF options; this could lead to an uninformed decision about post-hospital care. Findings: Review of the facility’s policy and procedure (P&P) titled, “Discharge Process,” last reviewed on 9/2025, indicated “The discharge process consists of a discharge evaluation leading to a discharge plan. It is a collaborative, multidisciplinary workflow performed by healthcare professionals in conjunction with patients and/or patient’s families or surrogate decision makers to develop an appropriate transition for continuing care after hospitalization. This effort is essential to ensuring quality of patient care, for enhancing medical outcomes, and making appropriate use of hospital resources.” The P&P also indicated “Discharge Planning ...If a patient plan includes ... Skilled Nursing Facilities (SNF) placement the discharge plan must include a list of ... SNFs that are available to the patient, that are participating in the Medicare program (a federal health insurance program primarily for Americans aged 65 or older, as well as younger individuals with specific disabilities or illnesses)...” During a record review on 1/22/26 at 10:49 AM with the Director of Medical/Surgical Services (DMSS), Patient 26’s Discharge Summary (DCS, a summary of a patient’s hospital stay that includes their diagnosis, treatments, medications, and information for the continuation of care following discharge), dated 12/15/25 at 2:42 PM, was reviewed. The DCS indicated Patient 26 was admitted on 12/9/25 for worsening cervical myelopathy (compression of the spinal cord in the neck area) and was expected to be discharged to a SNF. The DCS also indicated Patient 26 was transferred to 4A SNF (located within the facility) on 12/19/25. During a concurrent interview and record review on 1/23/26 at 10:55 AM with Social Worker (SW) 2, the Social Work Consult Note dated 12/15/25 at 1:20 PM was reviewed. The note indicated, “ ...Discussed SNF referral options and pt (patient) and family agreed to 4A SNF. CCRN (Care Coordination Registered Nurse) is assisting with 4A SNF referral.” When asked how SNF referral options are presented to the patient, SW 2 stated, “We discuss options (with the patient), present a list to the patient; patient chooses from that list then refer patient (to the SNF).” Upon further review of Patient 26’s medical record, SW 2 could not provide documentation that a list of SNFs was presented to Patient 26 or their representative. During a concurrent interview and record review on 1/23/26 at 11:14 AM with the Associate Chief Medical Officer for Department of Care Coordination (ACMO), Care Coordination Nurse Manager (CCNM), and SW 2, an untitled facility-document, dated 1/6/25, showing a list of SNFs was reviewed. SW 2 stated that this was the same list given to Patient 26. 4A SNF, where Patient 26 was transferred on 12/19/25, was not on the list; this was confirmed by the ACMO, CCNM, and SW 2.”

“DISCHARGE PLANNING- PAC FINANCIAL DISCLOSURE CFR(s): The discharge plan must identify any HHA or SNF to which the patient is referred in which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare. Financial interests that are disclosable under Medicare are determined in accordance with the provisions of part 420, subpart C, of this chapter. This Standard is not met as evidenced by: 38612 Based on interview and record review, the hospital failed to inform one of five sampled patients (Patient 26) discharged to skilled nursing facilities (SNF) whether it has financial interest in any of the SNFs they were referred to. This failure violated the patient’s right to be fully informed when making decisions about their post-hospital care options. Findings: 1. Review of the hospital’s policy and procedure (P&P) titled, “ ...Discharge Process,” last reviewed on 9/2025, indicated “The discharge process consists of a discharge evaluation leading to a discharge plan ...” The P&P further indicated “The discharge plan must identify any HHA (home health agency, a company that provides a wide range of health services a patient can get in their home for an illness or injury) or SNF to which the patient is referred in which ZSFG (Zuckerberg San Francisco General Hospital) has a disclosable financial interest (any financial relationship or ownership stake that must be reported because it could influence decisions or create a conflict of interest), as specified by the Secretary (of the Department of Health and Human Services), and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare (a federal health insurance program primarily for Americans aged 65 or older, as well as younger individuals with specific disabilities or illnesses)...” Review of the hospital’s license from the California Department of Public Health (valid until 4/13/26) shows the hospital is licensed to operate a distinct part skilled nursing unit (also known as 4A SNF, a special unit inside the hospital that provides 24-hour skilled nursing and rehabilitation care). During a record review on 1/22/26 at 10:49 AM with the Director of Medical/Surgical Services (DMSS), Patient 26’s Discharge Summary (DCS, a summary of a patient’s hospital stay that includes their diagnosis, treatments, medications, and information for the continuation of care following discharge), dated 12/15/25 at 2:42 PM, was reviewed. The DCS indicated Patient 26 was admitted on 12/9/25 and was transferred on 12/19/25 to 4A SNF. During a concurrent interview and record review on 1/23/26 at 11:14 AM with the Associate Chief Medical Officer for the Department of Care Coordination (ACMO), Care Coordination Nurse Manager (CCNM), and Social Worker (SW) 2, an untitled facility-document, dated 1/6/25, showing a list of SNFs was reviewed. SW 2 stated that this was the same list of available SNF options given to Patient 26 during hospitalization from 12/9/25 to 12/19/25. When asked who operates 4A SNF, the ACMO and CCNM both stated 4A SNF is operated by San Francisco Health Network (SFHN, SF’s public healthcare system). Further review of the list of SNFs also indicated Laguna Honda Hospital SNF (LHH) as one of the available options to the patient. The ACMO and CCNM both confirmed LHH is also operated by SFHN. When asked if disclosable financial interest with SNFs is provided to patients referred to SNFs, the ACMO, CCNM, and SW 2 stated, “No.” During an interview on 1/26/26 at 10:14 AM with the Chief Quality Officer (CQO), the list of SNFs was reviewed. The CQO was asked if the hospital has disclosable financial interest in any of the SNFs on the list. The CQO stated, “No. The only two SNFs we have a relationship with are LHH and 4A. 4A is part of the hospital.” The CQO further stated, “LHH and 4A are operated by city and county of San Francisco but they’re publicly owned, not privately owned.” Review of the SFHN: Website: About the San Francisco Health Network | SF.gov; accessed on 1/29/26, indicated “The San Francisco Health Network is a community of top-rated clinics, hospitals and programs operated by the Health Department (referring to San Francisco Department of Public Health). We connect San Franciscans to quality health care. Every year we serve more than 100,000 people in our clinics and hospitals, such as...Zuckerberg San Francisco General and Laguna Honda Hospital and Rehabilitation Center.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 31794 The facility failed to ensure the Condition of Participation for Patient’s Rights, §482.13 was met when: 1.The facility failed to provide the Notice of Patient’s Rights to patients and/or their legal representative upon admission for eight (8) of 30 sampled patients. Refer to Tag A-0116. 2. The facility failed to provide the standardized notice, “An Important Message from Medicare (IM)”, to 15 of 15 Medicare beneficiary patients and/or their legal representatives within 2 days of admission. Refer to Tag A-0117. 3. The facility failed to ensure the “Terms and Condition of Admission (COA, a contract between the hospital and the patient)” was provided and was signed by 50 of 50 sampled patients upon admission. Refer to A0129. 4. The facility failed to ensure the Plan of Care were developed for seven (7) of 30 sampled patients. Refer to A-0130. 5. The facility failed to ensure the Advance Health Care Directive (AHCD, a patient instruction that state their choices for medical treatment and/or designates who should make treatment choices if the patient lacks medical decision-making capacity, as define in the facility policy) was provided to three (3) of 30 sampled patients. Refer to A-0132. 6. The facility failed to ensure the Attending Physician was consulted in the use of Seclusion (a form of restraint; the involuntary confinement of a person in a locked or unlocked room or area where the person is physically prevented from leaving, as defined by the facility policy) for one (1) of 30 sampled patients. Refer to A-0170. 7. The facility failed to ensure the Plan of Care addressing the use of Restraints (any mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, as define in the facility policy) and/or Seclusion (a form of restraint; the involuntary confinement of a person in a locked or unlocked room or area where the person is physically prevented from leaving, as defined by the facility policy) were developed based on the ongoing assessment for three (3) of six (6) sampled patients. Refer to A-0172. 8. The facility failed to ensure the Seclusion Order was discontinued at the earliest possible time, when the unsafe situation ends, for one (1) of three (3) sampled patients. Refer to A-0174. 9. The facility failed to ensure the patient’s conditions were monitored while on Seclusion and/or Restraint for three (3) patients of six (6) sampled patients. Refer to A-0175. 10. The facility failed to ensure the 1-hour face to face assessment and behavioral evaluation by the Provider was completed after the initiation of Seclusion for two (2) of three (3) sampled patients. Refer to A-0184. The cumulative effect of these failures resulted in the hospital’s inability to promote, maintain, and protect the rights of each patient in compliance with the Condition of Participation for Patient’s Rights.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 38612 Based on interviews and record reviews the facility failed to ensure eight (8) of 30 sampled patients (Patients 5, 6, 7, 10, 12, 20, 22, and 23) and/or their legal representatives were provided /informed of the Patient’s Rights upon admission when: 1. For Patient 5, there was no documentation the Notice of Patient’s Rights was provided. 2. For Patient 6, there was no documentation the Notice of Patient’s Rights was provided. 3. For Patient 7, there was no documentation the Notice of Patient’s Rights was provided. 4. For Patient 10, there was no documentation the Notice of Patient’s Rights was provided. 5. For Patient 12, there was no documentation the Notice of Patient’s Rights was provided. 6. For Patient 20, there was no documentation the Notice of Patient’s Rights was provided. 7. For Patient 22, there was no documentation the Notice of Patient’s Rights was provided. 8. For Patient 23, there was no documentation the Notice of Patient’s Rights was provided. These deficient practices violated patient’s rights to have an informed medical decision. Findings: 1. Review of the Patient 5’s face sheet indicated Patient 5 was admitted on 3/12/24 at 3:40 PM to the Inpatient Psychiatric Unit (PU) with diagnosis of schizophrenia (mental illness that affects the way the individual think, feel and behave). During a concurrent interview and record review with Charge Nurse (CN) 1 and Quality Management Nurse (QMN) 2 on 3/27/24 at 2:24 PM, CN 1 reviewed Patient 5’s electronic health record (EHR). CN 1 confirmed there was no evidence Patient 5 was provided the Notice of Patient’s Rights upon admission. 