College Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its physician and trained Registered Nuse (RN) performed a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour on two of 64 sampled patients (Patient 13 and Patient 14), in accordance with the facility’s policy and procedure regarding restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) when: 1. Emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) physician did not document the time of face-to-face assessment performed after Patient 13 was placed on a 4-point (both upper and lower extremities) keyed polyurethane restraint (a type of restraint that utilizes a key-lock mechanism for closure) on 7/28/2025. 2. Registered Nurse (RN) performed face-to-face assessment two (2) hours after the administration of chemical restraint (use of medications to control a patient’s behavior or restrict freedom of movement) on Patient 14 on 7/22/2025. These deficient practices had the potential to result in Patient 13 and Patient 14 not receiving prompt assessment to evaluate response to restraint, possible side effects from medications and possible need for additional interventions to manage behavior. Findings: 1. During a review of Patient 13’s “Emergency Department Note - Physician (ED note, medical notes completed by ED physician),” dated 7/28/2025, the ED note indicated Patient 13 presented to the facility’s ED for agitation (being upset, annoyed, angry, and physically disturbed) and bizarre (strange, unusual) behavior. The ED note also indicated Patient 13 exhibited signs of severe psychiatric distress and agitated delirium (a sudden, temporary state of confusion) representing an immediate physical danger to self and others. During a review of Patient 13’s physician order, dated 7/28/2025, the physician order indicated Patient 13 was placed on keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraint for danger to others. During a review of Patient 13’s “Restraint Initiation (nursing document relating to application of restraint)” form, dated 7/28/2025, the “Restraint Initiation” form indicated, Patient 13 was placed on keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraint to both upper and lower extremities on 7/28/2025 at 6:40 p.m. During a concurrent interview and record review on 7/29/2025 at 2:51 p.m. with the Director (DIR 1) of Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery)/Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Unit , Patient 13’s “Emergency Department Note - Physician (ED note),” dated 7/28/2025, was reviewed. The ED note indicated, “I performed a face-to-face assessment within one hour of the restraint/seclusion at [time] ... restraints were [removed/continued].” DIR 1 stated the ED note did not indicate the exact time of face-to-face assessment performed. DIR 1 was unable to tell what time the face-to-face assessment was completed. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 7/2025, the P&P indicated, “Restraints will be used for clinically appropriate and adequately justified situations based on individually assessed patient need and behavioral risk factors ... Monitoring a. Restraints i. A Physician, their designee, or a qualified Registered Nurse must see (face to face) and evaluate the need for seclusion and restraints within one (1) hour after the initiation of this intervention. The evaluation must be documented in the patient medical record and the physician /their designee must be notified of the evaluation if performed by RN.” 2. During an interview on 7/29/2025 at 11:08 a.m. with Registered Nuse (RN) 1, RN 1 stated the following: the facility Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) would use seclusion, physical restraints and/or chemical restraint (use of medications to control a patient’s behavior or restrict freedom of movement) on patients depending on the situation and the physician order. A chemical restraint was usually a combination of intramuscular (IM, into the muscles) injections with Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect), Haldol (medication to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] agitation [being upset, annoyed, angry and physically disturbed]) and Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect). Within an hour after the injections were given, the RN would perform face-to-face assessment to make sure patient was responsive and check for the effectiveness of medications and potential side effects. During a review of Patient 14’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 7/22/2025, the Psych Eval indicated Patient 14 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others with admitting diagnosis of schizoaffective (a mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]), bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of the facility’s BHU restraint log titled, “Restraint Documentation Verification,” dated 7/22/2025, the restraint log indicated, Patient 14 received chemical restraint on 7/22/2025 at 9:05 p.m. During a review of Patient 14’s “Orders (physician orders),” dated 7/22/2025, the physician order indicated, Behavioral Restraint and/or Seclusion order set initiated with emergency medication administration restraint of Benadryl 50 milligrams (mg, a unit of measurement) IM once (one time only), Versed 5 mg IM and Geodon (medication to treat acute agitation in schizophrenia) 20 mg IM once.” During a review of Patient 14’s Medication Administration Record (MAR, record of medications given to patients), dated 7/22/2025, Patient 14 received one time IM injections of Geodon 20 mg, Versed 5 mg and Benadryl 50 mg on 7/22/2025 at 9:05 p.m. During a concurrent interview and record review on 7/29/2025 at 2:35 p.m. with the Nurse Manager (NM) 1 of BHU, Patient 14’s “Progress Note Non-Physician (nurse notes),” dated 7/22/2025, was reviewed. The nurse notes indicated, “The patient (Patient 14) punched another patient ... multiple times on the right side of the face on the hallway .... (physician) was notified immediately and provided verbal orders for the following intramuscular medications: Geodon 20 mg, Versed 5 mg, Benadryl 50 mg. All orders were reviewed, verified and administered as directed ... A face-to-face assessment was conducted following medication administration.” NM 1 stated the nurse notes did not indicate what time the face-to-face assessment was performed. During a concurrent interview and record review 7/29/2025 at 2:40 p.m. with the Nurse Manager (NM) 1 of BHU, Patient 14’s “BH Face to Face (face-to-face assessment, RN documentation of face-to-face assessment),” dated 7/22/2025, was reviewed. The face-to-face assessment indicated Registered Nuse (RN) 2 completed the face-to-face assessment for Patient 14 on 7/22/2025 at 11:09 p.m. NM 1 confirmed the entry time was beyond one hour from the medication administration time (2 hours after the medication administration time). During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 7/2025, the P&P indicated, “Restraints will be used for clinically appropriate and adequately justified situations based on individually assessed patient need and behavioral risk factors ... Monitoring a. Restraints i. A Physician, their designee, or a qualified Registered Nurse must see (face to face) and evaluate the need for seclusion and restraints within one (1) hour after the initiation of this intervention. The evaluation must be documented in the patient medical record and the physician/their designee must be notified of the evaluation if performed by RN.” During review of the facility’s policy and procedure (P&P) titled, “Emergency Medications,” dated 7/2025, the P&P indicated, “To provide guidelines for administering antipsychotic medications or intramuscular medications to a patient without his consent to maintain safety for the patient and other people on the unit ... Procedure ... A. Definition: An emergency exists when there is a sudden marked change in the patient’s condition so that action is immediately necessary for preservation of the life or the prevention of serious bodily harm to the patient or others ... The nurse will reassess the patient within 1 hour of administering an emergency IM ... Chemical Restraint ... A medication used to control behavior or to restrict the patient’s freedom of movement that is not a standard treatment for the patient’s medical or psychiatric condition.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its physician performed a complete face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on one of 64 sampled patients (Patient 13), in accordance with the facility’s policy and procedure regarding restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving), when the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) physician did not indicate whether restraint should be continued or removed at the end of a face-to-face assessment on 7/28/2025. This deficient practice had the potential to result in prolonged or unnecessary restraint use for Patient 13. Findings: During a review of Patient 13’s “Emergency Department Note - Physician (ED note, medical notes completed by ED physician),” dated 7/28/2025, the ED note indicated Patient 13 presented to the facility’s ED for agitation (being upset, annoyed, angry, and physically disturbed) and bizarre (strange, unusual) behavior. The ED note also indicated Patient 13 exhibited signs of severe psychiatric distress (a state of emotional suffering characterized by symptoms of anxiety [characterized by excessive and persistent worry, fear, and unease] and depression [a serious mood disorder that can affect how you think, feel, and behave]) and agitated delirium (a sudden, temporary state of confusion) representing an immediate physical danger to self and others. During a review of Patient 13’s physician order dated 7/28/2025, the physician order indicated Patient was placed on keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for danger to others. During a review of Patient 13’s “Restraint Initiation (nursing document relating to application of restraint),” dated 7/28/2025, the “Restraint Initiation” form indicated, Patient 13 was placed on keyed polyurethane restraint to both upper and lower extremities on 7/28/2025 at 6:40 p.m. During a concurrent interview and record review on 7/29/2025 at 2:51 p.m. with the Director (DIR 1) of Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery)/Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Unit, Patient 13’s “Emergency Department Note - Physician (ED note),” dated 7/28/2025, was reviewed. The ED note indicated, “I performed a face-to-face assessment within one hour of the restraint/seclusion at [time] ... restraints were [removed/continued].” DIR 1 stated the ED physician did not clarify if restraints were removed or continued at the end of face-to-face assessment. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraint,” dated 7/2025, the P&P indicated, “Restraints will be used for clinically appropriate and adequately justified situations based on individually assessed patient need and behavioral risk factors ... Monitoring a. Restraints i. A Physician, their designee, or a qualified Registered Nurse must see (face to face) and evaluate the need for seclusion and restraints within one (1) hour after the initiation of this intervention. The evaluation must be documented in the patient medical record and the physician /their designee must be notified of the evaluation if performed by RN.””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility’s Quality Assessment and Performance Improvement program (QAPI, a structured, ongoing process where the hospital collects and analyzes data to identify problems, monitor performance, and implement solutions to improve patient care and safety) failed to ensure that effective monitoring systems were in place to identify and correct missed patient safety rounding in the Behavioral Health Unit (BHU, a hospital unit for patients with mental health conditions requiring inpatient care). The facility’s “rounding, Observation and Monitoring of Patients,” policy required q (every) 15-minute rounding (a mandated patient safety protocol where staff members, often mental health technicians or nurses, visually observe patients at least every 15 minutes with the primary goal is to ensure the safety and well-being of patients in a high-risk environment) for all patients in the BHU. For 31 of 64 sampled patients (Patients 10, 11,12, 15, 17, 18, 19, 39, 42, 43, 44, 45, 46, 47,48, 49, 50, 51, 52, 53, 54, 55, 56,57, 58, 59, 60, 61, 62, 63, and 64), q 15-minute rounding was not completed as required. This deficient practice had the potential to leave patients, including those at high risk for self-harm or aggression (behavior aimed at harming others), without required safety checks, thus increasing the risk of serious injury or death. This deficient practice also had the potential to render the facility’s QAPI program ineffective in its ability to promptly detect, address, and prevent recurrence of patient safety risks. Findings: During a concurrent interview and record review on 7/30/2025 at 9:55 a.m. with the Lead Security Officer (LSO) and the Nurse Manager (NM) 1, the ABC unit in Campus 1’s video surveillance, dated 7/4/2025 and 7/25/2025 from 4 a.m. through 5 a.m., were reviewed. The videos showed the following: Video reviewed dated 7/4/2025: - At 4:08 a.m., Mental Health Worker (MHW) 4 walked down the hallway of unit ABC but only opened the doors of 3 to 4 rooms to look inside. During the same interview on 7/30/2025 at 10:02 a.m., Lead Security Officer (LSO) confirmed that MHW 4 did not open the doors to all patient rooms. -At 4:24 a.m., MHW 4 was scheduled to complete the next 15-minute rounding but did not perform the rounding. Instead, MHW 4 entered information into the tablet at 4:32 a.m. During the same interview at on 7/30/2025 10:54 a.m. NM 1 confirmed that there was a missed rounding at 4:24 a.m. -At 4:48 a.m., rounding was delayed by 24 minutes, and not all room doors were opened. -At 5:00 a.m., rounding was completed but still without opening all patient room doors. During the same interview on 7/30/2025 at 10:40 a.m., NM1 confirmed that MHW 4 did not open the doors to all patient rooms during rounding, and NM1 stated that opening all patient room doors was required to visually confirm patient safety. Video reviewed date 7/25/2025: -At 4:15 a.m., the scheduled 15- minute rounding was not completed. -At 4:30 a.m., MHW 10 completed q 15-minutes rounding. -At 4:45 a.m., the scheduled 15- minute rounding was not completed. During the same interview on 7/30/2025 at 10:54 a.m., NM1 confirmed that on 7/25/2025 at 4:15 a.m., and at 4:45 a.m., there was a missed rounding, and at 4:08 a.m., MHW 10 walked down hallway but did not enter all rooms. NM 1stated it was expected for staff to check on all patients, including the patient in the isolation room (a specially designed room used to separate patients with infectious diseases from other patients and healthcare staff). During a review of the facility’s “Current Census Detail (the number of patients receiving care at a healthcare facility unit at a given time),” report for Unit ABC dated 7/4/2025 (date surveillance video was reviewed during survey), the report indicated that Patients 11, 15, 48, 51, 52, 53, 54, 55, 56,57, 58, 59, 60, 61, 62, 63, and 64, were roomed on Unit ABC on 7/4/2025. During a review of Patients 11, 15, 48, 51, 52, 53, 54, 55, 56,57, 58, 59, 60, 61, 62, 63, and 64’s medical record titled, “Rounding reports,” dated 7/4/2025, indicated that rounding was completed at 4:30 a.m. or 4:31 a.m. and 4:47 a.m., which did not reflect the video surveillance reviewed. During a review of the facility’s “Current Census Detail (the number of patients receiving care at a healthcare facility unit at a given time),” report for Unit ABC dated 7/25/2025 (date surveillance video was reviewed during survey), the report indicated that Patients 10, 11,12,15,17,19, 39, 42, 43, 44, 45, 46, 47,48, 49,50, and 51, were roomed on Unit ABC on 7/25/2025. During a review of Patients 10, 11,12,15,17,19, 39, 42, 43, 44, 45, 46, 47,48, 49,50, and 51’s medical record titled, “Rounding reports,” dated 7/25/2025, indicated that rounding was completed at 4:15 a.m. and 4:47 a.m., which did not reflect the video surveillance reviewed. During an interview on 7/29/2025 at 4:00 p.m. with the Director of Performance Improvement/Quality Management (DQM, the facility leader responsible for ensuring that QAPI functions effectively), DQM stated that the facility was aware of the missed rounding and had developed a plan to install a monitor in the DQM’s office to track rounding. However, the DQM confirmed that this surveillance-based auditing plan would not be conducted on a scheduled basis, and it had not yet been implemented. During the same interview on 7/29/2025 at 4:00 p.m. with the DQM, the DQM stated that there were no other systems in place, aside from reviewing security surveillance videos, to verify whether staff rounding actually occurred as documented in the medical record (the legal record of a patient’s care). The DQM confirmed that reviewing surveillance videos for auditing was neither a scheduled nor routine monitoring practice. During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated June 2025, the P&P indicated, that patients rounds must be performed on all patients at least every 15 minutes, in a manner that allows visual confirmation of patient safety. Standard observations may not be completed by standing in a doorway or at a distance; staff are expected to look directly into the room, particularly for patients who may be sleeping. During a review of the facility’s “Organizational Performance Improvement Plan (a structured, systematic approach designed to enhance the quality and efficiency of healthcare services within a hospital)” dated April 2025, the plan indicated, “The purpose of the Organizational Performance Improvement Plan at (name of the facility) is to ensure that the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ... Assure that the improvement process is organization-wide, monitoring, assessing and evaluating the quality and appropriateness of patient care, patient safety practices and clinical performance to resolve identified problems and improve performance... The status of identified problems and action plans is tracked to assure improvement or problem resolution at the department and organization levels ... Important key aspects of care to the health and safety of patients are identified. Included are those that occur frequently or affect large numbers of patients; place patients at risk of serious consequences of deprivation of substantial benefit if care is not provided correctly or not provided when indicated; or care provided is not indicated, or those tending to produce problems for patients, their families or staff ...