2. Review of Patient 6’s face sheet indicated Patient 6 was admitted on 10/11/23 at 10:37 PM to the PU with diagnosis of major depression (a mental health condition that is characterized by a low mood or loss of pleasure or interest in activities for long periods of time). During a concurrent interview and review of Patient’s health records with CN 1 and QMN 2 on 3/27/24 at 10:21 AM, CN 1 stated documentation can be found in the admission flow sheet in the EHR if the written notice of Patient’s Rights was provided to the patient on admission. CN 1 reviewed Patient 6’s EHR including the admission flow sheet. CN 1 verified there was no documentation Patient 6 was provided written notice of Patient’s Rights upon admission. 3. Review of the Patient 7’s face sheet indicated Patient 7 was admitted on 11/21/23 at 9:00 PM to PU with diagnosis of schizophrenia. During a concurrent interview and record review with CN 1 and QMN 2 on 3/27/24 at 2:30 PM, CN 1 reviewed Patient 7’s EHR. CN 1 stated, “Nothing is listed on the admission flow sheet for him.” CN 1 continued reviewing Patient 7’s EHR and confirmed she could not find documentation of provision of Notice of Patient’s Rights to Patient 7 upon admission. 4. Review of the “Patient Demographics” indicated, Patient 10 was admitted to the PU on 2/15/24 with diagnoses that include psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). During a concurrent interview and review of Patient 10’s health records with CN 1 and QMN 2 on 3/28/24 at 9:24 AM, CN 1 stated, “Sometimes, patient’s rights booklets are given to patients in the unit.” CN 1 reviewed Patient 10’s EHR and stated, “It’s not documented she was given a booklet. It should be.” 5. Review of the Patient 12’s face sheet indicated Patient 12 was admitted on 2/16/24 at 6:20 AM to PU with diagnosis of major depressive disorder with recurrent, severe psychotic features (a distinct type of depressive illness in which mood disturbance is accompanied by either delusion, hallucinations, or both). During a concurrent interview and review of Patient 12’s health records with CN 1 and QMN 2 on 4/3/24 at 2:36 PM, CN 1 reviewed Patient 12’s EHR including Patient 12’s admission flow sheet for documentation of provision of notice of Patient’s Rights to Patient 12 on admission. CN 1 stated, “I don’t see it.” During a panel interview with Nurse Manager (NM) 1, Interim Director of Psychiatry (DoP), and QMN 1 on 4/3/24 at 9:18 AM, NM 1 stated a written Notice of Patient’s Rights should be given to patients “as soon as they get admitted.” When NM 1 was asked of the reason for providing a written notice to the patients, she stated, “It’s very important. Patients need to know who to reach out to if rights are being suspended... they will be able to know who to reach out to during their stay in the hospital ...” 31794 6. Review of the Face sheet dated 4/2/24 indicated, Patient 20 was admitted in the Inpatient PU, 7B, on 3/5/24 at 10:40 AM. Record review of the H & P Initial Encounter Note, dated 3/6/24 indicated, “history of Schizophrenia”, “severe stimulant disorder (continued use of stimulants despite harm to the user)”, and “paranoid delusion (intense and irrational mistrust or suspicion which can bring on feelings of fear, anger) surrounding food being poisoned. In a concurrent and interview on 3/27/24, at 1:50 PM, with the Registered Nurse /Care Coordinator (RN/CC 1) and the Quality Nurse Manger (QMN 1), the Flowsheet on Patient’s Rights was reviewed. The RN/CC 1 stated, Patient’s Rights was the “most important thing” for patients to know in the unit, what things they can request, who they will contact for concerns, it is a “helpful information” for patient’s on how to reach out to patient advocates. RN/CC 1 stated, the section on Patient’s Rigths was not marked, it was not provided to the patient on admission. 7. Review of the Face sheet, dated 3/28/24 indicated, Patient 22 was admitted in the inpatient PU, 7B, on 3/7/24. Record review of the H & P Initial Encounter Note, dated 3/8/24 indicated, “trauma history”, “multiple substance use disorder” and the Principal Diagnosis was schizophrenia (mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality). In a concurrent and interview on 3/28/24, at 9:17 AM, with the RN/CC 1 and QMN 1 the Flowsheet was reviewed. The RN/CC 1 stated, it (Patient’s Rights Provided) “was not marked” on the flow sheet, it was not documented, and it was not provided to the patient. 8. Record review of the Patient Demographics, dated 3/28/24 indicated, Patient 23 was admitted in the inpatient PU, 7B, on 3/16/24. Record review of the H & P Initial Encounter Note, dated 3/24/24 indicated, patient with history of schizophrenia and amphetamine (stimulant drug) use disorder, recently presented to the Emergency Room for “episodic aggression”, was brought in by the ambulance “from jail after being unable or unwilling to focus and answer questions”, “attempting to kick the emergency department resident physician, unable to follow directions requiring multiple rounds of emergent psychiatric” medications. The Principal Diagnosis was “psychosis (symptoms that affect the mind when the person loss contact with reality) not due to a substance or known physiologic condition.” In a concurrent record review and interview on 3/28/24, at 10:10 AM, the RN/CC 1 and QMN 1, the Flow sheet was reviewed. The RN/CC 1 stated, the Patient’s Rights was “not marked”, it was not provided to the patient, and there was no documentation by nursing staff the Patient’s Rights was provided on admission.In a concurrent record review and interview on 3/28/24, at 10:10 AM, the RN/CC 1 and QMN 1, the Flow sheet was reviewed. The RN/CC 1 stated, the Patient’s Rights was “not marked”, it was not provided to the patient, and there was no documentation by nursing staff the Patient’s Rights was provided on admission. During a panel interview with Nurse Manager (NM) 1, Interim Director of Psychiatry (DoP), and QMN 1 on 4/3/24 at 9:18 AM, NM 1 stated a written Notice of Patient’s Rights should be given to patients “as soon as they get admitted.” When NM 1 was asked of the reason for providing a written notice to the patients, she stated, “It’s very important. Patients need to know who to reach out to if rights are being suspended” and “they will be able to know who to reach out to during their stay in the hospital ...” Record review of the facility’s Policy and Procedure (P & P), Administrative Policy Number: 16.04, titled, “Patient’s Rights and Responsibilities”, with the last review date of 5/23 indicated, “Purpose: The purpose of this policy is to list and describe the rights and responsibilities of the patient /client” at Hospital 1. Statement of Policy, ... it is the policy of ... (Hospital 1) that employees and medical staff ensure the rights and acknowledge the responsibilities of patients. ... .” Review of facility’s “Acute and Emergency Psychiatry Department Policy 4.3,” titled “Patient Rights,” with last review date of 12/22 indicated, “Policy: A. It is standard of practice that each person admitted voluntarily or involuntarily, is afforded rights as outlined in the Welfare and Institutions Code Section 5325 ... E. Each patient is notified of these rights on admission. Printed information regarding Patient Right’s is also provided at the time of admission. ... .” Review of the facility provided booklet, titled “Rights for Individuals in Mental Health Facilities,” with a revision date of 5/14, indicated “Your Rights as a Patient ... The person in charge of the facility in which you are receiving treatments is responsible for ensuring that all your rights in the handbook are protected. You should be informed of your rights in a language and a manner that you can understand: On admission to a facility; When there is a change in your legal status; When you are transferred to another unit or facility; at least once a year ...””

“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: 31794 Based on interviews and record reviews the facility failed to ensure the standardized notice titled, “An Important Message from Medicare (IM)”, was provided to 15 of 15 sampled Medicare beneficiary patients (sampled Patients 5, 6, 8, 11, 13, 14, 25, 27, 28, 29, and 30 and random sampled Patients 31, 32, 33, and 34) within 2 days of admission. This deficient practice resulted in the potential for Medicare beneficiary patients and/or their legal representatives to not be notified/informed of the patient’s “rights on admission”, the care they would recieve in advance, their “plan of discharge”, and “to make an appeal of their discharge.” Findings: 1. Record review of the List of Medicare beneficiaries for Inpatient Psychiatric Units (PUs), dated 3/28/24, provided by the facility indicated, there were five (5) Medicare beneficiary patients (Patients 25, 27, 28, 29, and 31) in 7B, Inpatient PU and 10 Medicare beneficiary patients (Patients 5, 6, 8,11,13, 14, 30, 32, 33, and 34) in 7C, Inpatient PU. In a concurrent record review and interview on 3/27/24 at 3:25 PM, with the Registered Nurse/Care Coordinator (RN/CC 1), the standard notice titled, “Important Message to Medicare (IM)” form could not be found in the Electronic Health Record (EHR). The RN/CC 1 stated, all forms that the patients signed should be scanned and the “Eligibility” staff was responsible to get the form signed and scanned it in the EHR. In an interview on 4/2/24, at 10:32 AM, with the Patient Access Manager (PAM), PAM stated, the purpose of providing the notice of IM was to notify patients of their “rights on admission”, “notify them of the care” they were receiving in the hospital, their “plan of discharge”, and “to make an appeal of their discharge”. The PAM stated, the facility should provide the Notice of IM to the Medicare beneficiary patients within two (2) days of admission and within two (2) days prior to discharge and for admitted patient who were incapacitated the Patient Access staff would note on the form “unable to sign”. In a follow -up interview on 4/2/24 at 10:45 AM, with the PAM stated, the Notice of IM was provided to the patients in every admission in the hospital and for the Inpatient PUs the notice of IM was not provided directly to the patients, “we are not issuing the IM” for patients admitted in the Inpatient PUs, “we do not go to the unit,” and the Patient Access staff would note on the Notice of IM form “unable to sign d/t psychiatric condition.” The PAM stated, through her knowledge, the fact that they (patients) were admitted as inpatient in the PUs they “do not have the mental capacity.” The Patient Access staff would choose the drop down “unable to sign” on the Electronic Health Record (EHR) and would scanned the Notice of IM form in the EHR with the note, “unable to sign d/t psychiatric condition.” The Patient Access staff have not reached out to the nursing staff in the Inpatient PUs to determine the patient’s mental capacity or if patients have legal representatives, the hospital policy did not identify if patient has legal representatives, and to reach out to them when patient can’t sign the Notice of IM. When asked why the Notice of IM should be provided to Medical beneficiary patients admitted in the inpatient PUs, PAM stated, if the notice of IM was not provided to the patients, patients “are not notified of the patient’s rights.” Review of the facility’s Policy and Procedure titled, “An important Message from Medicare about Your rights,” with the last revised date of 8/3/19 indicated, “Procedure: 1. Admitted Medicare patients ... will be provided the MEDICARE PATIENT RIGHTS (MPR), Form CMS-R-193. 