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) was met, as evidenced by: 1. The Governing Body failed to provide oversight on the facility’s Nursing Department when Staff failed to protect one (1) of 30 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), when staff did not provide appropriate physical response to an agitated (being upset, annoyed, angry, and physically disturbed) patient (Patient 1), in accordance with the facility’s policy and procedure (P&P) regarding Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare settings. These rights ensure that patients receive safe, quality care while respecting their autonomy and dignity) and GB bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB’s accountability for the safety and quality of care, treatment, and services provided. This deficient practice resulted in Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear). (Refer to A-0063) 2. The facility failed to provide a safe environment of care, in accordance with the facility’s policy regarding “Security of the Unit” and GB bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB’s accountability for the safety and quality of care, treatment, and services provided, for one (1) of 30 sampled patients (Patient 2), when Patient 2 was able to force open a locked door. This deficient practice resulted in Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown. (Refer to A-0063) 3. The facility failed to provide and maintain an appropriate level of observation and monitoring for two of 30 sampled patients, who required line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring, per physician order and in accordance with the facility’s policy and procedure on rounding (the process of regularly visiting patients to assess their condition) and monitoring, when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025. This deficient practice resulted in Patient 9 physically assaulting (to attack) Patient 8 on 6/14/2025. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault. This deficient practice also had the potential in putting other patients at risk for injury due to lack of monitoring. (Refer to A-0063) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met, as evidenced by: 1. The facility failed to ensure one of 30 sampled patient’s (Patient 12) and/or Patient 12’s representative, was provided with follow up of grievance (a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care) and or informed of any resolution of grievance as per facility’s policy and procedure regarding “Complaint and Grievance Procedure.” This deficient practice resulted in Patient 12’s and Patient 12’s representative to not be provided with a resolution about their complaint, which may leave Patient 12 and/or Patient 12’s representative being dissatisfied and feel ignored or dismissed for concerns raised regarding patient care. (Refer to A-0118) 2. The facility failed ensure one of 30 sampled patient’s (Patient 12) representative’s denial of visitation right was reevaluated and a justification for denial of visitation right provided, in accordance with the facility’s policy and procedure regarding “Visitation.” This deficient practice resulted in Patient 12’s representative (FM 3) not being allowed to exercise his right to visit Patient 12 causing potential distress to Patient 12 and/or Patient 12’s representative. (Refer to A-0217) 3. The facility failed to ensure two of 30 sampled patients’ (Patient 22 and Patient 23) family representatives were informed of the use of restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) on Patient 22 and Patient 23, in accordance with the facility’s policy and procedure regarding “Seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) and Restraint” and “Notification of Seclusion and/or Restraint Episode.” This deficient practice resulted in family representatives not being informed of the treatment provided at the facility including understanding the risk and benefits of the treatment (use of physical restraint on Patient 22 and Patient 23) and being able to help make informed decision (making healthcare choices based on a clear understanding of the available options, potential benefits, risks, and alternatives, as well as their own values and preferences) pertaining to Patient 22 and Patient 23’s care. (Refer to A-0131) 4. The facility failed to provide a safe environment of care, in accordance with the facility’s policy regarding “Security of the Unit” and Governing Body (GB) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB’s accountability for the safety and quality of care, treatment, and services provided, for one (1) of 30 sampled patients (Patient 2), when Patient 2 was able to force open a locked door. This deficient practice resulted in Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown. (Refer to A-0144) 5. The facility failed to ensure its nursing staff protected one (1) of 30 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), when staff failed to provide an appropriate physical response to an agitated (being upset, annoyed, angry, and physically disturbed) patient (Patient 1), in accordance with the facility’s policy & procedure (P&P) regarding Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare settings. These rights ensure that patients receive safe, quality care while respecting their autonomy and dignity). This deficient practice resulted in Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear). (Refer to A-0145) 6. The facility failed to protect one of 30 sampled patients (Patient 10) from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and respond to an alleged physical abuse in a timely manner, in accordance with the facility’s policy regarding “Patient Rights” and “Employee to Patient physical abuse,” when the Behavioral Health Worker (BHW 10) put hands on Patient 10 inappropriately, and pushed Patient 10 in the room. The Registered Nurse (RN 5) also failed to assess Patient 10’s left eyebrow wound and escalate the alleged abuse to the charge nurse and the house supervisor and notify the attending physician, after Patient 10 reported the alleged abuse on 4/20/2025. This deficient practice resulted in Patient 10 sustaining a left eyebrow wound and delay in treatment and care due to a delay in notifying the physician. This deficient practice also resulted in BHW 10 not being removed from the facility immediately, thus putting Patient 10 and other patients at risk for further abuse. (Refer to A-0145) 7. The facility failed to ensure nursing staff obtained a physician order, in accordance with the facility’s policy regarding “Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraints,” for one of 30 sampled patients (Patient 9), when nursing staff performed physical restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) by putting hands on Patient 9 and placed Patient 9 in locked seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on 6/20/2025. This deficient practice resulted in Patient 9 being physically restrained by BHU staff and placed on locked seclusion without a physician order which led to violation of Patient 9’s rights to be free from restraint/seclusion. This deficient practice also had the potential to result in unnecessary restraint/seclusion including the risk of psychological harm for Patient 9. (Refer to A-0168) 8. The facility failed to ensure the physician signed off on the telephone orders received for two of 30 sampled patients (Patient 22 and Patient 23) within 24 hours, when 4 point (both arms and legs) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) were applied on Patient 22 and Patient 23, in accordance with the facility’s policy regarding “Seclusion and Restraint.” This deficient practice had the potential to result in unnecessary restraints for Patient 22 and Patient 23, including the lack of appropriate monitoring of potential risks of restraints use such as skin breakdown (injury to the skin caused by prolonged pressure or friction [force]). (Refer to A-0168) 9. The facility failed to ensure one of 30 sampled patient’s (Patient 22) restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring was conducted every 15 minutes, in accordance with the facility’s policy and procedure regarding “Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraint,” when Registered Nurse (RN) 6 placed (Patient 22) on 4-point (both ankles and wrist) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) and Patient 22 was administered Thorazine (medication used to treat mental health condition and regulates a patient’s mood) 100 milligrams (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via intramuscular (IM, into the muscles), while on 4 point restraints. This deficient practice had the potential for inadequate oversight/monitoring of Patient 22’s response to the use of restraints, which can lead to complications such as poor circulation (a medical condition where blood flow to parts of the body is reduced or inadequate), injury and/or death. (Refer to A-0175) 10. The facility failed to ensure nursing staff consulted the physician after a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed by Registered Nurses (RNs) for three of 30 sampled patients (Patients 8, 9 and 20), in accordance with the federal regulations regarding physician notification after the completion of the face-to-face evaluation. This deficient practice had the potential to result in Patients 8, 9 and 20 not receiving evaluation from physicians to determine appropriate treatment and care and also had the potential for unnecessary seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use. (Refer to A-0182) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Quality Assurance and Performance Improvement (QAPI) was met, as evidenced by: 1. The facility’s Quality Assurance Performance Improvement team (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) failed to implement corrective action and mechanisms in a timely manner, to ensure there was proper observation or monitoring provided for patients who are placed on line of sight (a straight line along which an observer had unobstructed vision) and one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring in the Behavioral Health Unit (BHU, (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) after there was patient to patient altercation between two of 30 sampled patients (Patient 8 and Patient 9), which was identified on 6/14/2025. This deficient practice had the potential to put other patients at risk for injury or harm. (Refer to A-0286) 2. The facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure that the facility’s Quality Assurance Performance Improvement (a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) Committee, reviewed and addressed the facility’s Policy and Procedure (P&P) pertaining to “Seclusion (involuntary [without permission] confinement of a patient in a room or area from which the patient is physically prevented from leaving) and Restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body),” to ensure that the P&P was aligned with facility’s current practice and be able to comply with federal regulations, when the P&P did not indicate that a Registered Nurse could perform face to face assessment on patients following the initial application of seclusion/restraints other than the physician, and the P&P did not also indicate that a Registered Nuse must consult a physician after face-to-face assessment was completed. The physician was not consulted after a face-to- face assessment was completed for three (3) of 30 sampled patients (Patients 8, 9, and 20). This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to the P&P not reflecting up to date best practices. (Refer to A-0309) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure nursing staff provided and maintained an appropriate level of observation and monitoring for two of 30 sampled patients who required line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring, per physician order and in accordance with the facility’s policy and procedure on rounding (the process of regularly visiting patients to assess their condition) and monitoring, when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025. This deficient practice resulted in Patient 9 physically assaulting (to attack) Patient 8 on 6/14/2025. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault. This deficient practice also had the potential in putting other patients at risk for injury due to lack of monitoring. (Refer to A-0395) 2. The facility failed to conduct a comprehensive assessment upon admission, that included assessing a patient’s risk of suicide (killing self), homicide (killing others), or violence (assault towards others), for one of 30 sampled patients (Patient 4), in accordance with the facility’s policy regarding “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Nursing Standards of Care.” This deficient practice had the potential to result in harm to Patient 4 and other patients on the unit due to lack of assessment. (Refer to A-0395) 3. The facility failed to ensure its nursing staff adhered to policy and procedure regarding staff conduct, when a Registered Nurse (RN) 1 pursued an inappropriate relationship with one (1) of 30 sampled patients (Patient 3) after their (Patient 3) discharge from the facility. This deficient practice had the potential to compromise professional boundaries and undermine the therapeutic integrity of care provided during the inpatient stay. (Refer to A-0398) 4. The facility failed to ensure patients’ family members were informed of seclusion (apart from others) and/or restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) episodes for two of 30 sampled patients (Patient 22 and Patient 23), in accordance with the facility’s policy and procedures regarding “Seclusion and Restraint,” and “Notification of Patient Admission and Subsequent Events,” when Patient 22 and Patient 23 were placed on 4-point (both arms and legs) restraints in the seclusion room (is a room where a person is involuntarily confined alone). This deficient practice had the potential to negatively affect Patient 22 and Patient 23’s wishes for treatment and care that they would receive in the facility, when there is lack of designated patients’ family member’s participation in the care process. (Refer to A-0398) 5. The facility failed to ensure one of 30 sampled patient’s (Patient 22) restraint monitoring intervention, was implemented and conducted every 15 minutes, in accordance with the facility’s policy and procedure regarding “Seclusion and Restraint,” when Registered Nurse (RN) 6 placed Patient 22 on 4 point (both ankles and wrists) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely). Subsequently, Patient 22 received Thorazine (medication used to treat mental health condition and regulates your mood) 100 milligram (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via intramuscular (IM, into the muscles). This deficient practice had potential for negative consequences for Patient 22’s safety due to lack of oversight (absence or inadequacy of monitoring) to identify adverse effects of restraint use such as poor circulation (blood flow), injury and/or death. (Refer to A-0398) 6. The facility failed to ensure nursing staff adhered to the facility’s policy and procedure regarding “Rounding, Observation and Monitoring of Patients,” when staff did not perform the 15- minute rounding (observing patient location and behavior) for one of 30 sampled patients (Patient 21). This deficient practice had the potential for Patient 21’s safety to not be monitored and care needs to not be addressed. (Refer to A-0398) 7. The facility failed to ensure nursing staff adhered to the facility’s policy and procedure regarding notification of the physician for change of condition for one of 30 sampled patients (Patient 10), when Patient 10 reported a bleeding left eyebrow to the Registered Nurse (RN) 5, but RN 5 did not notify the attending physician. This deficient practice resulted in delay for Patient 10 to receive diagnostic exams including a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) scan of head thus have the potential to delay treatment and care. (Refer to A-0398) 8. The facility failed to ensure corrections to the medical records were documented appropriately, for one of 30 sampled patients (Patient 5), in accordance with the facility’s policy regarding documentation and corrections in the medical record, when staff wrote on top of original documentation, which obscured the original documentation for Patient 5’s location on 4/30/2025 from 5:45 p.m. to 6:30 p.m. This deficient practice had the potential to result in inaccurate information and may lead to incorrect treatment plans which may harm the patient. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Infection Prevention and Control and Antibiotic Stewardship (a set of coordinated strategies aimed at optimizing antibiotic use to improve patient outcomes, reduce antibiotic resistance, and minimize healthcare costs) Program was met, as evidenced by: 1. The facility failed to ensure for one of 30 sampled patients (Patient 16), the facility’s policy and procedure (P&P) for infection control was implemented when, Patient 16’s intravenous tubing (known as “piggyback,” a flexible tube that administers medication) was not labeled with a date for change of IV (Intravenous, into the vein) tubing, and IV site was not dated. This deficient practice had the potential to result in Patient 16 being exposed to infections such as phlebitis (infection of the veins) and/or bloodstream infection caused by prolonged use of IV tubing and IV insertion site. (Refer to A-0749) 2. The facility failed to ensure one of three sampled campuses (Campus 1) Behavioral Health Unit (BHU), was kept clean and free of flies, in accordance with the facility’s policy regarding Infection control and prevention. This deficient practice had the potential to cause infections through contaminated areas and objects, which could negatively impact the patients’ and staff’s overall health. (Refer to A-0750) 3. The facility failed to ensure its staff followed infection control policy and procedure (P&P), when the annual tuberculosis (TB, a serious infectious bacterial disease that primary affects the lung, is spread through the air, and can stay in the air for several hours) screening, was missing for one (1) of 10 sampled employees (Registered Nurse [RN] 5). This deficient practice had the potential to put the facility’s staff and patients at risk for acquiring (catching) TB. (Refer to A-0776) 4. The facility failed to ensure its staff followed infection control policy and procedure (P&P), when evidence of either influenza (the flu, a contagious viral disease that affects the lungs and is spread through coughing and sneezing) vaccination administration or declination, was missing for one (1) of 10 sampled employees (Behavioral Health Worker [BHW] 10). This deficient practice had the potential to put the facility’s staff and patients at risk for acquiring influenza. (Refer to A-0776) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 43236 Based on observation, interview, and record review, the facility’s governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight to ensure the facility’s staff protects patients and provides safe and quality patient care when: 1. Staff failed to protect one (1) of 30 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury) when staff did not provide appropriate physical response to an agitated (being upset, annoyed, angry, and physically disturbed) patient (Patient 1), in accordance with the facility’s policy and procedure (P&P) regarding Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare settings. These rights ensure that patients receive safe, quality care while respecting their autonomy and dignity) and GB bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB’s accountability for the safety and quality of care, treatment, and services provided. This deficient practice resulted in Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear). 2. The facility failed to provide a safe environment of care, in accordance with the facility’s policy regarding “Security of the Unit” and GB bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB’s accountability for the safety and quality of care, treatment, and services provided, for one (1) of 30 sampled patients (Patient 2), when Patient 2 was able to force open a locked door. This deficient practice resulted in Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown. 3. The facility failed to provide and maintain an appropriate level of observation and monitoring for two of 30 sampled patients who required line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring, per physician order and in accordance with the facility’s policy and procedure on rounding (the process of regularly visiting patients to assess their condition) and monitoring, when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025. This deficient practice resulted in Patient 9 physically assaulting (to attack) Patient 8 on 6/14/2025. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault. This deficient practice also had the potential in putting other patients at risk for injury due to lack of monitoring. Findings: 1. During a review of Patient 1’s “Face Sheet (front page of the chart that contains a summary of basic information about the patient),” not dated, the Face Sheet indicated Patient 1 was admitted to the facility’s behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 5/20/2025. During a review of Patient 1’s “Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]),” dated 5/20/2025, the 5150 hold paperwork indicated Patient 1 was detained for being a danger to herself and gravely disabled due to appearing paranoid (intense and irrational distrust and suspicion of others), internally preoccupied (focusing on things they are thinking or hearing inside their head instead of engaging with the world around them), not talking, and spitting. During a review of Patient 1’s “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition),” dated 5/21/2025, the 5250 hold paperwork indicated Patient 1’s involuntary legal hold was extended due to being a danger to herself and being gravely disabled. During a review of Patient 1’s “Progress Note,” dated 5/23/2025 at 2:11 p.m., the Progress Note indicated, “[At 11:40 a.m.], [Patient 1 was] throwing soiled diaper at staff and being aggressive towards staff ... [At 11:45 a.m.], [Patient 1 was] found on floor bleeding from head with cut slash on back of head [approximately] 4 inches long. [Patient 1 was] found attempting to throw blood on staff ... Walked [Patient 1] to seclusion room (a bare, enclosed space used to contain a patient who is experiencing a behavioral emergency, typically when less restrictive measures have failed to ensure the safety of the patient or others) to assess patient, meanwhile 911 was called.” During an interview on 6/24/2025 at 3:17 p.m. with the Quality Coordinator (QC), the QC stated that on 5/23/2025, Patient 1 was discovered on the floor in her (Patient 1) room bleeding from her head. The QC stated that it was reported she (Patient 1) was banging her head. She (Patient 1) was unable to be assessed in her room due to throwing blood at the staff, so she was walked to the seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) room and assessed. 911 was called and Patient 1 was taken to an outside general acute care hospital (GACH, a type of hospital that provides short-term, inpatient medical and surgical care for acute [sudden or severe] health conditions) to have her head wound treated. During an interview on 6/24/2025 at 3:27 p.m. with the Director of the BHU (Behavioral Health Unit, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at Campus 2 (DIR 1), DIR 1 stated that the staff thought Patient 1 was self-harming (hurting herself) until DIR 1 received an anonymous text message on 5/24/2025 indicating that Patient 1 had been pushed. DIR 1 stated Patient 1 was alone in her room with Behavioral Health Worker (BHW) 1, who was witnessed coming out of Patient 1’s room and calling for help. DIR 1 further stated they (the administrative team conducting the internal investigation) determined that BHW 1 most likely pushed her (Patient 1). During a concurrent observation and interview on 6/25/25 at 10:04 a.m. with the QC, the Nurse Manager of the Campus 2 (NM 1), and the Associate Administrator (AA), the video surveillance footage from 5/23/2025, was reviewed. The following events were observed at the indicated timestamps in the video: 1. 11:47 a.m.: BHW 1 was seen entering the hallway in Unit 1, speaking to a patient off-camera. BHW 1’s body language indicated that she was upset or agitated (being upset, annoyed, angry and physically disturbed). QC confirmed this was BHW 1. 2. 11:48 a.m.: BHW 1 stood outside of Patient 1’s room, looking inside. QC confirmed that was Patient 1’s room. 3. 11:51 a.m.: BHW 1 appeared to be hit by something from inside Patient 1’s room. BHW 1 then entered Patient 1’s room. 4. 11:52 a.m.: BHW 2 entered Patient 1’s room. BHW 2 then left the room with BHW 1 and both moved off-camera. BHW 1 then returned to Patient 1’s room. 5. 11:53 a.m.: Multiple staff entered Patient 1’s room. 6. 11:55 a.m.: Patient 1 was escorted out of her (Patient 1) room with three different staff. There was blood on Patient 1’s gown and one staff was holding a towel to the back of Patient 1’s head. During an interview on 6/25/2025 at 11:25 a.m. with the QC, the QC stated that BHW 1 was agitated in the surveillance footage, that BHW 1 was uncooperative during the facility’s internal investigation, and that there were also inconsistencies in BHW 1’s story, specifically that Patient 1 suffered a single laceration which was not consistent with the report that she (Patient 1) had been “banging her head.” During an interview on 6/25/2025 at 3:38 p.m. with Behavioral Health Worker (BHW) 2, BHW 2 stated that on 5/23/2025, Patient 1 threw a diaper in the hallway. BHW 1 went to Patient 1’s room and said something to her (Patient 1) that BHW 2 did not hear. BHW 1 then went to the nurses’ station, then back to Patient 1’s room; BHW 2 saw BHW 1 go inside and went in behind her (BHW 1). Upon entering, BHW 2 saw Patient 1 on the ground and holding her head, so BHW 2 blew her whistle which alerted the staff. BHW 2 asked BHW 1 what happened; she stated BHW 1 told her that Patient 1 “banged her head.” During a concurrent interview and record review on 6/25/2025 at 4:04 p.m. with the QC, the staffing assignment for 5/24/2025, was reviewed. The assignment indicated BHW 1 was scheduled to work the day after the incident with Patient 1. The QC stated Patient 1 returned to the facility from the outside GACH early in the morning on 5/24/2025; BHW 1 did not report to work that day (5/24/2025) to seek medical care for injuries sustained during the incident, and then once DIR 1 received the anonymous text, BHW 1 was placed on suspension later that day. During a review of Patient 1’s “Progress Note,” dated 5/23/2025 at 6:45 p.m., the Progress Note indicated Patient 1’s CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) of the head at the outside GACH was negative, and that staples were applied on the head laceration that was approximately 1.5 inches long. During a review of BHW 1’s “Personnel Action Report (PAR),” dated 6/2/2025, the PAR indicated BHW 1’s employment at the facility was terminated involuntarily on 6/2/2025 for the reason “patient abuse.” During a review of the facility’s list of “Governing Board of Directors,” not dated, the list indicated the Chief Executive Officer (CEO) was a voting member of the GB. During an interview on 6/27/2025 at 8:03 p.m. with the CEO, the CEO confirmed he (CEO) was a voting member of the GB. The CEO stated that “at the end of the day,” oversight and accountability for the facility fell on the governing board. The CEO further stated that the GB was responsible for quality patient care and had the ultimate say over what occurred in the facility. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights,” last reviewed 8/2022, the P&P indicated, “It is the policy of the Behavioral Health Unit to maintain and protect patients’ fundamental human, civil, constitutional and statutory rights in accordance with federal and California laws ... In addition, LPS (the Lanterman-Petris-Short Act, a California law regulating involuntary mental health holds) grants all patients these irrevocable rights: ... 4. To be free from harm ... 18. To be free from verbal and physical abuse.” During a review of the facility’s GB (Governing Body) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), approved by the GB on 10/19/2022, the bylaws indicated, “The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital’s compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard’s rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided.” 2. During a review of Patient 2’s “Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]),” dated 6/9/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others due to lighting objects on fire while assaulting his (Patient 2) parents. During a review of Patient 2’s “Face Sheet (front page of the chart that contains a summary of basic information about the patient),” not dated, the Face Sheet indicated Patient 2 was admitted to the facility’s behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 6/10/2025. During a review of Patient 2’s “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition),” dated 6/11/2025, the 5250 hold paperwork indicated Patient 2’s involuntary legal hold was extended due to being a danger to others and being gravely disabled. During a review of Patient 2’s “Progress Note,” dated 6/11/2025 at 1:57 p.m., the Progress Note indicated Patient 2 was agitated (being upset, annoyed, angry, and physically disturbed), irritable, making “attempts to go AWOL (Absent Without Leave, leaving the facility without authorization),” and verbalizing a desire to leave. During a review of Patient 2’s “Behavioral Health Acuity [the severity or intensity of a patient’s health condition] Assessment,” dated 6/11/2025 at 2:00 p.m., the Assessment indicated Patient 2 was placed on elopement precautions (strategies or protocols to prevent patients from leaving a health care facility without authorization). During a review of Patient 2’s “Individual Observations” flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 6/11/2025 to 6/12/2025, the flowsheet indicated Patient 2 was asleep and in his (Patient 2) room from 10:14 p.m. to 1:30 a.m. During a review of Patient 2’s “Progress Note,” dated 6/12/2025 at 6:42 a.m., the Progress Note indicated, “At approximately [1:40 a.m.], [Patient 2] came out of the room wrapped with the blanket to the nurse station responding to internal stimuli, pacing around the unit making nonsensical statement, disorganized and guarded, and continue talking to self. [Patient 2] was pacing around the back of the unit and suddenly [Behavioral Health Worker] called for help. [Patient 2] already make advance toward the exit door, ran left across the office and exit to the side door to [the street]. Staff unable to pursue the patient on the street. Police were called to report the incident.” During a concurrent observation and interview with the Director (DIR 1) of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility’s offsite campus (Campus 2) on 6/24/2025 at 11:13 a.m., the double doors leading to Unit 2 on Campus 2, were observed. There was a keypad on the wall to the right side of the double doors; DIR 1 entered a code to unlock the doors. DIR 1 stated these doors had a lock that was magnetized for up to 1200 pounds. During an interview on 6/24/2025 at 3:07 p.m. with the Quality Coordinator (QC) , the QC stated that on 6/12/2025 after midnight, Patient 2 was agitated and pacing the hall of Unit 2. Two staff, Charge Nurse (CN, the lead Registered Nurse on a shift) 4 and Behavioral Health Worker (BHW) 7 attempted to redirect Patient 2 away from the doors exiting out of Unit 2 (fire double doors without an alarm which should be opened only with a code). While CN 4 went to get more help, Patient 2 charged through the fire double doors of Unit 2. The doors were equipped with a magnetic lock rated at 1200 pounds (the amount of force necessary to force the lock open). The QC stated that instead of calling a “Code Green (a hospital-wide call for help when a patient elopes),” the staff decided to follow Patient 2 to try and stop him. DIR 1 stated that Patient 2 escaped onto the street and staff called the police. The facility did not know what happened to Patient 2 after he eloped. During a concurrent observation and interview on 6/24/2025 at 3:09 p.m. with the QC, the QC demonstrated the path Patient 2 took to escape the facility. After exiting Unit 2, which had a fire door that should have been opened only with a code, Patient 2 made a right into the Partial Hospitalization Program (PHP, an intensive form of outpatient mental health treatment that offers a structured therapeutic environment during the day while allowing patients to return home in the evenings) unit, which was unlocked. Inside the PHP unit, to the right, there was an exit door onto the street. During a concurrent observation and interview on 6/25/2025 at 9:26 a.m. with the QC, the Nurse Manager of Campus 2’s BHU (NM 1), and the Associate Administrator (AA), the surveillance footage from 5/23/2025, was reviewed. The security camera was pointed at the double doors of Unit 2. The following events were observed at the indicated timestamps in the video: 1. 1:42 a.m.: The doors (Unit 2’s doors) were shown with nobody present, including staff. Patient 2 then appeared on camera and walked toward the double doors. The QC confirmed that this was Patient 2. NM 1 stated that prior to this clip, Charge Nurse (CN) 4 was trying to talk to Patient 2 and left to get support. 2. 1:43:05 a.m.: Patient 2 attempted to open the door (Unit 2’s doors) twice by pressing on the push bar using his right shoulder and back. 3. 1:43:14 a.m.: Patient 2 was standing by the door (Unit 2’s doors). BHW 7 approached Patient 2 from off-camera, talking to him. 4. 1:43:15 a.m.: Patient 2 used his shoulder and back to open the door (Unit 2’s doors); Patient 2 exited the unit. BHW 7 followed Patient 2 out of the doors. The AA stated there was no alarm when that door opened. 5. 1:43:47 a.m.: Multiple staff followed Patient 2 and BHW 7 out of the doors. During an interview on 6/25/2025 at 2:16 p.m. with the Lead Maintenance Worker (LMW), the LMW stated that the doors in the BHU were equipped with a magnetic lock rated for 1200 pounds of force, which was required to force open the magnet lock. All the doors on Campus 2 were previously upgraded on 9/11/2024 from 600 pounds to 1200 pounds due to an elopement. The LMW stated he did not think it was possible for someone to apply 1200 pounds of force to open that door. During an interview on 6/26/2025 at 9:45 a.m. with DIR 1, DIR 1 stated elopement precautions or specific interventions (strategies and actions implemented by nurses and other healthcare staff to achieve a goal) that staff should take when a patient was on elopement precautions were not listed in any of the facility’s policy and procedures (P&P). DIR 1 further stated, “It [elopement precautions] just means to be ‘on high alert.’” During an interview on 6/26/2025 at 10:38 a.m. with the Associate Administrator (AA), the AA stated it was never acceptable for a patient to elope from the unit. During a concurrent interview and record review on 6/26/2025 at 11:51 a.m. with the AA and QC, a report from the outside vendor that supplied the door, dated 6/26/2025, was reviewed. The report indicated, “It was found that the exit device’s concealed vertical rod was intermittently failing to fully latch. The issue prevented the maglock from properly securing the door ... It is recommended to implement a quarterly preventative maintenance schedule to ensure continued reliable operation of the door hardware.” The AA and QC confirmed that the Unit 2 doors (which Patient 2 managed to open) were broken. During an interview on 6/26/2025 at 3:36 p.m. with the Nurse Manager of Campus 2’s BHU (NM 1), NM 1 stated that BHU staff were provided with a whistle to use to call for help without leaving the patient. NM 1 confirmed the whistle was not used when Patient 2 was attempting to elope. During an interview on 6/27/2025 at 7:22 p.m. with the Director of Performance Improvement and Quality (DQM), the DQM confirmed that there was no procedure in place at the time of the incident to regularly check the magnetic lock and door latch. The DQM also confirmed that in 2024, the magnetic locks on all the doors in Campus 2 were upgraded from a 600-pound rating to a 1200-pound rating due to an elopement as the patient at that time was able to open the door despite it being locked. During a review of the facility’s list of “Governing Board of Directors,” not dated, the list indicated the Chief Executive Officer (CEO) was a voting member of the GB. During an interview on 6/27/2025 at 8:03 p.m. with the Chief Executive Officer (CEO), the CEO stated that “at the end of the day,” oversight and accountability for the facility fell on the governing board. The CEO further stated that the GB was responsible for quality patient care and had the ultimate say over what occurs in the facility. During a review of the facility’s policy and procedure (P&P) titled, “Security of the Unit,” last reviewed 10/2021, indicated, “It is the policy of the Behavioral Health Unit to operate as a locked unit, in order to maintain safety and security of the treatment environment.” During a review of the facility’s GB bylaws, approved by the GB on 10/19/2022, the bylaws indicated, “The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital’s compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard’s rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided.” 3. During a review of Patient 8’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/16/2025, the Psych Eval indicated, Patient 8 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 8’s “Consultation Report,” dated 4/16/2025, the “Consultation Report” indicated, Patient 8 had past medical history of pseudoseizures (event that mimic seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness] but are not caused by abnormal electrical activity in the brain) and autism (neurodevelopmental disorder characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication). During a review of Patient 9’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 6/5/2025, the Psych Eval indicated, Patient 9 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 8’s “Progress Note Non-Physician (nurses progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “Patient (Patient 8) was attacked by his (Patient 8’s) roommate (Patient 9) approximately 1830 (6:30 p.m.). Patient (Patient 8) was witnessed falling back out of his (Patient 8’s) room into the hallway noted hitting the back of his (Patient 8’s) head ... Patient (Patient 8) unable to follow command for PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system). Right pupil 3 mm (millimeters, unit of measure) reactive to light. Left pupil nonreactive (the pupil [the black circle in the center of the eye] doesn’t constrict [get smaller] in response to light or when focusing on a near object). Rapid Response (a system designed to quickly address a patient’s sudden clinical deterioration before it escalates into a medical emergency) was called at 1838 (6:38 p.m.) ... [physician] was notified ... CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head, transfer