2. On admission, ... the Admission Eligibility worker (EW) will obtain the patient signature and the Medicare patient Rights Form. The Medicare Patient Rights Form will be scanned in EPIC (name of the facility software). ... 4. On Admission, if the patient is not mentally able due to medical condition, the Inpatient EW will note the form with patient unlable to sign. ... 6. The Medicare Patient Rights Form is scanned into EPIC (name of the facility software) ... .””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 31794 Based on interviews and record reviews, the facility failed: 1. To ensure 50 of 50 patients admitted to the Inpatient Psychiatric Units (PUs: 7B, 7C, and 7L Nursing Units) were given information on the “Terms and Condition of Admission (COA, a contract between the hospital and the patient)” when the Term and COA was not provided and was not signed by the patients admitted in the Inpatient PUs. This deficient practice resulted in the potential for patients admitted to the inpatient PUs to not exercise their rights to “consent to hospitalization and receive routine services”. 2. To ensure and promote the patient’s rights to be free of pain for one of 30 sampled patients (Patient 12) when pain assessment (an evaluation that measures the intensity, nature, duration, and location of pain) was not done before administration of pain medication and pain re-assessment was not done according to policy facility. This deficient practice had the potential to lead to inadequate pain management outcomes and can negatively affect the physical, emotional, and psychosocial well-being of patients. Findings: 1. During the Entrance Conference and group interview on 3/25/24, at 9:20 AM, with the Interim Director of Psychiatry Unit (DoP), the Quality Management Nurse (QMN 1), the Nurse Managers (NM 1 and 2), NM 1 stated, the inpatient Psychiatry Units (PUs) consisted of: 7B which was the acute inpatient PU, 7C which was the long term inpatient PU, and 7L the locked inpatient PU for inmates admitted to the hospital, it was also called the “Jail unit.” The NM 1 stated, the census for 7B was 22, for 7C it was 22, and for 7L it was six (6), total census of 50. During a concurrent record review and interview on 3/28/24, at 11:07AM, with the Registered Nurse Care Coordinator (RN/CC 1), the Terms and Condition of Admission (COA) form were missing in the Electronic Health Record (EHR). The RN/CC 1 stated, most of the patients admitted in the inpatient PUs were on legal hold (involuntary psychiatric hold), patients would sign the “Admission to Inpatient Psychiatric Services” form or their legal representative if incapacitated, but not the Term and COA form. Review of the document titled, “Admission to Inpatient Psychiatric Services” dated 5/23 indicated, “... I understand that my proposed care and treatment will be explained to me ... I understand that ... Psychiatric Inpatient Services provide clinical experience for variety of health/behavioral health trainess. I understand these individuals, ... may provide treatment to me. I understand that my treatment records are confidential ... The condition of my admission and my rights have been explained to me fully ... voluntarily agree to accept those conditions. ... .” During a group interview on 3/25/24, at 2:45 PM, with the Medical Director of Inpatient Psychiatric Units (MDIP), Attending Physician 1, and In-House Physician 1, In -House Physician 1 stated, Patient 6 was admitted with the diagnosis of major depression (mood disorder) and was placed on four (4) point restraint (restraint placed on both arms and both legs. Restraint is any device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, as define in the facility policy) due to imminent danger to self. The In-House Physician 1 further stated, during the course of the patient’s stay in the inpatient UP, Patient 6 developed a medical problem, “UTI (urinary tract infection, bacteria gets into your urine and travels up to the bladder or in any part of the urinary system)” and was given medical treatment, an “antibiotic.” In an interview on 4/2/24, at 8:35 AM, with the Interim Director of Psychiatry (DoP), the NMs 1 and 2, NM 1 stated, ninety-eight (98) to ninety-nine (99) percent of patients admitted in the Inpatient PUs were on “legal hold” and the legal hold was “only for psychiatric care”, not for medical care. The NM 1 further stated, when patients developed medical problems during the course of their stay in the inpatient PUs, the physician talked to the patients, they explained the issue to the patient, and they get a medical consult. The interim DoP stated, patients admitted in the inpatient PUs “do not” sign the COA form, “they should sign it.” The interim DoP explained, the facility had started a “Workflow”, “last week” to get the COA form signed by patients admitted in the inpatient PUs and the facility wanted to get the Workflow started right away and eventually, it would be on “electronic “form. In an interview on 4/2/24, at 10:15 AM, with Patient Access Manager (PAM) with QMN 3 present, PAM stated, the COA consist of getting patient’s consent for treatment, certain privacy requirement, access to different care areas in the hospital, disclosure of information for services rendered and to initiate care.” The PAM stated, for inpatient PUs getting the patients to sign the COA was handled by the Psychiatry Unit staff, not by the Patient Access staff. The PAM stated, the Patient Access staff was responsible for getting patients to sign the COA for the medical acute units, elective surgery procedure, Emergency Room, and Outpatient Patient services.” In an interview on 4/3/24 at 2:01 PM, with the with Interim Chief of Psychiatry (CoP), CoP stated, the COA provided information to patient’s basic expectation with the hospital and get the patient’s agreement, provided information to the patient, and allowed the patient the opportunity to provide or withhold their consent (for admission), “it’s an important thing.” CoP stated legal hold was “only for psych care.” Record review of facility’s Policy and Procedure titled, “Terms and Condition of Admission”, with the last revised date of 8/22 indicated, “Hospital 1 utilizes the Terms and Conditions of Admission form to obtain and document each patient’s consent to hospitalization and routine services ... . Procedure: 1. General Guidelines: A. Obtaining the Patient’s Consent, 1. Patient Access staff will obtain the appropriate signature on the Terms and Condition of Admission form. ... B. Signature, 1. The Terms and Condition of Admission form mt be signed by the signed by the patient and/or the patients’ legal representative, eg., a parent, ... B. Timing of Signature, 1. The signature of the patient and/or patient’s legal representative should be obtained at the earliest possible opportunity ... .” 38612 2. Review of the Patient 12’s face sheet indicated Patient 12 was admitted on 2/16/24 at 6:20 AM to PU with diagnosis of major depressive disorder with recurrent, severe psychotic features (symptoms that affect the mind where there has been some loss of contact with reality). Review of Patient 12’s Medication Administration Record (MAR) indicated Patient 12 was given Acetaminophen 650 mg on 3/11/24 at 12:20 PM for the physician-ordered “acetaminophen (TYLENOL) tablet 650 mg (milligrams) Ordered Dose: 650 mg, Route: oral, Frequency: Every 6 hours PRN (as needed) for temperature over 38 degrees C (Celsius- a scale for measuring temperature), mild pain (pain score 1-3),” with a start date of 2/22/24 and end date of 3/27/24. Review of Patient 12’s “Pain Assessment (PA),” dated 2/16/24 to 3/27/24 indicated Patient 12 was assessed and reported no pain at 8 AM on 3/11/24. There was no PA prior to administration of Acetaminophen 650 mg to Patient 12 on 3/11/24 at 12:20 PM. Additionally, Patient 12 was not reassessed for pain until 3/12/24 at 8 PM (31 hours and 30 minutes after administration of Acetaminophen on 3/11/24 at 12:20 PM). During a concurrent interview and record review with Charge Nurse (CN) 1 with QMN 2 present, on 4/2/24 at 2:36 PM, CN 1 reviewed Patient 12’s MAR dated 3/8/24 to 3/17/24. Patient 12’s MAR indicated an order of “acetaminophen (Tylenol) tablet 650 mg (milligrams) Dose: 650 mg, Freq (frequency): Daily Route: oral, Indications of Use: toothache.” Further review of Patient 12’s MAR indicated “03/13 [3/13/24] 0924 [9:24 AM] ... (650 mg - Given).” CN 1 also reviewed Patient 12’s PA dated 2/16/24 to 3/27/24. The PA indicated Patient 12 reported toothache with a pain scale of 8 (indicating severe pain) on 3/13/24 at 9:24 AM. Further review of the Patient 12’s PA indicated Patient 12 was reassessed for pain on 3/13/24 at 12 PM (Two [2] hours and 30 minutes after Patient 12 was administered pain medication). CN 1 stated reassessment for pain was conducted “usually in one hour” after pain medication was given to the patient. During an interview with NM 1 and DoP, with QMN 1 present, on 4/3/24 at 9:18 AM, NM 1 stated pain reassessment is conducted one hour after pain medication administration, “only for PRN orders, so that we (staff) will know if medication is effective for them (patients).” During a concurrent interview with Clinical Pharmacist for Psychiatry (CPP), with QMN 1 present, on 4/3/24 at 3:59 PM, the CPP stated Tylenol (acetaminophen) is an immediate release pain medication and patient should be checked “in 30 minutes to one hour.” The CPP stated reassessment is important “to check if pain medication helped with the pain level.” The CPP answered “Yes,” when asked if the patient has the right to feel comfortable. Review of the document titled, “Patient Safety and Quality: An Evidence-Based Handbook for Nurse,” dated 4/08, provided by the CPP on 4/3/24 at 3:59 PM indicated “Chapter 17- Improving the Quality of Care Through Pain Assessment and Management. Assessment of Pain - Assessment of pain is a critical step to providing good pain management...lack of pain assessment was one of the most problematic barriers to achieving good pain control ... Principle of Analgesic Management of Pain. Based upon evidence and clinical practice, there are several principles of analgesic management to meet the objective of preventing moderate to severe pain ... Assessment of effect should be based upon the onset of action of the drug administered; for example ... oral opioids (a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant) and nonopioids are reassessed 45-60 minutes after administration. Review of the facility’s policy and procedure (P&P) titled, “Assessment and Management of Pain,” last revised on 1/23 indicated “Purpose: The purpose of this policy is to provide guidelines for the assessment and management of pain for patients at (Hospital 1’s name). Statement of Policy: It is the policy of (Hospital 1) that pain is comprehensively assessed and managed. The assessment and plan of care for pain management will be based on general pain management practices and, as relevant, specialty pain management guidelines defined by the scope of care of the unit or service area ... Procedure: I. Assessment of Pain ...A. Pain should be assessed when the patient first presents for care and continue to be assessed as warranted by the patient’s needs or condition ... C. An assessment is made to determine if pain is present, and the findings are documented in the patient’s medical record ... D. Based on the nature of the pain, the assessment may include: History. A. Intensity standard is on a 0-10 scale: no pain = 0, mild = 1-3, moderate = 4-6, severe = 7-10 ... II. Reassessment for Pain ... A. The patient will be reassessed by healthcare providers. The pain intensity and other relevant information will be documented in the patient’s medical record. Pain reassessment is required after treatment, activities, procedures that may worsen pain, and after non pharmacologic (Referring to therapies that do not involve drugs/medications) and pharmacologic (the treatment of disease through the application of medications) interventions. Timing for reassessment is dependent on the intervention. Recommended reassessment times ... 2. Pharmacologic interventions: i. Between 15-90 minutes following immediate release (fast acting and short-lasting) PO (per orem - by mouth) ... analgesics (medications that relieve different types of pain) ...””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 31794 Based on interview and record review the facility failed to ensure patients participated in the development of their Plan of Care for seven (7) of 30 sampled patients (Patients 17,19, 22, 23, 24, 27, and 28) when: 1. For Patient 17, there was no Care Plan (CP, is a document that outlines the patient’s healthcare needs, goals, and the nursing interventions) developed on admission. 2. For Patient 19, there was no Discharge CP developed on admission. 3. For Patient 22, there was no CP developed on admission. 4. For Patient 23, there was no CP developed on admission. 5. For Patient 24, there was no CP developed on admission. 6. For Patient 27, there was no CP developed on admission. 7. For Patient 28, there was no CP developed on admission. These deficient practices had resulted in the potential to not “identify patient’s centered goals and barriers to physical and mental health” and not meet the patient’s “functional level, medical, social” and psychological needs which may result in not providing adequate communication to assist/help patients transition to the “next level of care.” Findings: 1.Review of the Face sheet dated 4/2/24 indicated Patient 17 was admitted in the inpatient Psychiatric Unit (PU), 7B, on 2/28/24. Record review of the H & P (History and Physical), Initial Encounter Note, dated 2/28/24 indicated, patient with “extensive psychiatric and forensic history” who was brought in the by the ambulance “after spitting/aggressive towards children on street.” The Principal Diagnosis was schizoaffective disorder (mental illness that can affect thoughts, mood and behavior), bipolar type (extreme fluctuation in a person’s mood, energy, and ability to function). In a concurrent record review and interview on 2/28/24, at 9:05 AM, with the Registered Nurse /Care Coordinators (RN/CC 1) and the Quality Manger Nurse (QMN 1), the Care Plan (CP) was reviewed. After searching the Electronic Health Record (EHR), the RN/CC 1 stated, “I don’t have any Care Plans (CPs)”, CPs start at the time of admission, updated “every week for 6 (six) weeks, and then every “30 days”. The RN/CC1 stated, the Registered Nurse should start CPs on admission, there was an Interdisciplinary Plan of Care (IPOC) meeting done were patient’s goals and interventions were discussed, and the development of nursing CPs was separate from IPOC meeting. The RN/CC 1 further stte, there has to be CPs and there has to be an IPOC meeting to discuss the CPs, “we do not” have a policy that states the IPOC could replace the CPs. 2. Review of the Face Sheet, dated 3/27/24 indicated, Patient 19 was admitted in the inpatient PU, 7B, on 2/12/24. Record review of the H & P Initial Encounter Note, dated 2/13/24 indicated, patient was brought in by the ambulance “after endorsing AH (auditory hallucinations, hearing voices)”, “Floridly disorganized”, “unable to engage with treatment staff’, and “continued to struggle with disorganized, erratic and bizarre Bx (behavior) including refusing to be clothed, fecal smearing, urinating in own room, sexual and odd gestures.” The Principal Diagnosis included, “bipolar disorder (extreme fluctuation in a person’s mood, energy, and ability to function), r/o (rule out) substance induced psychosis (symptoms that affect the mind, where there has been some loss of contact with reality), opiate dependence (physical dependence on opioids, a controlled substance) d/o (disorder), and stimulant dependent (continued use of stimulants despite harm to the person) d/o.” In a concurrent record review and interview on 3/27/24, at 2:40, with the RN/CC 1 and the QMN 1, the Psychiatry Social Worker Initial Note (PSWIN), dated 2/13/24 at 7:50 AM, was reviewed. The CO 1 explained, the population the facility serve was “unique”, patients have “neglected health”, for a lot of patients there was not enough community resources to find appropriate placement, and discharge planning should start on admission. The CO 1 stated, the PSWIN did not have the documentation of discharge planning on admission, the discharge planning was discussed during the daily Interdisciplinary meeting and for Patient 19, nothing was documented on discharge planning, “we are missing” the Social Worker Note, the “re-assessment”, the “Transition Note”, and “Discharge Planning.” The CO 1 stated, the Social Work’s role was to gather collateral information and inform the patient/legal representative, and the LCSW 2 who followed Patient 19 no longer work in the inpatient Psychiatry Unit. The CO 1 stated the only documentation on discharge plan was done by the Physician on the Psychiatric Progress Note, dated 3/26/224 at 2:05 PM, “Discharge Plan: Home, shelter”, Residential Treatment 1. Review of the facility’s Policy and Procedure (P & P) titled, “Discharge Planning Process” with the last review date of 12/22 indicated, “Purpose: The purpose of this policy is to define the process by which the patient discharge goals and objectives are developed, updated, and communicated to the next level of care for every patient admitted to the inpatient unit ... Statement of Policy: Immediately upon admission, from the initial psychiatric assessment (IPA) the interdisciplinary team will focus on then recovery of the patient and begin the process of discharge planning that will continue through the entire course of treatment. ... Procedure: A. ... C. Social work ... conduct initial assessment to evaluate patient’s functional level, medical, social, and functional history as it relates to patient discharge needs. D. ... Social work will determine the patient’s community supports as part of the initial assessment. ... .” 3. Review of the Face sheet, dated 3/28/24 indicated, Patient 22 was admitted the inpatient PU, 7B, on 3/7/24. Record review of the H & P Initial Encounter Note, dated 3/8/24 indicated, “trauma history”, “multiple substance use disorder” and the Principal Diagnosis was schizophrenia (mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality). In a concurrent record review and interview on 3/28/24, at 9:15 AM, with the RN/CC 1 and the QMN 1, the CP was reviewed. The RN/CC1 stated, “we do not have any care plans.” The RN/CC 1 stated, there was an IPOC meeting done to discuss the patient’s goals and interventions, the IPOC meeting is a “stand alone”, and development of CPs was required on admission. 4. Record review of the Patient Demographics, dated 3/28/24 indicated, Patient 23 was admitted in the inpatient PU on 3/16/24. Record review of the H & P Initial Encounter Note, dated 3/24/24 indicated, patient with history of schizophrenia and amphetamine (stimulant drug) use disorder, recently presented to the Emergency Room for “episodic aggression”, was brought in the by the ambulance “from jail after being unable or unwilling to focus and answer questions”, “attempting to kick the emergency department resident physician, unable to follow directions requiring multiple rounds of emergent psychiatric” medications. The Principal Diagnosis was “psychosis (symptoms that affect the mind when the person loss contact with reality) not due to a substance or known physiologic condition. In a concurrent record review and interview on 3/28/24, at 10:31 AM, with the RN/CC 1 and the QMN 1, the CP was reviewed. The CC 1 stated, there was no CPs developed on admission, the IPOC met to discuss the patient’s goals and interventions. 5. Review of the document Patient Demographics, dated 3/28/24 indicated, Patient 24 was admitted to the inpatient PU, on 2/21/24. Record review of the H & P Initial Encounter Note, dated 2/21/24 indicated, patient with history of schizophrenia, was “alert, grossly oriented to situation”, and “poor attention span, easily distracted,” the Principal Diagnosis was schizoaffective disorder. In a concurrent record review and Interview on 3/28/24, at 10:53 AM, with the RN/CC 1 and QMN 1, the CP was reviewed. The RN/CC 1 stated, there was “no care plan” developed on admission and the IPOC meeting was done every week. 6. Review of the List of Patients on 7B Acute Psychiatric Unit, dated 3/28/24 indicated, Patient 27 was admitted on 3/22/4 and the Admission Diagnosis was “schizoaffective disorder, bipolar type”. In a concurrent record review and interview on 4/2/24, at 2:24 PM, with the RN/CC 1 and QMN 3, the CP was reviewed. The RN/CC 1 stated, there was “no care plan”, there should be an admission care plan. The RN/CC 1 further stated, the IPOC meeting was done on 3/27/24 and creating and developing the care plan was different from the IPOC meeting/discussion. 7. Review of the List of Patients on 7B Acute Psychiatric Unit, dated 3/28/24 indicated, Patient 28 was admitted on 3/21/24 and the Admission Diagnosis was “stimulant use disorder (continued use of stimulants despite harm to the user), depression (constant feeling of sadness and loss of interest which stops a person from doing normal activities).” In a concurrent record review and interview on 4/2/24, at 2:35 PM, with the RN/CC 1 and QMN 3, the CP was reviewed. The RN/CC1 stated, no CP was done on admission. In an interview on 4/3/24, at 9:18 AM, with the Nurse Manager (NM 1), the Interim Director of Psychiatry (DoP), and the QMN 1, NM 1 stated, the CPs shoud be developed “upon admission”, the nursing staff doing the admission was responsible for the development of the CPs, so they (staff) could start taking care of the patient and the staff would be aware of the patient’s special needs, and the developemnt of CPs was “different” from the IPOC meeting/discussion. Review of the facility’s P & P titled, “DPH (Department of Public Health) EHR (Electronic Health Record) Care Plan and Patient Education Policy”, with the last review date of 11/23 indicated, “2. Policy. 1. DPH sites comply with any and all regulatory requirements for documentation of care plan ... 3. All plans of care shall include evidence of: a. assessment/evaluations to identify patient centered goals and barriers to physical and mental health. b. development of plans and interventions to address barriers and move towards goals, ... .” Review of California Code of Regulations, Chapter 1. General Acute Care Hospitals, ...Article 3. Basic Services ... 70215, Planning and Implementing Patient Care. (a) A Registered nurse shall directly provide: (1) On going patient assessment ... upon receipt of the of the patient when he/she is transferred to another patient care area. ... .” Review of the facility’s P & P titled, “Hospital Plan for Provision of Patient Care, with the last revised date of 10/22 indicated. “III. Provision of Care, A. ... D. The entry process includes an assessment of patient’s needs ... 1. Patient Care Plan. Hospital 1 meets the identified needs of patients ... 3. Before and at Discharge. Discharge Planning is an important component in the coordination of patient care that focuses on the patients’ health care needs after discharge and begins on admission ... .””