to telemetry floor [room number]. Pending report.” The “Progress Note Non-Physician” also indicated Patient 8 was transferred to facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor at 7:31 p.m. During an interview on 6/24/2025 at 12 p.m. with Patient 8, Patient 8 stated he (Patient 8) was in the room, and someone attacked him (Patient 8). Patient 8 stated, “he hit my face to my left eye.” During an interview on 6/24/2025 at 3:10 p.m. with the Nurse Manager (NM 2) of BHU, NM 2 stated the following: there were different levels of monitoring aside from standard every 15-minute rounding in BHU. A specific staff was assigned to a specific patient who needed one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring and the staff had to stay with the patient within arm’s length. For patients who needed line of sight (a straight line along which an observer had unobstructed vision) monitoring, staff would need to keep a close eye on the patients and maintain visual on the patients outside their regular every 15-minute rounding. During an interview on 6/25/2025 at 10:02 a.m. with the Director of Performance Improvement/ Quality (DQM), DQM stated Patient 8 and Patient 9 were both in the same room when the incident happened on 6/14/2025. During a concurrent observation and interview on 6/25/2025 at 10:03 a.m. with DQM, the facility’s security video footage, dated 6/14/2025, was reviewed. The security video footage with no audio indicated the following: -At 6:23:27 p.m. a Behavioral Health Worker (BHW 5) was seen sitting in the hallway; -At 6:23:30 p.m. BHW 5 heard something and walked toward Patient 8 and Patient 9’s room. BHW 5 looked at the window on the door, then opened the door and walked in; -At 6:23:47 p.m. Patient 8 walked out from the room, limping, then fell to the floor in the middle of hallway; -At 6:25:45 p.m. Patient 9 was taken out by two BHWs out from the room. During the same interview on 6/25/2025 at 10:03 a.m. with DQM, DQM confirmed the identities of BHW 5, Patient 8 and Patient 9. DQM also stated there was an altercation between Patient 8 and Patient 9 in the room (with the closed door). During a review of Patient 8’s “Progress Note Non-Physician (nurses progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “2005 (8:05 p.m.) patient (Patient 8) on unit (Telemetry unit) ... Patient (Patient 8) has multiple bruises to his (Patient 8’s) face and head.” During an interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated on 6/14/2025, he (BHW 5) was sitting in the hallway and saw Patient 8 and Patient 9 went to the room. BHW 5 stated, “I heard feet shuffling in the room. I got up, peeked into the window and saw Patient 9 was on top of Patient 8 on the ground hitting Patient 8. Patient 9 was aggressive to Patient 8.” During the same interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. BHW 5 also stated Patient 8 was on one to one (1:1) monitoring that day but his (Patient 8’s) assigned sitter was flexed earlier that day due to overstaffing and no one was assigned to replace the sitter. BHW 5 stated there was no line of sight for both patients (Patient 8 and Patient 9) because the door was closed. During an interview on 6/25/2025 at 2:29 p.m. with the Charge Nurse (CN 3) of BHU, CN 3 stated the following: the charge nurse of the unit was responsible for making assignment for the shift. There was no specific person assigned to perform line of sight. Any staff not assigned as 1:1 monitoring would be watching patients who required line of sight monitoring. The staff would need to see those patients at all times. CN 3 also stated a physician order was required for starting and discontinuing any line of sight and 1:1 monitoring. During a concurrent interview and record review on 6/25/2025 at 2:52 p.m. with the Nurse Manager (NM 2) of BHU, the facility’s Campus 1 BHU assignment, “[Unit] AM Shift Assignment,” dated 6/14/2025 AM shift, was reviewed. The “[Unit] AM Shift Assignment” indicated, Patient 8 was 1:1 monitoring and Patient 9 was on line of sight monitoring. The “[Unit] AM Shift Assignment” did not indicate which nursing staff was assigned to Patient 8 and Patient 9 to perform the 1:1 monitoring and line of sight monitoring. NM 2 stated she (NM 2) could not tell which staff was assigned to perform line of sight monitoring because it was not written on the assignment. During a concurrent interview and record review on 6/25/2025 at 3:29 p.m. with the Quality and Performance Improvement Supervisor (QPS), Patient 8’s “Order Information for: Patient Monitoring (physician order),” dated 6/12/2025, was reviewed. The physician order indicated Patient 8 was placed on 1:1 sitter observation. QPS stated the order was active at the time of incident. QPS stated the order was discontinued on 6/14/2025 at 8:19 p.m. During a concurrent interview and record review on 6/25/2025 at 3:30 p.m. with QPS, Patient 9’s “Order Information for: Patient Monitoring (physician order),” dated 6/10/2025, was reviewed. The physician order indicated, Patient 9 was placed on line-of-sight observation. QPS stated the order was active and only discontinued on 6/20/2025. During an interview on 6/27/2025 at 7:43 p.m. with the Director of Performance Improvement/Quality (DQM), DQM stated the following: Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team met and performed a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) for the incident. The incident was still in discussion. Nothing was implemented. During an interview on 6/27/2025 at 8:02 p.m. with the Chief Executive Officer (CEO), CEO stated he (CEO) sits on the Governing Board (GB) as a voting board member. During an interview on 6/27/2025 at 8:09 p.m. with CEO, CEO stated the following: GB relied on QAPI and Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) to report quality of care and patient safety issues but at the end of the day, the oversight and accountability of the facility fell on the governing board. The CEO also stated GB was responsible for providing oversight on overall quality of care and patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 10/2021, the P&P indicated, “The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment ... Observation levels are designed to provide the right level of observation, precaution and oversight commensurate with physician and RN assessment of the safety needs of the patient in alignment with the current behavior and symptoms they are demonstrating ... Three levels of staff monitoring are provided ... Level II - moderate - line of sight ... Policy - A level of observation wherein the patient remains in staff view at all times. A specific staff member is assigned and the line of observation is maintained by staff in person and not through video monitoring ... Level III - intensive - one to one ... Policy - consists of one-to-one staff observation with a patient never farther away than arm’s length. The patient remains within arm’s length at all times ... The RN is responsible for obtaining an MD order for an observation level that is line of sight or 1 to 1 ... When the patient’s status permits, the RN will notify the MD and get an order to down-grade the observation status to that of “least restrictive” in a manner to maintain the patient in an optimal level of safety.” During a review of the facility’s policy and procedure (P&P) titled, “Psychiatric Nursing Standards of Care,” dated 10/2021, the P&P indicated, “It is the policy of the Behavioral Health Unit that all nursing services rendered will be consistent with established nursing standards ... Role of the Registered Nurse: the Registered Nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. Nursing care may be directed to other licensed nursing staff or unlicensed nursing staff...” During a review of the facility’s “Governing Board of Directors Bylaws of [the facility] (GB Bylaws),” approved by the GB on 10/19/2022, the GB Bylaws indicated, “The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital’s compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard’s rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided.””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 50515 Based on interview and record review, the facility failed to ensure one of 30 sampled patient’s (Patient 12) and/or Patient 12’s representative, was provided with follow up of grievance (a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care) and or informed of any resolution of grievance as per facility’s policy and procedure regarding “Complaint and Grievance Procedure.” This deficient practice resulted in Patient 12’s and their representative to not be provided with a resolution about their complaint, which may leave Patient 12 and/or Patient 12’s representative being dissatisfied and feel ignored or dismissed for concerns raised regarding patient care. Findings: During a review of Patient 12’s “Face Sheet (a document containing a patient’s medical and demographic information),” undated, the face sheet indicated Patient 12 was admitted to the facility on 3/12/2025 at 6:58 p.m., with a medical diagnosis of psychosis (mental condition in which thought, and emotions are affected, and reality is affected). During a phone interview on 6/25/2025 at 9:00 a.m. with Patient 12’s representative (FM 3), FM 3 stated, he (FM 3) emailed a written complaint to the facility on 3/16/2025 with no response after a follow up email to the facility. FM 3 further stated he (FM 3) received no phone call or mail response from facility regarding his complaint. During an interview on 6/25/2025 at 3:20 p.m. with the Patient Relations Manager (PRM), PRM stated, he (PRM) received Patient 12’s FM 3’s complaint, forwarded it to the unit Manager and the Director of Quality for investigation. PRM further stated he (PRM) was not sure of the result of the investigation or the resolution of Patient 12’s FM3’s complaint and does not remember speaking to Patient 12’s FM3. During a review of the facility’s “Grievance Documentation Form,” dated 3/16/2025, 3/17/2025, 3/23/2025 and 3/27/2025, the record indicated the following: -on 3/16/2025 Patient 12’s FM3 filed a complaint and agreed to a phone call with PRM. -on 3/17/2025 Patient 12’s FM 3 sent a follow up email to PRM requesting a response. -on 3/23/2025 Patient 12’s FM 3 sent a follow up email to PRM requesting a response. -on 3/27/2025 Patient 12’s FM 3 sent a follow up email to PRM stating he feels ignored and requesting resolution to concerns. During a concurrent interview and record review on 6/25/2025 at 4:00 p.m. with the PRM, the “The Acknowledgement Letter,” dated 3/24/2025 and the “Response/Closing Letter,” dated 4/8/2025, were reviewed. “The Acknowledgement Letter” indicated the letter was sent to Patient 12’s assisted living facility (provides housing and personal care services to individuals who need help with daily activities but do not require the level of care offered in a nursing home) under Patient 12’s name and the “Response/Closing Letter” was returned to facility (where FM 3 filed a complaint) from Patient 12’s Assisted living facility. The PRM stated letters were not sent to FM 3. During a review of the facility’s policy and procedures (P&P) titled, “Complaint and Grievance Procedure,” revised 6/2024, indicated, “Every employee upon receipt of a complaint or grievance should acknowledge the patient’s/family’s concern and explains the process for resolution. Step by step grievance: ...3. The Patient relation manager will mail a letter acknowledging and resolving the grievance within 7 days of receipt. If grievance requires greater than 7 days for investigation or resolution, an acknowledgement letter may be sent informing the complainant that the facility requires more time to investigate the matter. A final response letter will be mailed to the complainant no later than 30 days of receiving grievance.””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50594 Based on interview and record review, the facility failed to ensure two of 30 sampled patients’ (Patient 22 and Patient 23) family representatives were informed of the use of restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) on Patient 22 and Patient 23, in accordance with the facility’s policy and procedure regarding “Seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) and Restraint” and “Notification of Seclusion and/or Restraint Episode.” This deficient practice resulted in family representatives not being informed of the treatment provided at the facility including understanding the risk and benefits of the treatment (use of physical restraint on Patient 22 and Patient 23) and being able to help make informed decision (making healthcare choices based on a clear understanding of the available options, potential benefits, risks, and alternatives, as well as their own values and preferences) pertaining to Patient 22 and Patient 23’s care. Findings: 1. During a review of Patient 22’s medical record titled, “History and Physical Exam (H&P, a formal and complete assessment of the patient and the problem),” dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief of complaint of status post (after) fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) with dizziness. During a review of Patient 22’s medical record titled, “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 6/13/2025, the psychiatric evaluation indicated Patient 22 was brought in from medical floor on 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for gravely disability (unable to care for one’s self) and danger to self (to harm one’s self). During a concurrent interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22’s “Orders,” dated 6/16/2025, was reviewed. The Orders indicated Patient 22 had a physician’s order for restraint for 4 hours, use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints, and danger to others (to harm others). The HS 1 stated the use of keyed polyurethane restraints indicated that Patient 22 was placed in a seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) room. During the same interview on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22’s “Notification of seclusion and/or restraint episode consent form,” dated 6/12/2025, was reviewed. The consent form indicated Patient 22 had requested to notify family member (FM) 1 of episode of seclusion and/or restraint use. HS 1 stated there was no documentation in Patient 22’s clinical record that FM 1 was notified about Patient 22’s restraint use, and placement in the seclusion room. HS 1 further stated the family member should have been notified per Patient 22’s request according to the consent form and that Patient 22’s wish should have been honored. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” reviewed in 6/2023, the P&P indicated, “A family member will be contacted by phone to notify the seclusion/restraint episode and patient condition, after obtaining the patient’s consent.” During a review of the facility’s policy and procedure (P&P) titled, “Notification of Patient Admission and Subsequent Events,” reviewed in 10/2021, the P&P indicated, “It is the policy of Behavioral Unit to make reasonable attempts to notify any person designated by a patient admitted for mental health services in the following areas ...Notification of Seclusion and/or Restraint Episode.” 2. During a review of Patient 23’s “History and Physical (H&P),” dated 5/9/2025, the H&P indicated Patient 23 was admitted for chief complaint, “Patient endorses suicidal ideation (thoughts of taking one’s own life).” During a concurrent interview and record review on 6/25/2025 at 3:48 p.m. with the House Supervisor (HS) 1, Patient 23’s “Orders,” dated 5/12/2025, was reviewed. The HS 1 stated Patient 23 had a physician restraint order which indicated “4 hours [restraint use], keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure), danger to others.” During a concurrent interview and record review on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, Patient 23’s “Notification of Seclusion and/or Restraint episode,” dated 5/8/2025, was reviewed. The HS 2 stated Patient 23’s notification of seclusion and restraint consent form was signed by Patient 23 on admission. HS 2 further stated there was no documentation that the nurse informed Patient 23’s family member (FM) 2 regarding Patient 23 being on restraint and being placed in the seclusion room. During the same interview on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, HS 2 stated [the use of] restraint was a “higher level of intervention,” and it was important to notify the family (Patient 23) in case of injury or if anything were to happen. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” reviewed in 6/2023, the P&P indicated, “A family member will be contacted by phone to notify the seclusion/restraint episode and patient condition, after obtaining the patient’s consent.” During a review of the facility’s policy and procedure (P&P) titled, “Notification of Patient Admission and Subsequent Events,” reviewed in 10/2021, the P&P indicated, “It is the policy of Behavioral Unit to make reasonable attempts to notify any person designated by a patient admitted for mental health services in the following areas ...Notification of Seclusion and/or Restraint Episode.