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 31794 Based on interviews and record reviews the facility failed to ensure the Advance Health Care Directive (AHCD, [also called Advance Directive, AD], is a patient instruction that state their choices for medical treatment and/or designates who should make treatment choices if the patient lacks medical decision-making capacity, as define in the facility policy) was provided to three (3) of 30 sampled patients (Patient 18, 19, 23, and 24) when: 1. For Patient 23, the AHCD was not provided on admission. 2. For Patient 24, the AHCD was not provided on admission. 3. For Patient 19, no follow up was done to assist the patient to formulate an AHCD. This deficient practice resulted in the potential for patient’s inability to exercise their rights to make decisions concerning their medical care including the right to accept or refuse medical care. Findings: 1. Record review of the Patient Demographics dated 3/28/24 indicated, Patient 23 was admitted in the inpatient PU on 3/16/24. Record review of the H & P Initial Encounter Note, dated 3/24/24 indicated, patient with history of schizophrenia (mental illness that can affect thoughts, mood and behavior) and amphetamine (stimulant drug) use disorder, recently presented to the Emergency Room for “episodic aggression”, was brought in the by the ambulance “from jail after being unable or unwilling to focus and answer questions”, “attempting to kick the emergency department resident physician, unable to follow directions requiring multiple rounds of emergent psychiatric” medications. The Principal Diagnosis was “psychosis not due to a substance or known physiologic condition.” In a concurrent record review and interview on 3/28/24, at 10:10 AM, with the RN/CC 1 and the QMN 1, the Flowsheet Data dated 3/16/24, was reviewed The RN/CC 1 stated, the AD was not marked on the Flowsheet and after searching the Nursing Notes (NN) dated 3/16/24, the RN/CC 1 stated, she did not find documentation the AD was offered. The RN/CC 1 further stated, the nursing staff should filled up the Flowsheet within “24 hours” and the facility policy did not state there was a system in place to provide the AD to patients who were are incapacitated. 2. Review of the Patient Demographics dated 3/28/24 indicated, Patient 24 was admitted to the inpatient PU, on 2/21/24. Record review of the H & P Initial Encounter Note, dated 2/21/24 indicated, patient with history of schizophrenia, was “alert, grossly oriented to situation”, and “poor attention span, easily distracted,” the Principal Diagnosis was schizoaffective disorder (a mental health problem where a patient experience psychosis as well as mood symptoms). In a concurrent record review and interview on 3/28/24, at 10:40 AM, with the RN/CC 1 and the QMN 1, the Flowsheet dated 2/21/24 and the NN dated 2/21/24, were reviewed. The RN/CC 1 stated, the patient was alert and oriented, was cooperative on admission, and the AD was “not marked” on the Flowsheet. The RN/CC 1 stated, the NN dated 2/21/24 indicated, patient was “appropriate to make needs known” and the “Social Worker (SW)” Note on 2/21/24 indicated, patient was “unwilling to engage due to altered mental status”, patient “was focus on getting to a place in a hotel.” The RN/CC 1 stated, the SW should follow up with the patient, there was a lack of follow up and clear guidance on how to proceed if patient was not able to participate in the AD assessment. The RN/CC 1 further stated, the interdisciplinary clinical approach on how to get the patient’s AD need to be “clarified”, there was a need to “evaluate” the policy and “make amend” on the policy. Review of the facility’s Policy and Procedure (P & P) titled, “Advance Health Care Directives”, with the last revised date of 6/19 indicated, “Purpose: ... 4. To provide assistance to the patient who wishes to make his/her treatment preference known. The process should protect patient’s right to participate in health care decision making ... Procedure: I. In the Primary Care Clinics ... II. In the Acute Care Setting, ... III. Advance Health Care Directives in the Acute Psychiatric Units. In the Acute Psychiatric Units ... the Registered Nurse will ask the patient if an Advance health Care Directives has been executed. ... Patients who indicate thta they have executed an Advance Health Care Directive shall be asked to provide ... If the patient requests more information ... .” The AHCD policy in the Acute Psychiatric Units did not mention the process on how to proceed if the patient was incapacitated. 3. Review of the 3/27/24 Face Sheet indicated, Patient 19 was admitted in the inpatient Psychiatric Unit, 7B, on 2/12/24. Record review of the H & P (History and Physical) Initial Encounter Note, dated 2/13/24 indicated, patient was brought in by the ambulance “after endorsing AH (auditory hallucinations, hearing voices)”, “Floridly disorganized”, “unable to engage with treatment staff’, and “continued to struggle with disorganized, erratic and bizarre Bx (behavior) including refusing to be clothed, fecal smearing, urinating in own room, sexual and odd gestures.” The Principal Diagnosis included, “bipolar disorder (extreme fluctuation in a person’s mood, energy, and ability to function), r/o (rule out) substance induced psychosis (symptoms that affect the mind, where there has been some loss of contact with reality), opiate dependence (physical dependence on opioids, a controlled substance) d/o (disorder), and Stimulant dependent (continued use of stimulants despite harm to the person) d/o.” In a concurrent record review and interview on 3/27/24, at 11:42 AM, with the Registered Nurse/Care Coordinator (RN/CC 1) and the Quality Management Nurse (QMN 1), the Flowsheet Data, dated 2/12/24, for Patient 19 was reviewed. The Flowsheet Data did not indicate the patient had an Advance Directive (AD). The RN/CC 1 explained, on admission the Registered Nurse would inquire with the patient or legal representative if the patient has an AD, the Social Worker (SW) would document the existence of an AD, and if the patient wishes to formulate an AD the SW would provide assistance. In a concurrent record review and interview on 3/27/24 at 11:57 AM, with the RN/CC 1 and the QMN 1, the Psychiatry Social Work Initial Assessment (PSWIA), dated 2/13/24 at 7:50AM, was reviewed. The PSWIA indicated, “Advance Directive: Patient accepted. This writer will inform the Physician.” The RN/CC 1 stated, the patient had expressed desire to get an AD, there should be a follow up to notify the Physician, and after searching the entire Electronic Health Record, RN/CC 1 verified, there was no follow up documentation the Physician was notified. In an interview on 4/2/24, at 9:20 AM, with the Director of Psychiatric Social Work (DPSW) the Social Work assistant (SWA), the DPSW stated, the AD was part of the Social Work’s responsibility, if the patient was interested to formulate an AD, then the Provider (Physician) should be notified, and the Provider would have a conversation with the patient. The DPSW stated, if there was no documentation then the Physician was not notified, and the SW note was “lacking in terms of follow-up.” Review of the facility’s Policy and Procedure (P & P) titled, “Advance Health Care Directives”, with the last revised date of 6/19 indicated, “Procedure: I. In the Primary Care Clinics ... III. Advance Health Care Directives in the Acute Psychiatric Units. In the Acute Psychiatric Units ... If the patient requests more information a referral is made to the Psychiatric Social Service. If the patient wishes to make an Advance Health Care Directive, a referral is made to the Physician.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(7) The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. This Standard is not met as evidenced by: 31794 Based on interviews and record reviews, the facility failed to ensure the Attending Physician was consulted in the use of Seclusion (a form of restraint; the involuntary confinement of a person in a locked or unlocked room or area where the person is physically prevented from leaving, as defined by the facility policy) for one of 30 sampled patients (Patient 19) when the co-signature of the Attending Physician was missing on the “Psychiatric Significant Event Note,” dated 3/16/24, completed by the In-House Physician 2, indicating the patient was placed on Seclusion. This deficient practice had the potential to impact the selection for the most appropriate interventions to use to provide safety and continuity of care for the patient. Findings: Review of the 3/27/24 Face Sheet indicated, Patient 19 was admitted in 7B, inpatient Psychiatric Unit on 2/12/24. Record review of the H & P Initial Encounter Note, dated 2/13/24 indicated, patient was brought in by the ambulance “after endorsing AH (auditory hallucinations, hearing voices)”, “Floridly disorganized”, “unable to engage with treatment staff’, and “continued to struggle with disorganized, erratic and bizarre Bx (behavior) including refusing to be clothed, fecal smearing, urinating in own room, sexual and odd gestures.” The “Current Medical Necessity and Rationale for Hospitalization” indicated, “Recent significant deterioration in functioning as a result of mental illness: ... Patient noted disorganized in BART (Bay Area Railway Transit, a public form of transportation) train/station, with internal preoccupation and unable to express reality-based plan for self and Requiring Psychiatric Evaluation as a result of mental illness.” The Principal Diagnosis included, “bipolar disorder (extreme fluctuation in a person’s mood, energy, and ability to function), r/o (rule out) substance induced psychosis (symptoms that affect the mind, where there has been some loss of contact with reality), opiate dependence (physical dependence on opioids, a controlled substance) d/o (disorder), and Stimulant dependent (continued use of stimulants despite harm to the person) d/o.” Review of the Order History, dated 3/16/24 indicated, “Start date/time”: 3/16/24 at 4:30 PM, Restraint type, “Seclusion”, Violent restraint reason: “imminent danger to others”, Patient behavior: “pacing, challenging to redirect, made movements/references towards assaulting another patient,” and the “Good cause /clinical justification for denial of rights” indicated, “Patient has a hx (history) of assaultive bx (behavior) on the unit.” In a concurrent record review and interview on 3/27/24, at 10:17 AM, with the Registered Nurse Care Coordinator (RN/CC 1) and the Quality Management Nurse (QMN 1), the Psychiatric Significant Event Note, dated 3/16/24 at 4:56 PM, was reviewed. The Psychiatric Significant Event Note, dated 3/16/24 at 4:56 PM, had the electronic (e) signature of In-House Physician 2 but did not have the (e) signature of the Attending Physician. The RN/CC 1 stated, Patient 19 was on seclusion from 2/17/24 up to 3/7/24 and the seclusion was renewed on 3/16/24 because the patient was making intense eye contact and rubbing his hands together with a new patient admitted in the unit. Because of the patient’s history of an unprovoked assault with another patient in the unit, the patient was placed on a locked seclusion on 3/16/24 at 4:30 PM. The RN/CC 1 verified, the Psychiatric Significant Event Note, dated 3/16/24 at 4:56 PM, was not co-signed by the Attending Physician, it “should be” co-signed. RN/CC 1 stated, the Attending Physician 2 was the “back up” Physician on 3/16/24, “I don’t see her signature.” In an interview on 4/3/24, at 5:50 PM, with the Interim Chief of Psychiatry (CoP) and the QMN 1, Interim CoP stated, members of the staff should counter sign the Progress Notes done by the In-House Physicians. Record review of the facility’s document titled, “Medical Staff Rules and Regulations”, with the last revised date of 7/20 indicated, “1. ... E. Each hospitalized patient shall be evaluated everyday by a Member or his /her designee, and a note shall be recorded in the medical record. ... 