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 43236 Based on observation, interview, and record review, the facility failed to provide a safe environment of care, in accordance with the facility’s policy regarding “Security of the Unit” and Governing Body (GB) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB’s accountability for the safety and quality of care, treatment, and services provided, for one (1) of 30 sampled patients (Patient 2), when Patient 2 was able to force open a locked door. This deficient practice resulted in Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown. On 6/26/2025 at 4:37 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Performance Improvement and Quality (DQM), Associate Administrator (AA), the Director (DIR 1) of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility’s offsite campus (Campus 2), and Quality Coordinator (QC). The facility failed to provide a safe environment for care when Patient 2 was able to force open a locked door. This led to Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown. On 6/24/2025 at 3:07 p.m., the QC stated that on 6/12/2025 after midnight, Patient 2 was agitated and pacing the hall of Unit 2. Two staff, Charge Nurse (CN, the lead Registered Nurse on a shift) 4 and Behavioral Health Worker (BHW) 7 attempted to redirect Patient 2 away from the doors exiting out of Unit 2 (fire double doors without an alarm which should be opened only with a code). While CN 4 went to get more help, Patient 2 charged through the double doors of Unit 2. The doors were equipped with a magnetic lock rated for 1200 pounds (the amount of force necessary to force the lock open). The QC stated that instead of calling a “Code Green (a hospital-wide call for help when a patient elopes),” the staff decided to follow Patient 2 to try and stop him (Patient 2). DIR 1 stated that Patient 2 escaped onto the street and staff called the police. The facility did not know what happened to Patient 2 after he eloped. On 6/27/2025 at 11:11 p.m., the IJ was removed in the presence of the CEO via telephone, DQM, AA, QC, and DIR 1. The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, the facility contacted an outside vendor to repair the door to Unit 2 on 6/18/2025; the vendor returned to confirm the door was repaired on 6/24/2025 and 6/25/2025. Assessment of all locked doors, including the latching mechanism, was added to the plant operations team’s preventative maintenance tasks, occurring Monday to Friday. In addition, nursing staff were now responsible as of 6/27/2025 to conduct door checks every shift by pushing on the door to ensure it was locked. Any instances of the door being unlocked would be immediately escalated to plant operations for intervention, and a staff member would be stationed at the door until the door was confirmed to be working properly. Education began on 6/27/2025 with all nursing staff on duty at all three of the facility’s campuses (Campus 1, Campus 2, Campus 3) and would continue every shift until all nursing staff completed training. The topics included observing patients for unsafe behaviors such as eyeing the door and hovering around the door, consulting with the physician for enhanced monitoring, and calling a “Code Green” when a patient eloped to ensure all staff were notified and could assist with locating and/or retrieving the patient prior to exiting the campus. Findings: During a review of Patient 2’s “Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]),” dated 6/9/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others due to lighting objects on fire while assaulting his (Patient 2) parents. During a review of Patient 2’s “Face Sheet (front page of the chart that contains a summary of basic information about the patient),” not dated, the Face Sheet indicated Patient 1 was admitted to the facility’s behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 6/10/2025. During a review of Patient 2’s “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition),” dated 6/11/2025, the 5250 hold paperwork indicated Patient 2’s involuntary legal hold was extended due to being a danger to others and being gravely disabled. During a review of Patient 2’s “Progress Note,” dated 6/11/2025 at 1:57 p.m., the Progress Note indicated Patient 2 was agitated (being upset, annoyed, angry, and physically disturbed), irritable, making “attempts to go AWOL (Absent Without Leave, leaving the facility without authorization),” and verbalizing a desire to leave. During a review of Patient 2’s “Behavioral Health Acuity (the severity or intensity of a patient’s health condition) Assessment,” dated 6/11/2025 at 2:00 p.m., the Assessment indicated Patient 2 was placed on elopement precautions (strategies or protocols to prevent patients from leaving a health care facility without authorization). During a review of Patient 2’s “Individual Observations” flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 6/11/2025 to 6/12/2025, the flowsheet indicated Patient 2 was asleep and in his (Patient 2) room from 10:14 p.m. to 1:30 a.m. During a review of Patient 2’s “Progress Note,” dated 6/12/2025 at 6:42 a.m., the Progress Note indicated, “At approximately [1:40 a.m.], [Patient 2] came out of the room wrapped with the blanket, to the nurse station responding to internal stimuli, pacing around the unit making nonsensical statement, disorganized and guarded, and continue talking to self. [Patient 2] was pacing around the back of the unit and suddenly [Behavioral Health Worker] called for help. [Patient 2] already make advance toward the exit door, ran left across the office and exit to the side door to [the street]. Staff unable to pursue the patient on the street. Police were called to report the incident.” During a concurrent observation and interview on 6/24/2025 at 11:13 a.m. with the Director (DIR 1) of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility’s offsite campus (Campus 2), the double doors leading to Unit 2 on Campus 2, were observed. There was a keypad on the wall to the right side of the double doors; DIR 1 entered a code to unlock the doors. DIR 1 stated these doors had a lock that was magnetized for up to 1200 pounds. During an interview on 6/24/2025 at 3:07 p.m. with the Quality Coordinator (QC), the QC stated that on 6/12/2025 after midnight, Patient 2 was agitated and pacing the hall of Unit 2. Two staff, Charge Nurse (CN, the lead Registered Nurse on a shift) 4 and Behavioral Health Worker (BHW) 7 attempted to redirect Patient 2 away from the doors exiting out of Unit 2 (fire double doors without an alarm which should be opened only with a code). While CN 4 went to get more help, Patient 2 charged through the fire double doors of Unit 2. The doors were equipped with a magnetic lock rated for 1200 pounds (the amount of force necessary to force the lock open). The QC stated that instead of calling a “Code Green (a hospital-wide call for help when a patient elopes),” the staff decided to follow Patient 2 to try and stop him (Patient 2). DIR 1 stated that Patient 2 escaped onto the street and staff called the police. The facility did not know what happened to Patient 2 after he eloped. During a concurrent observation and interview on 6/24/2025 at 3:09 p.m. with the QC, the QC demonstrated the path Patient 2 took to escape the facility. After exiting Unit 2, which had a fire door that should have been opened only with a code, Patient 2 made a right into the Partial Hospitalization Program (PHP, an intensive form of outpatient mental health treatment that offers a structured therapeutic environment during the day while allowing patients to return home in the evenings) unit, which was unlocked. Inside the PHP unit, to the right, there was an exit door onto the street. During a concurrent observation and interview on 6/25/2025 at 9:26 a.m. with the QC, the Nurse Manager of Campus 2’s BHU (NM 1), and the Associate Administrator (AA), the surveillance footage from 5/23/2025, was reviewed. The security camera was pointed at the double doors of Unit 2. The following events were observed at the indicated timestamps in the video: 1. 1:42 a.m.: The doors (Unit 2’s doors) were shown with nobody present, including staff. Patient 2 then appeared on camera and walked toward the double doors. The QC confirmed that this was Patient 2. NM 1 stated that prior to this clip, Charge Nurse (CN) 4 was trying to talk to Patient 2 and left to get support. 2. 1:43:05 a.m.: Patient 2 attempted to open the door (unit 2’s doors) twice by pressing on the push bar using his right shoulder and back. 3. 1:43:14 a.m.: Patient 2 was standing by the door (Unit 2’s doors). BHW 7 approached Patient 2 from off-camera, talking to him. 4. 1:43:15 a.m.: Patient 2 used his shoulder and back to open the door (Unit 2’s doors); Patient 2 exited the unit (Unit 2). BHW 7 followed Patient 2 out of the doors. The AA stated there was no alarm when that door opened. 5. 1:43:47 a.m.: Multiple staff followed Patient 2 and BHW 7 out of the doors. During an interview on 6/25/2025 at 2:16 p.m. with the Lead Maintenance Worker (LMW), the LMW stated that the doors in the BHU were equipped with a magnetic lock rated for 1200 pounds of force, which was required to force open the magnet lock. All the doors on Campus 2 were previously upgraded on 9/11/2024 from 600 pounds to 1200 pounds due to an elopement. The LMW stated he did not think it was possible for someone to apply 1200 pounds of force to open that door. During an interview on 6/26/2025 at 9:45 a.m. with DIR 1, DIR 1 stated elopement precautions or specific interventions (strategies and actions implemented by nurses and other healthcare staff to achieve a goal) that staff should take when a patient was on elopement precautions were not listed in any of the facility’s policies or procedures. DIR 1 further stated, “It [elopement precautions] just means to be ‘on high alert.’” During an interview on 6/26/2025 at 10:38 a.m. with the Associate Administrator (AA), the AA stated it was never acceptable for a patient to elope from the unit. During a concurrent interview and record review on 6/26/2025 at 11:51 a.m. with the AA and QC, a report from the outside vendor that supplied the door, dated 6/26/2025, was reviewed. The report indicated, “It was found that the exit device’s concealed vertical rod was intermittently failing to fully latch. The issue prevented the maglock from properly securing the door. ... It is recommended to implement a quarterly preventative maintenance schedule to ensure continued reliable operation of the door hardware.” The AA and QC confirmed that the Unit 2 doors were broken. During an interview on 6/26/2025 at 3:36 p.m. with the Nurse Manager of Campus 2’s BHU (NM 1), NM 1 stated that BHU staff were provided a whistle to use to call for help without leaving the patient. NM 1 confirmed the whistle was not used when Patient 2 was attempting to elope. During an interview on 6/27/2025 at 7:22 p.m. with the Director of Performance Improvement and Quality (DQM), the DQM confirmed that there was no procedure in place at the time of the incident to regularly check the magnetic lock and door latch. The DQM also confirmed that in 2024, the magnetic locks on all the doors in Campus 2 were upgraded from a 600-pound rating to a 1200-pound rating due to an elopement as the patient at that time was able to open the door despite it being locked. During a review of the facility’s policy and procedure (P&P) titled, “Security of the Unit,” last reviewed 10/2021, the P&P indicated, “It is the policy of the Behavioral Health Unit to operate as a locked unit, in order to maintain safety and security of the treatment environment.””

“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: 43236 Based on observation, interview, and record review, the facility failed to: 1. Ensure its nursing staff protected one (1) of 30 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), when staff failed to provide an appropriate physical response to an agitated (being upset, annoyed, angry, and physically disturbed) patient (Patient 1), in accordance with the facility’s policy & procedure (P&P) regarding Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare settings. These rights ensure that patients receive safe, quality care while respecting their autonomy and dignity). This deficient practice resulted in Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear). 2. Protect one of 30 sampled patients (Patient 10) from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and respond to an alleged physical abuse in a timely manner, in accordance with the facility’s policy regarding “Patient Rights” and “Employee to Patient physical abuse,” when the Behavioral Health Worker (BHW 10) put hands on Patient 10 inappropriately, and pushed Patient 10 in the room. The Registered Nurse (RN 5) also failed to assess Patient 10’s left eyebrow wound and escalate the alleged abuse to the charge nurse and the house supervisor and notify the attending physician, after Patient 10 reported the alleged abuse on 4/20/2025. This deficient practice resulted in Patient 10 sustaining a left eyebrow wound and delay in treatment and care due to a delay in notifying the physician. This deficient practice also resulted in BHW 10 not being removed from the facility immediately, thus putting Patient 10 and other patients at risk for further abuse. On 6/25/2025 at 5:12 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Performance Improvement and Quality (DQM), Associate Administrator (AA), Nurse Manager (NM 1) of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility’s offsite campus (Campus 2), and Quality Coordinator (QC). The facility failed to ensure its nursing staff protected psychiatric patients (someone receiving treatment or care for a mental health disorder or illness) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury) when staff failed to provide an appropriate physical response to an agitated (being upset, annoyed, angry and physically disturbed) patient (Patient 1). This led to Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear). On 6/24/2025 at 3:17 p.m., the Quality Coordinator (QC) stated that on 5/23/2025, Patient 1 was discovered on the floor in her (Patient 1) room bleeding from her head. 911 was called and Patient 1 was taken to an outside hospital to have her head wound treated. On 6/24/2025 at 3:27 p.m., the Director of the BHU at Campus 2 (DIR 1) stated that the staff thought Patient 1 was self-harming until DIR 1 received an anonymous text message on 5/24/2025 indicating that Patient 1 had been pushed. Patient 1 was alone in her room with Behavioral Health Worker (BHW) 1, who was witnessed coming out of Patient 1’s room and calling for help. DIR 1 stated they determined that BHW 1 most likely pushed her (Patient 1). On 6/25/2025 at 11:25 a.m., the QC stated that BHW 1 was agitated in the surveillance footage, that BHW 1 was uncooperative during the facility’s internal investigation, and that there were also inconsistencies in BHW 1’s story, specifically that Patient 1 suffered a single laceration which was not consistent with the report that she (Patient 1) had been banging her head. BHW 1’s Personnel Action Report indicated that BHW 1’s employment at the facility was terminated involuntarily on 6/2/2025 for the reason “patient abuse.” On 6/27/2025 at 11:10 p.m., the IJ was removed in the presence of the CEO via telephone, DQM, AA, QC, and DIR 1. The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, the alleged staff member was suspended on 5/24/2025 and terminated on 6/2/2025. Education began on 6/27/2025 with all nursing staff on duty at all three of the facility’s campuses (Campus 1, Campus 2, Campus 3) and would continue every shift until all nursing staff completed training. The topics included de-escalation (the methods and actions taken to decrease the severity of a conflict, whether of physical, verbal or another nature) techniques, appropriate patient approach, skills such as safe restraining, calming techniques, and notifying other staff, post-event staff responsibilities, and the rights of mental health patients. The IJ Removal Plan also included distributing the annual de-escalation training schedule to all nursing staff to ensure training was completed timely as well as random daily leadership rounds to verify staff were engaging with patients in a respectful and therapeutic manner, following established policies and procedures, and maintaining appropriate boundaries. Findings: 1. During a review of Patient 1’s “Face Sheet (front page of the chart that contains a summary of basic information about the patient),” not dated, the Face Sheet indicated Patient 1 was admitted to the facility’s behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 5/20/2025. During a review of Patient 1’s “Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment- (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]),” dated 5/20/2025, the 5150 hold paperwork indicated Patient 1 was detained for being a danger to herself and gravely disabled due to appearing paranoid (intense and irrational distrust and suspicion of others), internally preoccupied (focusing on things they are thinking or hearing inside their head instead of engaging with the world around them), not talking, and spitting. During a review of Patient 1’s “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition),” dated 5/21/2025, the 5250 hold paperwork indicated Patient 1’s involuntary legal hold was extended due to being a danger to herself and being gravely disabled. During a review of Patient 1’s “Progress Note,” dated 5/23/2025 at 2:11 p.m., the Progress Note indicated, “[At 11:40 a.m.], [Patient 1 was] throwing soiled diaper at staff and being aggressive towards staff ... [At 11:45 a.m.], [Patient 1 was] found on floor bleeding from head with cut slash on back of head [approximately] 4 inches long. [Patient 1 was] found attempting to throw blood on staff ... Walked [Patient 1] to seclusion room to assess patient, meanwhile 911 was called.” During an interview on 6/24/2025 at 3:17 p.m. with the Quality Coordinator (QC), the QC stated that on 5/23/2025, Patient 1 was discovered on the floor in her (Patient 1) room bleeding from her head. The QC stated that it was reported she (Patient 1) was banging her head. She (Patient 1) was unable to be assessed in her room due to throwing blood at the staff, so she was walked to the seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) room and assessed. 911 was called and Patient 1 was taken to an outside general acute care hospital (GACH, a type of hospital that provides short-term, inpatient medical and surgical care for acute [sudden or severe] health conditions) to have her head wound treated. During an interview on 6/24/2025 at 3:27 p.m. with the Director of the BHU at Campus 2 (DIR 1), DIR 1 stated that the staff thought Patient 1 was self-harming (hurting herself) until DIR 1 received an anonymous text message on 5/24/2025 indicating that Patient 1 had been pushed. DIR 1 stated Patient 1 was alone in her (Patient 1) room with Behavioral Health Worker (BHW) 1, who was witnessed coming out of Patient 1’s room and calling for help. DIR 1 further stated they (facility administrative staff involved in the incident investigation) determined that BHW 1 most likely pushed her (Patient 1). During a concurrent observation and interview on 6/25/2025 at 10:04 a.m. with the QC, the Nurse Manager of the Campus 2 (NM 1), and the Associate Administrator (AA), the video surveillance footage from 5/23/2025 was reviewed. The following events were observed at the indicated timestamps in the video: 1. 11:47 a.m.: BHW 1 was seen entering the hallway in Unit 1, speaking to a patient off-camera. BHW 1’s body language indicated that she (BHW 1) was upset or agitated. QC confirmed this was BHW 1. 2. 11:48 a.m.: BHW 1 stood outside of Patient 1’s room, looking inside. QC confirmed that was Patient 1’s room. 3. 11:51 a.m.: BHW 1 appeared to be hit by something from inside Patient 1’s room. BHW 1 then entered Patient 1’s room. 4. 11:52 a.m.: BHW 2 entered Patient 1’s room. BHW 2 then left the room with BHW 1 and both moved off-camera. BHW 1 then returned to Patient 1’s room. 5. 11:53 a.m.: Multiple staff entered Patient 1’s room. 6. 11:55 a.m.: Patient 1 was escorted out of her room with three different staff. There was blood on Patient 1’s gown and one staff was holding a towel to the back of Patient 1’s head. During an interview on 6/25/2025 at 11:25 a.m. with the QC, the QC stated that BHW 1 was agitated in the surveillance footage, that BHW 1 was uncooperative during the facility’s internal investigation, and that there were also inconsistencies in BHW 1’s story, specifically that Patient 1 suffered a single laceration which was not consistent with the report that she (Patient 1) had been “banging her head.” During an interview on 6/25/2025 at 3:38 p.m. with the Behavioral Health Worker (BHW) 2, BHW 2 stated that on 5/23/2025, Patient 1 threw a diaper in the hallway. BHW 1 went to Patient 1’s room and said something to her (Patient 1) that BHW 2 did not hear. BHW 1 then went to the nurses’ station, then back to Patient 1’s room; BHW 2 saw BHW 1 go inside (Patient 1’s room) and went in behind her (BHW 1). Upon entering, BHW 2 saw Patient 1 on the ground and holding her (Patient 1) head, so BHW 2 blew her whistle which alerted the staff. BHW 2 asked BHW 1 what happened; she (BHW 2) stated BHW 1 told her (BHW 2) that Patient 1 “banged her head.” During a concurrent interview and record review on 6/25/2025 at 4:04 p.m. with the QC, the staffing assignment for 5/24/2025, was reviewed. The assignment indicated BHW 1 was scheduled to work the day after the incident with Patient 1. The QC stated Patient 1 returned to the facility from the outside GACH early in the morning on 5/24/2025; BHW 1 did not report to work that day to seek medical care for injuries sustained during the incident, and then once DIR 1 received the anonymous text, BHW 1 was placed on suspension later that day. During a review of Patient 1’s “Progress Note,” dated 5/23/2025 at 6:45 p.m., the Progress Note indicated Patient 1’s CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) of the head at the outside GACH was negative, and that staples were applied on the head laceration that was approximately 1.5 inches long. During a review of BHW 1’s “Personnel Action Report (PAR),” dated 6/2/2025, the PAR indicated BHW 1’s employment at the facility was terminated involuntarily on 6/2/2025 for the reason “patient abuse.