8. House Staff: A. Medical Staff Members shall supervise House Staff ... .””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (ii) After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, 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 must see and assess the patient. This Standard is not met as evidenced by: 31794 Based on interviews and record reviews, the facility failed to ensure the Plan of Care addressing the use of Restraints (any mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, as define in the facility policy) and/or Seclusion (a form of restraint; the involuntary confinement of a person in a locked or unlocked room or area where the person is physically prevented from leaving, as defined by the facility policy ) were developed based on the ongoing assessment for three (3) of six (6) sampled patients (Patients 17, 19, and 20) when: 1. For Patient 17, there was no Care Plan developed to address the use of Four (4) Point Restraints (restraint placed on both arms and both legs at the same time) on 3/10/24 and for the use of Seclusion on 3/11/24. 2. For Patient 19, there was no Care Plan developed to address the use of Seclusion on 3/16/24. 3. For Patient 20, there was no Care Plan developed to address the use of four (4)-point restraint (restraint applied on both arms and both legs) on 3/20/24. This failure had the potential to impact the quality of care delivered in meeting the patient’s “set goals and treatment” and to not be able to evaluate their progress in recovery/rehabilitation process. Findings: 1.Review of the 4/2/24 Face Sheet indicated Patient 17 was admitted in the acute Inpatient Psychiatric Unit (PU), 7B, on 2/28/24 at 2:23 AM. Record review of the History and Physical (H & P), Initial Encounter Note, dated 2/28/24 at 8:34 AM indicated, patient with “extensive psychiatric and forensic history” who was brought in the by the ambulance “after spitting/aggressive towards children on street.” The Principal Diagnosis was schizoaffective disorder (mental illness that can affect your thoughts, mood and behavior), bipolar type (extreme fluctuation in a person’s mood, energy, and ability to function). Review of the March 2024 Seclusion and Restraint Log indicated, a four (4)-Point Restraint was placed on Patient 17 on the following dates: On 3/10/24, at 3:25 PM and was discontinued on 3/10/25 at 5:05 PM. On 3/10/24, at 5:10 PM and was discontinued on 3/10/24 at 9:10 PM. On 3/11/24, at 6:30 PM and was discontinued on 3/11/24 at 10:30 PM. Review of the March 2024 Seclusion and Restraint Log indicated, Patient 17 was placed on Seclusion on the following dates: On 3/10/24, at 9:10 PM and was discontinued on 3/11/24 at 4:15 PM. On 3/11/24, at 10:30 PM and was discontinued on 3/11/24 at 11:30 PM. In a concurrent record review and interview on 2/28/24, at 9:05 AM, with the Registered Nurse /Care Coordinators (RN/CC 1) and the Quality Manager Nurse (QMN 1), RN/CC 1 stated, the Care Plan (CP) was reviewed. After searching the Electronic Health Record (EHR), the RN/CC 1 stated, “I don’t have any Care Plans”, there was an interdisciplinary Plan of Care (IPOC) meeting, and the goals and interventions were discussed in IPOC. The RN/CC 1 stated, CPs should be “started at the time of admission”, updated every “week”, till 6 weeks and then every “30 days”. The RN/CC 1 stated, there has to be a CP, and there has to be an IPOC meeting, and the facility policy did not indicate the IPOC meeting could replace the development of CPs. 2. Review of the 3/27/24 Face Sheet indicated, Patient 19 was admitted in the acute Inpatient PU, 7B, on 2/12/24 at 9:23 PM. Record review of the document titled, History and Physical (H & P), Initial Encounter Note, dated 2/13/24 indicated, Patient 1 had “Recent significant deterioration in functioning as a result of mental illness” and “Requires containment due to high-risk behaviors.” The Principal Diagnosis included, “bipolar disorder, r/o (rule out) substance induced psychosis (symptoms that affect the mind, where there has been some loss of contact with reality), opiate dependence (physical dependence on opioids, a controlled substance) d/o (disorder), and Stimulant dependent (continued use of stimulants despite harm to the person) d/o.” Review of the March 2024 Seclusion and Restraint Log indicated, Patient 19 was on Seclusion from 3/16/24 at 4:50 PM and Seclusion was discontinued on 3/22/24 at 2:04 PM. In a concurrent record review and interview on 3/27/24, at 1:23 PM, with the RN/CC 1 and the QMN 1, the Care Plan (CP) for Patient 19 was reviewed. The RN/CC 1 stated, for Patient 19 the seclusion order was renewed on 3/16/24 because the patient was making intense eye contact and rubbing his hands together with a new patient admitted in the unit. Because of the patient’s history of an unprovoked assault with another patient in the unit, the patient was placed on a locked seclusion on 3/16/24 at 4:30 PM. After searching the EHR, the RN/CC 1 verified there was no CP developed “since admission” to address the goals and interventions on seclusion and stated, the nursing staff were “not consistent” in developingthe CPs, “we’re working on it.” 3. Review of the 4/2/24 Face Sheet indicated Patient 20 was admitted in the acute Inpatient PU, 7B, on 3/5/24 at 10:40 PM. Record review of the document titled, History and Physical (H & P), Initial Encounter Note, dated 3/6/24, at 8:09 AM indicated, Patient 20 have “delusions (false belief about external reality) surrounding food being poisoned and the Principal Diagnosis was psychosis (mental disorders that cause abnormal thinking and perceptions). Review of the March 2024 Seclusion and Restraint Log indicated, a Four (4)-Point Restrained placed on Patient 20 the following dates: on 3/20/24, at 6:10 PM and was discontinued on 3/21/24, at 10:00 AM. On 3/23/24, at 11:30 PM and was discontinued on 3/24/24, at 2:12 PM. In a concurrent record review and interview on 3/27/24, at 2:28 PM, with the RN/CC 1 and the QMN 1, the Care Plan (CP) was reviewed. After searching the EHR, the RN/CC 1 verified there was no CP developed to address the use of Restraints on 3/20/24. The RN/CC 1 stated, the template for the CP was in place, but the CP was not initiated. In an interview on 3/27/24, at 1:35 PM, with the RN/CC 1 and QMN 1, RN/CC 1 stated, Care Plan was important because it “guides the treatment”, staff can assess if patient was meeting the set goals, treatment, and interventions and evaluate if patient was progressing or not. Review of the facility Policy and Procedures titled, “Care Plan and Patient Education Policy”, with the last review date of 11/23 indicated, “1. Purpose of Policy ... 2. Policy 1. ... 3. All plans of care shall include evidence of: a. assessments/evaluation to identify patient centered goals and barriers to physical mental health. b. development of plans and interventions to address barriers and move toward goals. c. The intent to perform patient education regarding their plan of care. ... .””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 31794 Based on interviews and record reviews the facility failed to ensure the Seclusion (a form of restraint; the involuntary confinement of a person in a locked or unlocked room or area where the person is physically prevented from leaving, as defined by the facility policy) was discontinued at the earliest possible time, when the unsafe situation ends, for one (1) of three (3) sampled patients (Patient 19) when, patient was able to “contract for safety” on 3/21/24, at 8:46 AM and the Seclusion was continued to be implemented until the following day, 3/22/24. The Seclusion was discontinued on 3/22/24, at 2:04 PM. This deficient practice had resulted in the potential to impact the patient’s physical and emotional well-being, dignity and safety. Findings: Review of the Face Sheet, dated 3/27/24 indicated, Patient 19 was admitted in the Inpatient Psychiatric Unit, 7B, on 2/12/24. Record review of the document titled, “Initial Encounter Note”, dated 2/13/24 indicated, patient was brought in by the ambulance “after endorsing AH (auditory hallucinations, hearing voices)”, “Floridly disorganized”, “unable to engage with treatment staff’, and “continued to struggle with disorganized, erratic and bizarre Bx (behavior) including refusing to be clothed, fecal smearing, urinating in own room, sexual and odd gestures.” The Principal Diagnosis included, “bipolar disorder (extreme fluctuation in a person’s mood, energy, and ability to function), r/o (rule out) substance induced psychosis (symptoms that affect the mind, where there has been some loss of contact with reality), opiate dependence (physical dependence on opioids, a controlled substance) d/o (disorder), and Stimulant dependent (continued use of stimulants despite harm to the person) d/o.” Review of the Order History, dated 3/16/24 indicated, “Start date/time”: 3/16/24 at 4:30 PM, Restraint type, “Seclusion”, Violent restraint reason: “imminent danger to others”, Patient behavior: “pacing, challenging to redirect, made movements/references towards assaulting another patient,” and the “Good cause /clinical justification for denial of rights: “Patient has a hx (history) of assaultive bx (behavior) on the unit.” In an interview on 4/3/24, at 10:50 AM, with the Nurse Manger (NM 1), NM 1 stated, the criteria for the use of Restraint/Seclusion were imminent Danger to self (DTS) and imminent Danger to others (DTO). Record review of the Nursing Progress Notes (NPN), dated 3/19/24 at 2:39 PM indicated, Patient 1 “was received in seclusion room asleep. He was calm and cooperative ... He was med (medication) complaint ... med were given for yelling and kicking the door. He was observed resting ... No aggressive /assaultive behavior noted.” Record review of the NPN, dated 3/19/24 at 6:29 PM indicated, “No change in behavior. ... rested in bed most of the afternoon. At moment he would kick the door without saying anything. He eventually stop and returned to his bed and he appears to be calm.” Record review of the Nursing Notes, dated 3/20/24 at 6:09 PM indicated, “No change in behavior. ... was quiet for the most part. But a few minutes he continued to kick the door without saying anything. He stop as directed. After dinner he was observed standing at the door crying. He refused to respond ... wiped his tears away then lay in his bed. No other behavior issue noted.” Record review of the Order History, dated 3/19/24 and 3/20/24 indicated, the Seclusion order was renewed every four (4) hours. Record review of the NPN, dated 3/21/24 at 5:26 AM indicated, “when he awoke, he demonstrated poor insight to safety plan and difficulty processing information regarding safety.” Record review of the NPN, dated 3/21/24 at 10:12 PM indicated, “Denied S/I (suicidal ideation, also known as suicidal thought, thoughts of about killing oneself), H/I (homicidal ideation, thoughts about harming/killing others) or psychotic (symptoms that happen when a person is disconnected from reality) sx (symptoms). He was observed laughing to himself ... He was running around his bed and laughing ... He was cooperative with v/s (vital signs, measure the basic functions of the body such as the body temperature, blood pressure, pulse and breathing rate) and medication administration. Showed little insight as to why he was in seclusion.” In a concurrent record review and interview on 3/27/24, at 10:13 AM with the Registered Nurse Care Coordinator (RN/CC 1) and the Quality Management Nurse (QMN 1), the NPN dated 3/19/24 to 3/21/24 were reviewed. The RN/CC 1 stated, there were two (2) criteria for Seclusion which were: patient was unable to contract for safety and patient exhibits behavior that they were not safe. The RN/CC 1 stated, “poor insight” was not a criteria to continue Seclusion. Review of the Order History, dated 3/21/24 at 3:00 AM untill 3/22/24, at 10:44 AM indicated, the order for Seclusion were renewed every four hours and the Seclusion order was discontinued on 3/22/24 at 2:04 PM. In a concurrent record review and interview on 3/27/24, at 10:44 AM, with the RN/CC 1 and the QMN 1, the Flowsheet Data, dated 3/21/24 and 3/22/24, were reviewed. The RN/CC 1 stated, the order for Seclusion was renewed every four hours and the monitoring for Seclusion was done every 15 minutes. Record review of the Physician’s “Psychiatric Progress Notes (PPN)”, dated 3/21/24 at 8:46 AM indicated, “While he contracts for safety, he continues to endorse auditory (hearing voices and sounds despite lack of external source) and visual hallucination (seeing things that are not real) and can be unpredictable in how he reacts to them, ...”, e-signed by the In-House Physician 1 on 3/21/24 at 3:05 PM. Record review of the PPN, dated 3/22/24, at 9:09 AM indicated, “Today and for the past several days, he contracts for safety and identifies coping skills. ...”, e-signed by the In-House Physician 1 on 3/22/24, at 2:00 PM. In a concurrent record review and interview on 3/27/24, at 10:30 AM, with the RN/CC 1 and the QMN 1, the PPN dated 3/21/24 and 3/22/24 were reviewed. The RN/CC 1 stated, the patient was meeting criteria to get off seclusion, in her experience with behavior patients, she noticed that Providers would like to see patient exhibits safety behavior at a certain period before the order for seclusion and/or restraint would be discontinued. When asked what the facility’s policy was to discontinue seclusion, RN/CC 1 stated, the policy was to discontinue seclusion when the criteria was met, which happened on 3/21/24 and the Seclusion was continued untill the following day, on 3/22/24, when it was discontinued. In an interview on 4/3/24, at 3:15 PM, with the NM 1 and the RN/CC 1, the RN/CC 1 stated, when patient was contracted for safety on 3/21/24, a least restrictive measures should have been implemented, example was a “1:1 ( an intervention aimed to keep patients safe through continuous observation of the staff)”, which the patient was currently having “now”. Record review of facility’s Policy and Procedure titled, “Behavior Seclusion and Restraint Policy,” with the last review date of 12/22 indicated, “Statement of Policy, A. The use of seclusion/restraints is limited to situation where there is imminent risk of a patient harming his/herself or others, ... . Procedure: ... F. Reassessment: 1. ... 5. All forms of seclusion/restraint are discontinued at the earliest possible time, when the patient no longer presents a risk to him/herself or others or when the risk of restraint outweighs the risk of alternative interventions. ... H. Release Criteria and Procedure: 1. ... 2. Seclusion, a. Discontinue seclusion if patient is no longer a danger to self or others shown by: i. Contracting safety, ii. Decreased agitation and/or aggression, iii. Follows staff directions. ....””

“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: 31794 Based on interview and record review the facility failed to ensure patient’s conditions were monitored while on Seclusion (a form of restraint; the involuntary confinement of a person in a locked or unlocked room or area where the person is physically prevented from leaving, as defined by the facility policy) and/or Restraint (any mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, as define in the facility policy) for three (3) patients (Patients 19, 20, and 25) of six (6) sampled patients when: 1. For Patient 19, the “Registered Nurse (RN) Restraint Monitoring (a systemic observation of the patient to provide information about changes in condition, as per facility policy) Every 1 (one) Hour” was not done on 3/16/24, at 5:30 PM and on 3/16/24, at 6:30 PM. 2. For Patient 20, the Range of Motion (ROM, amount of movement that a particular joint can achieve in a specific direction) monitoring for the use of four (4) point restraint (restraint placed on both arms and both legs) was not done from 3/20/24, at 6:10 PM up to 3/21/24, at 9:45 PM. 3. For Patient 25, the baseline ROM monitoring was not done when the four (4) point restraint was applied on 2/21/24 at 3:22 PM and the monitoring of blood circulation for the use of four (4) point restraint was not done on 2/21/24 at 7:45 PM and on 2/21/24 at 9:45 PM. Failure to perform the required monitoring of patients placed on Seclusion and/or Restraints (R/S) had the potential to negatively affect the “physical and emotional well-being, dignity and safety” of the patients and had the potential to place patients at risk of harm and/or death. Findings: 1. Review of the March 2024 “Seclusion and Restraint Log” indicated, there were three (3) patients on Seclusion (Patients 19, 21, and 32) and three (3) patients on Restraint (Patients 9, 17, and 20) in the Acute inpatient Psychiatric Units (PU). Review of the Face Sheet dated 3/27/24 indicated, Patient 19 was admitted in 7B, Inpatient Psychiatric Unit (PU), on 2/12/24. Record review of the document titled, History and Physical (H & P) “Initial Encounter Note”, dated 2/13/24 indicated, the patient had “Recent significant deterioration in functioning as a result of mental illness” and “Requires containment due to high-risk behaviors.” The Principal Diagnosis included, “bipolar disorder (extreme fluctuation in a person’s mood, energy, and ability to function), r/o (rule out) substance induced psychosis (symptoms that affect the mind, where there has been some loss of contact with reality), opiate dependence (physical dependence on opioids, a controlled substance) d/o (disorder), and Stimulant dependent (continued use of stimulants despite harm to the person) d/o.” Record review of the Order History, dated 3/16/24, at 4:30 PM indicated, “Restraint Type: Seclusion”, “Violent restraint reason: imminent danger to others”, Describe patient’s behavior: pacing, challenging to redirect, made movements/references towards assaulting another patient”, and “Good cause/clinical justification for denial of rights: patient has a hx (history) of assaultive bx (behavior) on the unit.” The “Order Details” indicated, “Frequency, Continuous x 4 (four) hours, Duration: 4 (four) hours.” Record review of the Order History, dated 3/16/24, at 8:00 PM, indicated the restraint order was renewed. It indicated, “Restraint Type: Seclusion”, “Violent restraint reason: imminent danger to others”, Describe patient’s behavior: pacing, challenging to redirect, made movements/references towards assaulting another patient”, and “Good cause/clinical justification for denial of rights: patient has a hx (history) of assaultive bx (behavior) on the unit.” In a concurrent record review and interview on 3/27/24, at 10:38 AM, with the Registered Nurse Care Coordinator (RN/CC 1) and the Quality Nurse Manger (QMN 1), the “Flowsheet Data” for the use of Restraint/Seclusion (R/S), dated 3/16/24 to 3/22/24, were reviewed. The RN/CC 1 verified the RN (Registered Nurse) Restraint Monitoring Every 1 (one) Hour on the Flow sheet Data were missing on 3/16/24 at 5:30 PM and on 3/16/24 at 6:30 PM. The RN/CC 1 stated, as per policy the monitoring of patients on R/S was every 15 minutes and the RN Restraint Monitoring was every one (1) hour. The RN/CC 1 stated, every 15 minutes monitoring was delegated to a non-licensed staff and only the RN can perform assessment (an in-depth evaluation of the patient’s condition) to make sure patients were “safe.” Record review of facility’s Policy and Procedure (P & P) titled, “Behavior Seclusion and Restraint Policy,” with the last reviewed date of 12/22 indicated, “F. Re-assessment: 1. The team continually assess, monitors, and re-evaluates the condition of the secluded/restrained patient. Monitoring ensures physical and emotional well-being, dignity and safety of the patient. Monitoring determines if there are changes in thepatient’s beahvior or clinical condition ... 2. Minimal frequency of reassessment, observation and monitoring; a. ... b. RN Assessment: Face to face with the patient prior to initiation of seclusion/restraint and every 1 (one) hour. c. Monitoring: Every 15 minutes ... d. Observation: Constant direct visual observation by RN, ... 3. a. Monitoring is a systemic observation of the patient to provide information about changes in condition. ... .” 2. Review of the Face sheet dated 4/2/24 indicated, Patient 20 was admiited in 7B, Inpatient PU, on 3/5/24 at 10:40 AM. Record review of the H & P Initial Encounter Note, dated 3/6/24 indicated, “history of Schizophrenia (mental illness that affects the way the individual think, feel and behave)”, “severe stimulant disorder (continued use of stimulants despite harm to the user)”, and “paranoid delusion (intense and irrational mistrust or suspicion which can bring on feelings of fearand/or anger) sorrounding food being poisoned. Record review of the Order History, dated 3/20/24, at 6:10 PM indicated, Restraint Type was “Locked restraint”, “Locked restraint location, left wrist, right wrist, left ankel, right ankle”, the “Violent restraint reason: Imminent danger to others”, and the “Describe patient’s behavior: Patient attempeted to assault staff, requiring emergent IM (intramuscular injection of medication) for agitation”, and the “Good cause/clinical justification for denial of rights, DTO (dangers to others).” Record review of the “Flowsheet Data” dated 3/20/24 to 3/21/24 indicated, “Restraint Monitoring Every 2 (two) hours, Range of Motion, Date, “3/20/24, 1810 (6:10 PM) --- (line means no data), 3/20/24, 2015 (8:15 PM) --- (line means no data), 3/20/24, 2215 (10:15 PM) --- (line means no data), 3/21/24, 0000 (12 MN) --- (line means no data), 3/21/24, 0215 (2:15 AM), --- (line means no data), 3/22/24, 0415 (4:15 AM), --- (line means no data), 3/21/24, 0615 (6:15 AM), --- (line means no data), 3/21/24, 0815 (8:15 AM), --- (line means no data), 3/21/24, 0945 (9:45 AM), --- (line means no data).” In a concurent record review and interview on 3/27/24, at 2:20 PM, with the RN/CC 1 and the QMN 1, the “Flowsheet Data” for the “Restraint Monitoring Every 2 (two) Hours, Range of Motion (ROM)”, dated 3/20/24 to 3/21/24 were reviewed. The RN/CC 1 stated, the ROM monitoring should be done every two (2) hours, it was not done on 3/20/24 at 6:10 PM unitl 3/21/24 at 9:45 AM. The RN/CC 1 stated, the ROM monitoring should be done to assesss for “blood circulation”, to assess for injury because sometimes patients would pull the restraints. The RN/CC 1 further stated, the facility policy stated the ROM monitoring was every “15 minutes”, the Flowsheet Data stated the ROM monitoring/assessment was every 2 (two) hours, the clinical practice was to do ROM monitoring every two hours, the policy need to be “updated. 