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights,” last reviewed 8/2022, the P&P indicated, “It is the policy of the Behavioral Health Unit to maintain and protect patients’ fundamental human, civil, constitutional and statutory rights in accordance with federal and California laws ... In addition, LPS (the Lanterman-Petris-Short Act, a California law regulating involuntary mental health holds) grants all patients these irrevocable rights: ... 4. To be free from harm ... 18. To be free from verbal and physical abuse.” 2. During a review of Patient 10’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/16/2025, the Psych Eval indicated, Patient 10 was a 77-year-old admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a concurrent observation and interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), the facility’s security video footage dated 4/20/2025, was reviewed. The security video indicated the following: -At 11:26 p.m.: Patient 10 was seen standing by the doorway of his (Patient 10’s) room holding a pair of green pants; -At 11:27 p.m.: a Behavioral Health Worker (BHW 10) was seen walking towards Patient 10 and handed Patient 10 a diaper. Patient 10 and BHW 10 exchanged some conversation; -At 11:27:25 p.m.: BHW 10 put hands on Patient 10’s left shoulder area and right arm and pushed Patient 10 into the room. Both BHW 10 and Patient 10 went into the room; -At 11:27:41 p.m.: BHW 11 was seen walking down the hallway and looked into Patient 10’s room but did not go inside; -At 11:27:49 p.m.: BHW 10 came out of Patient 10’s room; -At 11:27:56 p.m.: Patient 10 walked to the doorway and pointed at his (Patient 10) left eye to BHW 11 During the same interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), DQM confirmed the Patient 10, BHW 10 and BHW 11 identities in the video surveillance footage. DQM also stated the following: what BHW 10 did (putting hands on Patient 10 and the act of pushing Patient 10 into the room) was inappropriate. Patient 10 was not aggressive. The hands on (Patient 10) was not necessary. During a review of Patient 10’s “Progress Note Non-Physician (nursing progress notes),” dated 4/20/2025, the “Progress Note Non-Physician,” indicated, at 3:17 a.m., Patient 10 went to nursing station with bleeding at corner of (Patient 10’s) left eyebrow, Patient 10 informed Registered Nurse (RN) 5 that “I got my pants wet and requested for another pair. The BHW (Behavioral Health Worker 10) put his hand on me, held me tight on my neck, and pushed me back from the door of my room to my bed. I hit myself somewhere, not sure if it was on my bed or on the wall. I had a scar on my left eyebrow since I was 9 years old. I started bleeding where the scar is.” The “Progress Note Non-Physician,” also indicated RN 5 spoke with BHW 10 with BHW 10 stating, “This guy came talking shit to me. He put his hand on me and I tried to defend on myself by pulling my arm away from him and he (Patient 10) lost his balance.” During an interview on 6/26/2025 at 9:44 a.m. with DQM, the DQM stated the following: Patient 10 accused BHW 10 of having caused the injury. It would be considered as an alleged physical abuse. Patient 10’s primary nurse (RN 5) did not escalate the reported alleged physical abuse to the charge nurse or the house supervisor that night. BHW 10 should have been removed immediately (from patient care) after the alleged abuse for the safety of the patient. However, BHW 10 stayed and worked throughout the remainders of the shift. The incident was discovered the next day. During an interview on 6/26/2025 at 11:32 a.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated RN 5 was terminated because RN 5 did not assess Patient 10’s wound (left eyebrow) when it was reported, did not call the physician for Patient 10’s change of condition, did not escalate the incident to charge nurse or house supervisor, and did not offer Patient 10 the opportunity to file a police report. NM 2 further stated BHW 10 was also terminated because BHW 10 had placed hands on Patient 10, causing Patient 10 to slip and got hurt. During an interview on 6/27/2025 at 9:48 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3, DIR 3 stated the following: BHW 11 heard yelling and went to the room (Patient 10’s room) that day. He (BHW 11) noted there was a cut on Patient 10’s (left eyebrow), but he (BHW 11) thought BHW 10 told the nurse already, so he (BHW 11) did not report. DIR 3 stated education was given to BHW 11 about “see something say something.” During a review of RN 5’s “Personnel Action Report,” dated 4/24/2025, the “Personnel Action Report” indicated reason for termination as “involuntary - neglect of patient care,” with effective date on 4/24/2025. During an interview on 6/27/2025 at 4:45 p.m. with the Director of Infection Control (DIR) 4, DIR 4 stated BHW 10 was terminated by the facility on 4/24/2025. During an interview on 6/27/2026 at 10:55 p.m. with the Charge Nurse (CN) 5 of BHU, CN 5 stated when the alleged abuse involved a staff member, the staff member should be sent home right away to ensure patient safety. CN 5 stated if the alleged staff member was not sent home, he or she might hurt other patients, putting other patients at risk for injury. During a review of the facility’s policy and procedure (P&P) titled, “Employee to Patient Physical Abuse,” dated 8/2024, the P&P indicated, “It is an expectation that [the facility] will provide high quality patient care, in a compassionate manner and in a safe environment. Any employee who mistreats a patient, either verbally or physically, or witnesses any abuse or mistreatment of a patient and who failed to promptly report the incident to their immediate supervisor will be subject to appropriate disciplinary action ...Definitions: physical abuse: the use of physical force resulting in pain, discomfort or injury, including slapping, hitting burning, rough handling ... Investigation Process: A. The Charge Nurse will initiate investigation and when allegations include descriptions of the physical environment or if an investigation of the physical environment may provide useful information to an investigation to an investigator the Charge Nurse shall preserve the scene ...D. The Director of the BHU will notify the accused employee that he/she is subject to an abuse investigation and place that individual(s) on administrative leave immediately until the investigation is completed.” During a review of the facility’s policy and procedure (P&P) titled, “Patient to Patient Physical Abuse,” dated 8/2024, the P&P indicated, “Policy: Staff shall take seriously all statements from patients claiming to be victims of physical abuse and respond supportively and non-judgmentally ... Procedure ... A. Attend to the immediate first aid needs of victim; including psychological/ emotional support. B. Any patient who alleges that he or she has been physical abuse shall be offered immediate protection from the assailant and referred for a medical examination and/or a clinical assessment of the potential for negative symptoms. C. Patient have the right to call the Police. D. Immediate notification to the following: 1. Charge Nurse 2. Director of BHU or designee 3. Security (if needed) 4. Police (if applicable) 5. Medical Physician 6. Quality/Risk Management designee 7. Family - if the patient provided consent to do so.” During a review of the facility’s policy and procedure (P&P) titled, “Adult & Elder Abuse,” dated 10/2021, the P&P indicated, “To establish policy for BHU employees that are mandated reporters to ensure that elder abuse is reported in accordance with current law ... It is the responsibility of all health care professionals at [the facility] to report any suspected incidents of Dependent Adult/Elder Neglect and Abuse ... Definitions: A. Elder: Any person 65 years of age or older.” During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights,” dated 8/2022, the P&P indicated, “It is the policy of the Behavioral Health Unit to maintain and protect patients’ fundamental human, civil, constitutional and statutory rights in accordance with federal and [state] laws ... Procedure ... LPS grants all patients these irrevocable rights ... 4. To be free from harm, including unnecessary or excessive physical restraint, isolation, medication abuse or neglect.” During a review of the facility’s policy and procedure (P&P) titled, “Physician Notification,” dated 10/2024, the P&P indicated, “the attending physician will be notified regarding patient issue in a timely manner ... the primary attending physician will immediately be notified of patient’s change in condition.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50594 Based on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff obtained a physician order, in accordance with the facility’s policy regarding “Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraints,” for one of 30 sampled patients (Patient 9), when nursing staff performed physical restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) by putting hands on Patient 9 and placed Patient 9 in locked seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on 6/20/2025. This deficient practice resulted in Patient 9 being physically restrained by BHU staff and placed on locked seclusion without a physician order which led to violation of Patient 9’s rights to be free from restraint/seclusion. This deficient practice also had the potential to result in unnecessary restraint/seclusion including the risk of psychological harm for Patient 9. 2. Ensure the physician signed off on the telephone orders received for two of 30 sampled patients (Patient 22 and Patient 23) within 24 hours, when 4 point (both arms and legs) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) were applied on Patient 22 and Patient 23, in accordance with the facility’s policy regarding “Seclusion and Restraint.” This deficient practice had the potential to result in unnecessary restraints for Patient 22 and Patient 23, including the lack of appropriate monitoring and reassessment for further use of restraints including potential risks of restraints use such as skin breakdown (injury to the skin caused by prolonged pressure or friction [force]). Findings: 1. During a review of Patient 9’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 6/5/2025, the Psych Eval indicated, Patient 9 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntarily detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 9’s “Progress Note Non-Physician (nursing progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “at 1830 (6:30 p.m.), BHW (behavioral health worker [BHW 5]) doing rounds (the process of regularly visiting patients to assess their condition) and heard a commotion in room (Patient 9’s room shared with another patient [Patient 8]). BHW (BHW 5) witnessed Patient (Patient 9) sitting on top of roommate (Patient 8), hitting him (Patient 8) in the face ... Patient (Patient 9) was detained by BHW ... escorted to seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) room, two men assist for decrease stimulation.” During an interview on 6/24/2025 at 12:49 p.m. with the Charge Nurse (CN) 1 at BHU, CN 1 stated nurses needed to obtain a physician order when putting a patient in seclusion and/or restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body). During a concurrent observation and interview on 6/25/2025 at 10:44 a.m. with the Nurse Manager (NM) 2 of BHU, the facility’s security video footage, dated 6/14/2025, was reviewed. The security video footage indicated, at 6:25 p.m., Patient 9 was walking with two BHWs, one BHW on each of Patient 9’s side grabbing Patient 9’s arm, from Patient 9’s room to the hallway. NM 2 stated the two BHWs put hands on Patient 9 and took Patient 9 to the seclusion room. During an interview on 6/25/2025 at 2:05 p.m. with the Behavioral Health Worker (BHW) 5, BHW 5 stated he (BHW 5) and another BHW took Patient 9 to the seclusion room after Patient 9 hit Patient 8 in the room (room shared by Patient 9 and Patient 8). During a concurrent interview and record review on 6/26/2025 at 10:41 a.m. with NM 2, Patient 9’s “physician orders,” dated 6/14/2025, was reviewed. The physician order indicated there were no physician orders relating to seclusion and physical hold (any manual and physical method of holding a patient against patient’s will that restricts freedom of movement or normal access to one’s body) given on 6/14/2025. NM 2 stated it would be considered as physical restraints when the two BHWs were holding Patient 9’s arm and walked him (Patient 9) to the seclusion room. NM 2 stated there was no order for the physical hold in Patient 9’s medical record. During a concurrent interview and record review on 6/27/2025 at 10:13 a.m. with the Director (DIR) 3 of BHU for Campus 1 and 3, Patient 9’s “Individual Observation Record (15-min rounding record),” dated 6/14/2025, was reviewed. The “Individual Observation Record” indicated, Patient 9 was in “locked seclusion” from 6:53 p.m. to 9:18 p.m. (almost 2 hours 30 minutes). DIR 3 stated a physician order was required when placing a patient in locked seclusion. During an interview on 6/27/2025 at 10:18 a.m. with NM 2, NM 2 stated the following: there was no physician order for locked seclusion on 6/14/2025. Patient 9 was placed in seclusion without a physician order. It was a violation of patients’ rights. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 6/2023, the P&P indicated, “Policy ... The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient ... Procedure ... B. Types of Restraints and Orders 1. Safety a. Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely ... Seclusion: Seclusion refers to the involuntary confinement of a person alone in a room where the person is physically prevented from leaving ... Patient care for behavioral restraints: i. All orders for behavioral modification restraints/seclusion shall be dated and times and shall include: ii. Type of restraint iii. The behavior necessitating the use of restraint/seclusion iv. Length of time the restraint/seclusion may be utilized ... 3. Orders a. Only a physician or Registered Nurse may write a restraints order. In clear case of emergency, the RN may authorize the use of restraints and obtain a telephone order from physician within one hour of application of restraints.” 2. During a review of Patient 22’s medical record titled, “History and Physical Exam (H&P, a formal and complete assessment of the patient and the problem),” dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief complaint of status post (after) fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) with dizziness. During a review of Patient 22’s medical record titled, “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 6/13/2025, the psychiatric eval indicated Patient 22 was brought in from medical floor on a 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for grave disability (someone is unable to provide for their basic personal needs due to a mental disorder) and danger to self (a person is not able to care for him/herself or likely to inadvertently place him/herself in a position of danger). During a concurrent interview and record review on 6/25/2025 at 3:48 p.m. with the House Supervisor (HS) 1, Patient 22’s “Orders,” dated 6/16/2025, was reviewed. The orders indicated Patient 22 had a physician’s telephone order for 4-point restraints (both arms and legs), to be used for 4 hours, keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints use for being a danger to others, ordered on 6/16/2025 at 9:06 a.m. The HS 1 stated Patient 22’s restraint telephone order was not signed off by the ordering physician within 24 hours (6/17/25 at 9:06 a.m.) and had no follow up documented. During the same interview on 6/25/2025 at 3:48 p.m. with HS 1, HS 1 stated telephone orders should have been signed off by the physician and it was important for physicians to sign off telephone orders to verify/confirm they had given the orders. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraints,” reviewed in 6/2023, the P&P indicated, “Only a physician or Registered Nurse may write a restraints order. In clear case of emergency, the RN may authorize the use of restraints and obtain a telephone order from physician within one hour (1 hour for behavioral restraint) of application of restraints. The physician must authenticate order within 24 hours of implementation.” During a review of the facility’s Medical Staff Bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), dated November 2023, the Medical Staff Bylaws indicated, “Basic responsibilities of medical staff membership ...preparing and completing in timely and accurate manner, the medical records for all the patients to whom they provide care in the hospital including compliance with electronic health (EHR) policies and protocols.” 3. During a review of Patient 23’s medical record titled, “History and Physical (H&P),” dated 5/9/2025, the H&P indicated Patient 23 was admitted for chief complaint, “Patient endorses suicidal ideation (thoughts of taking one’s own life).” During a concurrent interview and record review on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, Patient 23’s telephone “Orders,” dated 5/12/2025, was reviewed. The HS 2 stated Patient 23’s telephone “Orders” was given on 5/12/2025 at 1:32 p.m. for 4-point restraints, for 4 hours duration, use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints for being a danger to others. However, the telephone order was not signed off by the ordering physician. During the same interview on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, the HS 2 stated it was important for the physician to cosign (sign jointly with another or others) or sign off the telephone order to know patient was on restraint, to follow up with patient afterwards, adjust plan of care, verify the fact that restraint orders was placed and a validation of physician order. During a review of the facility’s policy and procedures (P&P) titled, “Seclusion and Restraints,” reviewed in 6/2023, the P&P indicated, “Only a physician or Registered Nurse may write a restraints order. In clear case of emergency, the RN may authorize the use of restraints and obtain a telephone order from physician within one hour (1 hour for behavioral restraint) of application of restraints. The physician must authenticate order within 24 hours of implementation.” During a review of the facility’s Medical Staff Bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), dated November 2023, the Medical Staff Bylaws indicated, “ Basic responsibilities of medical staff membership ...preparing and completing in timely and accurate manner, the medical records for all the patients to whom they provide care in the hospital including compliance with electronic health (EHR) policies and protocols.””