3. Review of the Face sheet dated 4/3/24 indicated Patient 25 was admitted in 7B, Inpatient PU, on 1/29/24 at 11:35 PM. Record review of the admitting H & P Initial Encounter Note, dated 1/30/24 inidcated, patient was brought in by the ambulance for “aggressive and disorganized behavior.” The Principal Diagnosis included schizophrenia and other active problems included, oveveweight and vitamin D deficiency. Record reveiw of the Order History, dated 2/21/24, at 3:22 PM indicated, “Restraint type: Seclusion, Locked resraint. Locked restraint location: left wrist, right wrist, left ankle, right ankle. Violent restraint reason: imminent danger to others. Describe patient’s behavior: Pt (patient) assaulted staff, unpredictable and unable to be verbally redirected.” In a concurrent record review and interview on 4/2/24, at 4:25 PM with the RN/CC 1 and the QMN 3, the “Flowsheet Data”, dated 2/21/24, was reviewed. The RN/CC 1 stated, when patient was on four point restraint the staff would assess the Range of Motion (ROM) every two (2) hours and document it on the Flow sheet. The RN/CC1 stated, for Patient 25, the four point restraint was applied on 2/21/24 at 3:22 PM and the baseline ROM monitoring was not done, “they (staff) should, it was not done.” The RN/CC1 further stated, the ROM was assessed on 2/21/24 at 5:45 (more than 2 hours after the restraint was placed) and the ROM monitoring were “missing” on 2/21/24 at 7:45 PM and on 2/21/24 on 9:45 PM. The RN/CC 1 stated, the ROM monitoring of circulaiton on the Flowsheet was every two (2) hours but the facility policy stated the monitoring of circulation was every “15 minutes”. The RN/CC 1 explained, the every 15 minutes was for “monitoring” of restraint not for the monitoring of blood circulation, and the policy need to “be changed”. Record review of facility’s Policy and Procedure (P & P) titled, “Behavior Seclusion and Restraint Policy,” with the last reviewed date of 12/22 indicated, “F. Re-assessment: 1. The team continually assess, monitors, and re-evaluates the condition of the secluded/restrained patient. Monitoring ensures physical and emotional well-being, dignity and safety of the patient. Monitoring determines if there are changes in the patient’s behavior or clinical condition ... 2. Minimal frequency of reassessment, observation and monitoring; a. ... b. RN Assessment: Face to face with the patient prior to initiation of seclusion/restraint and every 1 (one) hour. c. Monitoring: Every 15 minutes ... d. Observation: Constant direct visual observation by RN, ... 3. a. Monitoring is a systemic observation of the patient to provide information about changes in condition. ... .””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 31794 Based on interview and record review the facility failed to ensure two (2) of three (3) sampled patients (Patients 10 and 30) who were placed on Seclusion (a form of restraint; the involuntary confinement of a person in a locked or unlocked room or area where the person is physically prevented from leaving, as defined by the facility policy) had the 1 hour face to face medical and behavioral evaluation to manage the patient’s violent or self-destructive behaviors when: 1. For Patient 30, there was no documentation the Physician completed the face-to-face medical and behavioral evaluation following an order to place the patient on Seclusion on 12/30/23, at 1:00 AM. 2. For Patient 10, there was no documentation the Physician completed the face-to-face medical and behavioral evaluation following an order to place the patient on seclusion on 2/16/24, 2/17/24, 2/18/24, 2/20/24, 2/21/24, and 2/22/24. These deficient practices had the potential to result in the patient’s inability to maintain his/her dignity and had the potential to place patients at risk of harm and unsafe environment. Findings: 1. Review of the undated Face sheet indicated, Patient 30 was admitted to the acute Inpatient Psychiatric Unit (PU), on 12/30/23 at 1:00 AM. Record review of the Physician’s “H&P (History and Physical) Initial Encounter Note, dated 12/30/23 at 10:50 AM indicated, patient has been requiring placement in locked seclusion for unpredictable behavior and allegedly threatening PES (Psychiatric Emergency Services) staff ... .” The Principal Diagnosis included schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior), bipolar type (include days of extreme highs (mania) and can have severe lows (depression). Review of the Order History dated 12/30/23 at 1:00 AM indicated, “Restraint type: seclusion”, “Violent restraint reason: imminent danger to others”, “Describe patient’s behavior: patient with assaultive behavior”. The “Process Instructions” located on the bottom of the Order History form indicated, “the MD (Physician) must conduct a face-to-face assessment within 1 (one) hour of initiation of each restraint order.” In a concurrent record review and interview on 4/2/24 at 3:00 PM with the Registered Nurse /Care Coordinator (RN/CC 1) and with the Quality Management Nurse (QMN 3), the Flowsheet Data, dated 12/30/23 at 1:00 AM, and the Physician’s Initial Encounter Note, dated 12/30/23 at 10:50 AM, were reviewed. The RN/CC 1 stated, Patient 30 was placed on seclusion upon admission in the acute Inpatient PU and the reason for seclusion was danger to others, patient had assaultive behavior requiring multiple “PRN (as needed) meds (medications).” The RN/CC 1 stated, the Physician placed the order for seclusion on 12/30/23 at 1:00 AM and verified there was no face-to-face assessment and evaluation of the patient done by the Physician after the order was placed. The RN/CC 1 stated, the face to face was marked only on the Flow sheet, the Physician did not complete a face-to-face assessment, and there was no evaluation of the patient “within minutes” after the initiation of seclusion, “no notes at all.” The RN/CC 1 explained, the Physician’s “Initial Encounter Note”, dated 12/30/23 at 10:58 AM, was an admission “H&P”, it was the earliest Physician’s Notes, and it was done about “eight (8) hours” since the seclusion order was placed. When asked why the face to face assessment and evaluation was necessary, the RN/CC 1 stated, a face to face was needed to assess patient’s safety and safety of others, to assess if patient was ready to come out of seclusion or the seclusion order needed to be renewed, and to assess the behavior if the behavior leads to seclusion and the patient can be deemed safe to come out of seclusion, a face-to face “is a detailed justification for the seclusion order.” 38612 2. Review of the “Patient Demographics” indicated, Patient 10 was admitted to the PU on 2/15/24 with diagnoses that include psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). Review of Resident 10’s “Psychiatric Significant Event Note,” dated 2/15/24, indicated “Rationale for Seclusion Use ... Patient was found to be experiencing acute symptoms requiring emergent intervention, as noted by the following behaviors: patient yelling in a disorganized manner, speech difficult to follow, escalating, posturing, threatening, unable to be verbally redirected. These behaviors constitute DTO (danger to others) and DTS (danger to self) and I am concerned that behavior may inadvertently cause harm to pt (patient) ...” Review of Patient 10’s “Order History,” dated 2/16/24 at 6:30 AM and 10:30 AM, indicated “Restraint type: Seclusion, Violent restraint reason: imminent danger to others. Describe patient’s behavior: Agitated, threatening, not able to be verbally deescalated.” The “Process Instructions” on the Order History indicated, “The MD (physician) must conduct a face-to-face assessment within 1 (one) hour of initiation of each restraint order.” Patient 10’s “Order History,” dated 2/16/24 at 10:30 PM indicated a seclusion order for the following behaviors: agitated, threatening, not able to be verbally deescalated, unable to contract for safety; with the reason for restraint order as imminent danger to others. Further review of Patient 10’s “Order History” indicated physician’s order of seclusion on the following dates: - 2/17/24 at 10:30 AM; - 2/18/24 at 4:00 AM; - 2/20/24 at 7:30 AM, 11:30 AM, 3:30 PM, and 7:30 PM; - 2/21/24 at 7:30 AM and 11:30 AM; - 2/22/24 at 7:30 AM, and 3:30 PM. During a concurrent interview and review of Patient 10’s clinical records with Charge Nurse (CN) 1 and QMN 2 on 3/28/24 at 9:24 AM, CN 1 was unable to find documentation that a face-to-face assessment of Patient 10 was completed by the physician within one hour after placing the restraint order on the aforementioned dates and times. CN 1 stated, “there was no note” to indicate face to face evaluation by the physician. During an interview with the Medical Director of Inpatient Psychiatric Units (MDIP), Attending Physician 1, and In House Physician 1 on 3/28/24 at 2:43 PM, the MDIP stated face-to-face evaluations are important due to “all forms of restraints are pretty severe interventions.” The MDIP stated that the goal of face-to-face assessment is to assess “whether restraints are useful or beneficial for patients, whether restraints are necessary, and to check is less restrictive measures” can be implemented. Review of facility’s policy and procedure (P&P) titled, “Behavior Seclusion and Restraint Policy,” with last review date of 12/22 indicated, “Purpose: The purpose of this policy is to outline the conditions and procedures associated with the use of seclusion and restraints ... This policy is to be used as a complement to Administrative policy 18.09 ... Statement of Policy: A. The use of seclusion/restraints is limited to situation where there is imminent risk of a patient harming his/herself or others, ... Procedure: A. Assessment: 1. ... 6. A face-to- face assessment by the provider is completed within minutes after the initiation of seclusion/restraints. This assessment includes: a. An evaluation of the patient’s immediate situation: i. The patient’s reaction to the intervention. ii. The patient’s medical and behavioral condition. iii. Identify ways to help the patient regain control. iv. The need to continue or terminate the restraint or seclusion...F. Reassessment ... 2. Minimal frequency of reassessment, observation and monitoring: a. MD Assessment: face to face with the patient - Initial assessment within minutes of beginning of seclusion/restraint and every 4 hours ...” Review of the facility’s P&P titled, “Administrative Policy Number: 18.09, Title: Restraint/Seclusion. Purpose: The purpose of the Restraint Policy is to ensure the use of restraints maintain a safe environment, prevents injury, and maintains dignity of patients ...””