“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: 50594 Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patient’s (Patient 22) restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring was conducted every 15 minutes, in accordance with the facility’s policy and procedure regarding “Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraint,” when Registered Nurse (RN) 6 placed (Patient 22) on 4 point (both ankles and wrist) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) and Patient 22 was administered Thorazine (medication used to treat mental health condition and regulates a patient’s mood) 100 milligrams (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via intramuscular (IM, into the muscles), while on 4 point restraints. This deficient practice had the potential for inadequate oversight/monitoring of Patient 22’s response to the use of restraints, which can lead to complications such as poor circulation (a medical condition where blood flow to parts of the body is reduced or inadequate), injury and/or death. Findings: During a review of Patient 22’s medical record titled, “History and Physical Exam (H&P, a formal and complete assessment of the patient and the problem),” dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief of complaint of status post (after or following) fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) with dizziness. During a review of Patient 22’s medical record titled, “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 6/13/2025, the psychiatric evaluation indicated Patient 22 was brought in from medical floor on a 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for grave disability (someone is unable to provide for their basic personal needs due to a mental disorder) and danger to self. During an observation and interview on 6/24/2025 at 11:51 a.m. with the Director of Behavioral Unit (DIR) 1 in Campus 2 Unit 2 seclusion (involuntary confinement of a person alone in a room where the person is physically prevented from leaving) room, there was a bed and a camera inside. DIR 1 stated seclusion room criteria included a patient on 4-point restraint, and someone will stay in the room with the patient. During a concurrent observation and interview on 6/24/2025 at 12:19 p.m. with DIR 1 in Campus 2 Unit 1, there was a female staff sitting outside the room of Patient 22. DIR 1 stated Patient 22 had a 1:1 sitter (is a caregiver who provides direct observation and support to a patient). During a concurrent interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22’s telephone “Order” dated 6/16/2025, was reviewed. The HS 1 stated Patient 22 had a telephone order for 4-point restraints (both arms and legs) restraint, with 4 hours duration, and use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints for being a danger to others. HS 1 further stated, keyed polyurethane restraints would be applied in the seclusion room. During the same interview on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22’s “Progress Notes Non-Physician” and “Medication Order,” dated 6/16/2025, were reviewed. HS 1 stated, Patient 22’s progress notes indicated Patient 22 was placed on 4-point restraints. HS 1 also stated Patient 22 received Thorazine (medication used to treat mental health condition and regulates a patient’s mood) 100 milligrams (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via IM (intramuscular, into the muscles) route, on 6/16/2025 at 8:16 a.m. During a concurrent observation, interview and record review on 6/26/2025 at 2:45 p.m. with the Associate Administrator (AA), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video: 1. 7:53 a.m.: Staff brought Patient 22 to the seclusion room unrestrained at this time 2. 7:58 a.m.: Patient 22 was put on 4-point restraints applied to both ankles and wrists During a concurrent observation, interview, and record review on 6/26/2025 at 3:07 p.m. with the AA, the DIR 1 and the Quality Coordinator (QC), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video and confirmed by the AA, the Dir 1, and the QC: 1. 8:15 a.m.: Patient 22 received injection medications to right deltoid (triangular shoulder muscle) and to left buttocks 2. 8:18 a.m.: RN 6 (primary nurse) left the room 3. 8:26 a.m.-8:52 a.m. - Patient 22 was observed alone in the room with no staff 4. 8:53 a.m. RN 6 entered the room and quickly stepped out of the room During an interview on 6/27/2025 at 8:44 a.m. with Registered Nurse (RN) 7, the RN 7 stated that for restraint monitoring conducted every 15 minutes, the RN would check for circulation (the continuous movement of blood though-out the body) by physically checking the pulse, ensuring restraint was not too tight cutting circulation, and check skin discolorations (a change in the original color). RN 7 said it was important to check patients on restraints as change of condition could happen especially when they (the patients) were on medications as well. During a concurrent observation, interview, and record review on 6/27/2025 at 9:02 a.m. with the AA, the DIR 1 and the Quality Coordinator (QC), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video and confirmed by the AA, the Dir 1, and the QC: 1. 8:53:57 RN 6 entered the room and walked out of the room at 8:54:00 (3 seconds) 2. 8:54-9:25 a.m. Patient alone in the room, no staff present 3. 9:26:23 -Behavior Mental Worker step in and out of the room 4. 9:28:50-9:29:26 a.m.: RN 6 went near the Patient 22 and just looked at her. 5. 9:30 -10:13:24 a.m.: RN 6 entered the room, approached the patient and appeared to be talking with Patient 22. 6. 10:14:10: RN 6 still in the room, started to unlock and to remove the keyed polyurethane restraint on Patient 22’s ankles and wrists. Subsequently, other facility staff entered the room During the same interview on 6/27/2025 at 9:02 a.m. with DIR 1, DIR 1 stated a more thorough assessment could have been done for Patient 22 to address safety concerns, that an adverse event (an undesirable medical occurrence associated with the use of a drug or treatment) can occur for patients on 4-point restraints and being medicated, and circulation can be compromised. DIR 1 acknowledged RN 6 was seen with Patient 22 at 8:53 a.m., 9:28 a.m. and 10:13 a.m. DIR 1 also acknowledged the time gaps (a period of time between two events or moments) Patient 22 was not monitored while being restrained in the seclusion room. During the same concurrent interview and record review on 6/27/2025 at 9:02 a.m. with DIR 1, Patient 22’s “Progress Note Non-Physician,” dated 6/16/2025, was reviewed. DIR 1 stated Patient 22’s progress notes did not reflect what was done (referring to the monitoring) for the patient according to the video footage observed (gaps in monitoring instead of the standard every 15-minute monitoring frequency) and that the expectation would be the documentation should match what staff were doing for the patient. During a review of facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” reviewed in 6/2023, the P&P indicated, “Patients in behavioral modification restraint shall be monitored continually by staff on face to face basis at arms length for duration of seclusion, when audiovisuals are not available ...Patient in seclusion only shall be monitored continually by staff on face to face basis for the first hour. This is followed by observation at intervals not greater than every fifteen (15) minutes and continuous monitoring visual equipment in close proximity to the patient ...The flow sheet will include type of restraint, LOC and circulation checks every 15 minutes ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to ensure nursing staff consulted the physician after a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed by Registered Nurses (RNs) for three of 30 sampled patients (Patients 8, 9 and 20), in accordance with the federal regulations regarding physician notification after the completion of the face-to-face evaluation. This deficient practice had the potential to result in Patients 8, 9 and 20 not receiving evaluation from physicians to determine appropriate treatment and care and also had the potential for unnecessary seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use. Findings: 1. During a review of Patient 8’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/16/2025, the Psych Eval indicated, Patient 8 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 8’s “Order Information for: Restraints (physician order),” dated 6/10/2025, the “Order Information for: Restraints” indicated keyed (a special key is needed to unlock the restraint device) polyurethane (a type of polymers [man-made materials] that is durable and resistant to wear and tear) restraints was ordered on 6/10/2025 at 9:01 p.m. with reason for danger to self or others. During an interview on 6/24/2025 at 12:45 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated nurse would perform a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after initiation of seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and/or restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body). CN 3 also stated there was no follow up call with the physician after the face-to-face assessment was completed unless there were any abnormal findings identified. During an interview on 6/24/2025 at 12:56 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated nurses would only call physician if there was any issue identified during the face-to-face assessment. During a concurrent interview and record review on 6/26/2025 at 10:44 a.m. with the Nurse Manager (NM) 2 of BHU, Patient 8’s “Progress Notes Non-Physician (nursing progress notes),” dated 6/10/2025, was reviewed. The “Progress Notes Non-Physician” indicated, Patient 8 was placed on 4-point (both wrists and both ankles) restraints which started at 8:52 p.m., the Registered Nurse (RN) 11 performed face-to-face assessment at 9:30 p.m. The “Progress Notes Non-Physician” did not indicate any communication with physician after the face-to-face assessment. NM 2 stated RN 11 did not call physician after face-to-face assessment. During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 6/2023, was reviewed. The P&P indicated, “The physician must conduct a face-to-face assessment of the patient’s need for restraints or seclusion within one hour after the initiation of the intervention ... 4. Evaluations, Documentations and Monitoring a. Behavioral Restraints i. A physician or other licensed independent practitioner must see (face to face) and evaluate the need for seclusion and restraints within one hour after the initiation of this intervention, the evaluation must be documented in the patient medical record.” The P&P did not indicate any procedures relating to having a Registered Nurse to perform face to face assessment. DIR 3 stated the following: the facility’s current practice allowed nurses to perform the face-to-face assessments for patients on seclusion and/or restraints. Current practice did not align with policy. DIR 3 confirmed the facility’s P&P did not cover face-to-face assessment completed by nurses and did not give directions to nurses what to follow. During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the Code of Federal Regulation Title 42 (federal regulations), “Condition of Participation: Patient’s Rights,” dated 2/2020, was reviewed. The federal regulations indicated, “§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation.” DIR 3 and NM 2 both stated they (DIR 3 and NM 2) were not aware of this regulation. DIR 3 stated the current practice did not follow the regulations. DIR 3 also stated nurses should assess the patient, then call and inform the physician about the assessment so that the physician could determine and update the treatment plan for the patient. 2. During a review of Patient 9’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 6/5/2025, the Psych Eval indicated, Patient 9 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 9’s “Progress Note Non-Physician (nursing progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “at 1830 (6:30 p.m.), BHW (behavioral health worker [BHW 5]) doing rounds and heard a commotion in room (Patient room shared by patient 9 and Patient 8). BHW (BHW 5) witness Patient (Patient 9) sitting on top of roommate (Patient 8), hitting him (Patient 8) in the face ... Patient (Patient 9) was detained by BHW ... escorted to seclusion room, two men assist for decrease stimulation ... [physician] informed of patient status and ordered Benadryl (usually used for allergic reaction, can cause drowsiness) 50 milligrams (mg, unit of measure) IM (Intramuscular injection, delivering medication directly into the muscle tissue), Haldol (medication to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] agitation [being upset, annoyed, angry and physically disturbed]) 5 mg IM, Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg IM STAT (as soon as possible). IM delivered as ordered.” During an interview on 6/24/2025 at 12:45 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated nurse would perform a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after initiation of seclusion and/or restraints. CN 3 also stated there was no follow up call with the physician after the face-to-face assessment was completed unless there were any abnormal findings identified. During an interview on 6/24/2025 at 12:56 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated nurses would only call physician if there was any issue identified during the face-to-face assessment. During a concurrent interview and record review on 6/26/205 at 10:19 a.m. with NM 2, Patient 9’s “Progress Note Non-Physician (nursing progress notes),” dated 6/14/2025, was reviewed. The “Progress Note Non-Physician” indicated, “Face to Face ... at 1930 (7:30 p.m.) Face to Face evaluation completed ... Patient (Patient 9) has even and unlabored breaths (normal, effortless breathing) and is calm during face-to-face evaluation ... Patient (Patient 9) is calm at this time.” NM 2 stated the face-to-face assessment was performed by the Registered Nurse (RN) 9 and RN 9 did not need to call the physician after face-to-face assessment because there was no need. During a concurrent interview and record review on 6/27/2025 at 10:20 a.m. with NM 2, Patient 9’s Individual Observation Record (15-min rounding record),” dated 6/14/2025, was reviewed. The “Individual Observation Record” indicated, Patient 9 was in “locked seclusion” from 6:53 p.m. to 9:18 p.m. (almost 2 hours 30 minutes) with behavior described as “cooperative.” The “Individual Observation Record” also indicated RN 10 documented Patient 9 was calm and cooperative at 8 p.m. NM 2 stated the seclusion should have been discontinued at earlier time because Patient 9 was calm and cooperative. NM 2 stated the seclusion was not necessary. During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 6/2023, was reviewed. The P&P indicated, “The physician must conduct a face-to-face assessment of the patient’s need for restraints or seclusion within one hour after the initiation of the intervention ... 4. Evaluations, Documentations and Monitoring a. Behavioral Restraints i. A physician or other licensed independent practitioner must see (face to face) and evaluate the need for seclusion and restraints within one hour after the initiation of this intervention, the evaluation must be documented in the patient medical record.” The P&P did not indicate any procedures relating to having a Registered Nurse to perform face to face assessment. DIR 3 stated the following: the facility’s current practice allowed nurses to perform the face-to-face assessments for patients on seclusion and/or restraints. Current practice did not align with policy. DIR 3 confirmed the facility’s P&P did not cover face-to-face assessment completed by nurses and did not give directions to nurses what to follow. During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the Code of Federal Regulation Title 42 (federal regulations), “Condition of Participation: Patient’s Rights,” dated 2/2020, was reviewed. The federal regulations indicated, “§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation.” DIR 3 and NM 2 both stated they (DIR 3 and NM 2) were not aware of this regulation. DIR 3 stated the current practice did not follow the regulations. DIR 3 also stated nurses should assess the patient, then call and inform the physician about the assessment so that the physician could determine and update the treatment plan for the patient. 3. During a review of Patient 20’s “Psychiatric Evaluation (Psych Eval, a formal assessment of the patient done by a Psychiatrist [physician who specializes in mental health]),” dated 6/17/2025, the Psych Eval indicated, Patient 20 was admitted to the facility on a 5150 hold (allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for being a danger to others. The Psych Eval also indicated Patient 20 was hearing voices and had a history of schizophrenia (mental illness affecting how someone behaves, feels, and thinks). During an interview on 6/24/2025 at 11:40 a.m. with Licensed Vocational Nurse 2 (LVN) 2, LVN 2 stated Patient 20 was trying to hit staff in the day room (activity room), was given emergency medications and placed on 4 point restraints (physical device applied to the person’s wrists and ankles to limit movement) in the seclusion room (involuntary [without permission] confinement of a patient alone in a room or area from which the patient is physically prevented from leaving). During an interview on 6/24/2025 at 12:48 p.m. with Nurse Manager (NM) 2 and Charge Nurse (CN) 1, CN 1 stated when a patient was placed on restraints, the nurse would call the physician for a restraint order. CN 1 also stated the nurse sees the patient immediately after restraint application and will complete a “Face to Face” assessment within an hour. NM 2 stated the nurses were not required to call the physician after (completing the face-to-face assessment), unless there was something abnormal (unusual) with the patient. During a review of Patient 20’s “Progress Note Non-Physician (nursing progress note),” dated 6/24/2025, the progress note indicated, “At around 0830 (8:30) a.m., Patient (Patient 20) was knocking hard on the back door of the nursing station, the patient’s 1:1 sitter (individual who stays with the patient as a safety precaution) redirected (guide an individual’s thoughts and behavior to a different action) him (Patient 20) not to do it and patient (Patient 20) became aggressive (behavior that is forceful and potentially hostile or threatening) and doing a fist fight to the 1:1 sitter ...wanted to fight with the staff, doing a fist, approaching the staff, staff got hit on the face with the patient’s fist ...ordered to place patient on seclusion and restraint (4-point restraints). Ordered, Haldol (medication used to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] and agitation [being upset, annoyed, angry and physically disturbed]) 5 milligrams (mg- a unit of measure), Ativan (medication used for relaxation) 2 mg, Benadryl (medication used to cause sleepiness) 50 mg. Per pharmacy, out of stock for Ativan, replaced with Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg... order noted and carried out.” Patient 20 was placed on 4-point restraints in the seclusion room and received intramuscular (IM, injection in the muscle) medications. During a concurrent interview and record review on 6/26/2025 at 9:56 a.m. with CN 3, Patient 20’s two “Restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)” orders, both dated 6/24/2025, were reviewed. Patient 20 had an order placed at 8:32 a.m. for “Emergency Medication Administration” for being a “Danger to others.” Patient 20 also had a second order placed at 8:55 a.m. for the use of “Keyed Polyurethane (type of restraint that is applied to the person’s wrists and ankles and uses a key and lock for application)” restraints for being a “Danger to others.” During a concurrent interview and record review on 6/26/2025 at 9:56 a.m. with CN 3, Patient 20’s “Medication Administration Record (MAR),” dated 6/24/2025, was reviewed. The MAR indicated, on 6/24/2025 at 8:44 a.m. Patient 20 received Haldol (medication used to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] and agitation [being upset, annoyed, angry and physically disturbed]) 5 milligrams (mg, a unit of measure) Intramuscular (IM, injection into the muscle), Benadryl (medication used to cause sleepiness) 50 mg IM and Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg. During an interview on 6/26/2025 at 10:25 a.m. with CN 3, CN 3 stated if the patient was in the seclusion room or on restraints, the nurse did not have to call the doctor again unless there was a change in condition. During an interview on 6/26/2025 at 10:42 a.m. with CN 3, CN 3 stated the physician did not document a “Face to Face” assessment after Patient 20 was placed on 4-point restraints in the seclusion room on 6/24/2025. During a concurrent interview and record review on 6/26/2025 at 3:35 p.m. with CN 3, Patient 20’s “Progress Note Physician,” dated 6/24/2025 and 6/25/2025, were reviewed. CN 3 stated the Progress notes did not indicate the incident (use of 4-point restraints and seclusion room placement of patient 20) that occurred on 6/24/2025. The Progress notes did not also indicate the completion of a face-to-face assessment by the physician following the initiation of seclusion/restraints on Patient 20. During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of the Behavioral Health Unit (BHU) and Nurse Manager (NM) 2, the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 6/2023, was reviewed. DIR 3 stated their practice was for the nurses to perform the face-to-face assessments for patients who are placed on seclusion/restraints. DIR 3 acknowledged their policy did not cover face to face assessments completed by nurses. During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the DIR 3 and NM 2, the “Code of Federal Regulation Title 42, ‘Condition of Participation: Patient’s Rights, §482.13(e)(14),’” dated 2/2020, was reviewed. DIR 3 acknowledged they (facility staff) were not following the regulation on the nurses consulting the physician for a face-to-face evaluation within 1 hour following the application of seclusion/restraints. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 6/2023, the P&P indicated, “The physician must conduct a face-to -face assessment of the patient’s need for restraint or seclusion within one hour after the initiation of the intervention.””

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h)(3), (h)(4) [A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. A hospital must meet the following requirements]: (3) Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. (4) Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences. This Standard is not met as evidenced by: 50515 Based on interview and record review, the facility failed to ensure one of 30 sampled patient’s (Patient 12) representative’s denial of visitation right was reevaluated and a justification for denial of visitation right provided, in accordance with the facility’s policy and procedure regarding “Visitation.” This deficient practice resulted in Patient 12’s representative (FM 3) not being allowed to exercise his right to visit Patient 12 causing potential distress to Patient 12 and/or representative. Findings: During a review of Patient 12’s “Face Sheet (a document containing a patient’s medical and demographic information),” undated, the face sheet indicated Patient 12 was admitted to the facility on 3/12/2025 at 6:58 p.m., with a medical diagnosis of psychosis (mental condition in which thought, and emotions are affected and reality is affected). During a phone interview on 6/25/2025 at 9:00 a.m. with Patient 12’s representative (FM 3), FM 3 stated, he (FM 3) was escorted out of facility unit after complaining regarding Patient 12’s care and was not allowed to visit. During an interview on 6/25/2025 at 2:26 p.m. with Charge Nurse (CN) 1, CN 1 stated a denial of right for family visitation required a doctor’s order and must be renewed every day after reassessment of the need for the order. The CN further stated denial of right for family visitation could be requested when family was being abusive to patient, causing harm or being aggressive to patient. During a concurrent interview and record review on 6/25/2025 at 3:00 p.m. with the CN 1, Patient 12’s “Nursing Progress Note,” dated 3/15/2025, was reviewed. The record indicated that at 4:26 p.m., Patient 12’s FM 3 was escorted out of the facility and a physician order was acquired for denial of rights for visitation for Patient 12’s FM 3. The CN 1 stated, Patient 12’s FM 3 was verbally aggressive towards staff thus, requiring restricting Patient 12’s FM 3’s visitation rights. During a record review of Patient 12’s “Denial of Rights” physician order, dated 3/15/2025, the record indicated a verbatim order for denial of rights for Patient 12’s representative’s visitations. During a concurrent interview and record review on 6/25/2025 at 3:00 p.m. with the CN 1, Patient 12’s “Nursing Progress Note,” dated 3/16/2025, was reviewed. The record indicated the denial of visitation rights for Patient 12’s FM 3 was requested to be renewed, but with no documented indication or rationale (reason) for continuation of order. The CN stated, the indication should be based on nurse’s assessment need for the order. During a record review of Patient 12’s “Denial of Rights” physician order, dated 3/16/2025, the record indicated a verbatim order for denial of rights for Patient 12’s FM 3 visitations. During an interview on 6/25/2025 at 3:15 p.m. with the Behavioral Health Unit Nurse Manager (NM) 2, NM 2 stated, the facility did not need to indicate or document in the patient’s chart the rationale for renewing a denial of rights of visitation order because it involved the patient’s representative (FM 3), not the patient. During a review of the facility’s policy and procedure (P&P) titled, “Visitation,” reviewed 10/2021, the P&P indicated, “Any restriction of visitors imposed by the treatment staff must be ordered by the attending psychiatrist and a justified for good cause (means there is a valid and legally acceptable reason for an action or inaction. It implies that the reason is substantial, reasonable, and sufficient to warrant the specific action) [documented] documented in the medical record. The patient will be informed of the restriction, as well as the rationale. Such restrictions will be reviewed every 24 hours by the attending psychiatrist and documented in the medical record.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility’s Quality Assurance Performance Improvement team (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) failed to implement corrective action and mechanisms in a timely manner, to ensure there was proper observation or monitoring provided for patients who are placed on line of sight (a straight line along which an observer had unobstructed vision) and one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring in the Behavioral Health Unit (BHU, (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) after there was patient to patient altercation between two of 30 sampled patients (Patient 8 and Patient 9), which was identified on 6/14/2025. This deficient practice had the potential to put other patients at risk for injury or harm. Findings: During a review of Patient 8’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/16/2025, the Psych Eval indicated, Patient 8 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 8’s “Consultation Report,” dated 4/16/2025, the “Consultation Report” indicated, Patient 8 had past medical history of pseudoseizures (event that mimic seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness] but are not caused by abnormal electrical activity in the brain) and autism (neurodevelopmental disorder characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication). During a review of Patient 9’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 6/5/2025, the Psych Eval indicated, Patient 9 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and had symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 8’s “Progress Note Non-Physician (nurses progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “Patient (Patient 8) was attacked by his (Patient 8’s) roommate (Patient 9) approximately 1830 (6:30 p.m.). Patient (Patient 8) was witnessed falling back out of his (Patient 8’s) room into the hallway noted hitting the back of his (Patient 8’s) head ... Patient (Patient 8) unable to follow command for PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system). Right pupil 3 mm (millimeters, unit of measure) reactive to light. Left pupil nonreactive (the pupil [the black circle in the center of the eye] doesn’t constrict [get smaller] in response to light or when focusing on a near object). Rapid Response (a system designed to quickly address a patient’s sudden clinical deterioration before it escalates into a medical emergency). Rapid Response (a system designed to quickly address a patient’s sudden clinical deterioration before it escalates into a medical emergency) was called at 1838 (6:38 p.m.) ... [physician] was notified ... CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head, transfer to telemetry floor [room number]. Pending report.” The “Progress Note Non-Physician” also indicated Patient 8 was transferred to the facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor at 7:31 p.m. During an interview on 6/24/2025 at 12 p.m. with Patient 8, Patient 8 stated he (Patient 8) was in the room (Patient room shared by Patient 9 and Patient 8), and someone attacked him (Patient 8). Patient 8 stated, “he (Patient 9) hit my face to my left eye.” During an interview on 6/24/2025 at 3:10 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated the following: there were different levels of monitoring aside from standard every 15-minutue rounding in BHU. A specific staff was assigned to a specific patient who needed one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring and the staff had to stay with the patient within arm’s length. For patients who needed line of sight (a straight line along which an observer had unobstructed vision) monitoring, staff would need to keep a close eye on the patients and maintain visual on the patients outside their (referring to the staff) regular every 15-minute rounding. During an interview on 6/25/2025 at 10:02 a.m. with the Director of Performance Improvement/ Quality (DQM), DQM stated Patient 8 and Patient 9 were both in the same room when the incident happened on 6/14/2025. During a concurrent observation and interview on 6/25/2025 at 10:03 a.m. with DQM, the facility’s security video footage dated 6/14/2025, was reviewed. The security video footage with no audio indicated the following: -At 6:23:27 p.m. a Behavioral Health Worker (BHW 5) was seen sitting in the hallway; -At 6:23:30 p.m. BHW 5 heard something and walked toward Patient 8 and Patient 9’s room. BHW 5 looked at the window on the door, then opened the door and walked in; -At 6:23:47 p.m. Patient 8 walked out from the room, limping then fell to the floor in the middle of hallway; -At 6:25:45 p.m. Patient 9 was taken out by two BHWs from the room (room shared by Patient 9 and Patient 8). During the same interview on 6/25/2025 at 10:03 a.m. with DQM, DQM confirmed the identities of BHW 5, Patient 8 and Patient 9. DQM also stated there was an altercation between Patient 8 and Patient 9 in the room. During a review of Patient 8’s “Progress Note Non-Physician (nurses progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “2005 (8:05 p.m.) patient (Patient 8) on unit (Telemetry unit) ... Patient (Patient 8) has multiple bruises to his (Patient 8’s) face and head.” During an interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated on 6/14/2025, he (BHW 5) was sitting in the hallway and saw Patient 8 and Patient 9 enter the room (the patient room shared by patient 9 and Patient 8). BHW 5 stated, “I heard feet shuffling in the room. I got up, peeked into the window and saw Patient 9 was on top of Patient 8 on the ground hitting Patient 8. Patient 9 was aggressive to Patient 8.” During the same interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. BHW 5 also stated Patient 8 was on one to one (1:1) monitoring that day (6/14/2025) but his (Patient 8’s) assigned sitter was flexed earlier that day due to overstaffing and no one was assigned to replace the sitter. BHW 5 stated there was no line of sight for both patients (Patient 8 and Patient 9) because the door (to both patients’ [Patient 9 and Patient 8] room) was closed. During an interview on 6/25/2025 at 2:29 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated the following: the charge nurse of the unit was responsible for making assignment for the shift. There was no specific person assigned to perform line of sight. Any staff not assigned as 1:1 monitoring would be watching patients who required line of sight monitoring. The staff would need to see those patients at all times. CN 3 also stated a physician order was required for starting and discontinuing any line of sight and 1:1 monitoring. During a concurrent interview and record review on 6/25/2025 at 2:52 p.m. with the Nurse Manager (NM) 2 of BHU, the facility’s Campus 1 BHU assignment, “[Unit] AM Shift Assignment,” dated 6/14/2025 AM shift, was reviewed. The “[Unit] AM Shift Assignment” indicated, Patient 8 was on 1:1 monitoring and Patient 9 was on line of sight monitoring. The “[Unit] AM Shift Assignment” did not indicate which nursing staff was assigned to Patient 8 and Patient 9 to perform the 1:1 monitoring and line of sight monitoring. NM 2 stated she (NM 2) could not tell which staff was assigned to perform line of sight monitoring because it was not written on the assignment. During a concurrent interview and record review on 6/25/2025 at 3:29 p.m. with the Quality and Performance Improvement Supervisor (QPS), Patient 8’s “Order Information for: Patient Monitoring (physician order),” dated 6/12/2025, was reviewed. The physician order indicated Patient 8 was placed on 1:1 sitter observation. QPS stated the order was active at time of incident. QPS stated the order was discontinued on 6/14/2025 at 8:19 p.m. During a concurrent interview and record review on 6/25/2025 at 3:30 p.m. with QPS, Patient 9’s “Order Information for: Patient Monitoring (physician order),” dated 6/10/2025, was reviewed. The physician order indicated Patient 9 was placed on line-of-sight observation. QPS stated the order was active and only discontinued on 6/20/2025. During an interview on 6/27/2025 at 7:43 p.m. with the Director of Performance Improvement/ Quality (DQM), DQM stated the following: Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team met and performed a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) for the incident (physical assault on Patient 8). The incident was still in discussion. Nothing was implemented. During a review of the facility’s policy and procedure (P&P) titled, “Mandated Adverse Event Reporting to the California Department of Public Health,” dated 12/2023, the P&P indicated, “The Committee will identify systems, issues, and events that negatively affect the process of care in a case or could potentially impact the care of the other patients. If necessary, a thorough and credible root-cause analysis will be completed on all identified adverse events and the results with corrective actions will be forwarded to the appropriate medical staff committee for critical evaluation and then to the Medical Executive Committee and Governing Board for final approval ... the Committee will meet and review the case, conducts interviews, prepared records of findings and action plans, assigned responsibilities for action steps to clinical or hospital departments, set deadlines for completion, refers system issues and/or hospital-wide issues to the appropriate responsible services or individuals, ensure the reporting of action plan results, and report the findings and actions taken as the result of the adverse event review to the appropriate Medical Staff Department Committee and Medical Executive Committee.” During a review of the facility’s policy and procedure (P&P) titled, “Organizational Performance Improvement Plan,” dated 4/2025, the P&P indicated, “The purpose of the Organizational Performance Improvement Plan at [the facility] is to ensure that the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk.””

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure that the facility’s Quality Assurance Performance Improvement (a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) Committee, reviewed and addressed the facility’s Policy and Procedure (P&P) pertaining to “Seclusion (involuntary [without permission] confinement of a patient in a room or area from which the patient is physically prevented from leaving) and Restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body),” to ensure that the P&P was aligned with facility’s current practice and be able to comply with federal regulations, when the P&P did not indicate that a Registered Nurse could perform face to face assessment on patients following the initial application of seclusion/restraints other than the physician, and the P&P did not also indicate that a Registered Nuse must consult a physician after face-to-face assessment was completed. The physician was not consulted after a face-to- face assessment was completed for three (3) of 30 sampled patients (Patients 8, 9, and 20). This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to the P&P not reflecting up to date best practices. Findings: 1. During a review of Patient 8’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/16/2025, the Psych Eval indicated, Patient 8 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 8’s “Order Information for: Restraints (physician order),” dated 6/10/2025, the “Order Information for: Restraints” indicated keyed (a special key is needed to unlock the restraint device) polyurethane (a type of polymers [man-made materials] that is durable and resistant to wear and tear) restraints was ordered on 6/10/2025 at 9:01 p.m. with reason for danger to self or others. During an interview on 6/24/2025 at 12:45 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated nurse would perform a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after initiation of seclusion and/or restraints. CN 3 also stated there was no follow up call with the physician after the face-to-face assessment was completed unless there were any abnormal findings identified. During an interview on 6/24/2025 at 12:56 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated nurses would only call physician if there was any issue identified during the face-to-face assessment. During a concurrent interview and record review on 6/26/2025 at 10:44 a.m. with the Nurse Manager (NM) 2 of BHU, Patient 8’s “Progress Notes Non-Physician (nursing progress notes),” dated 6/10/2025, was reviewed. The “Progress Notes Non-Physician” indicated, Patient 8 was placed on 4-point (both wrists and both ankles) restraints which started at 8:52 p.m., the Registered Nurse (RN 11) performed face-to-face assessment at 9:30 p.m. The “Progress Notes Non-Physician” did not indicate any communication with physician after the face-to-face assessment. NM 2 stated RN 11 did not call physician after face-to-face assessment. During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 6/2023, was reviewed. The P&P indicated, “The physician must conduct a face to face assessment of the patient’s need for restraints or seclusion within one hour after the initiation of the intervention ... 4. Evaluations, Documentations and Monitoring a. Behavioral Restraints i. A physician or other licensed independent practitioner must see (face to face) and evaluate the need for seclusion and restraints within one hour after the initiation of this intervention, the evaluation must be documented in the patient medical record.” The P&P did not indicate any procedures relating to having a Registered Nurse to perform face to face assessment. DIR 3 stated the following: the facility’s current practice allowed nurses to perform the face-to-face assessments for patients on seclusion and/or restraints. Current practice did not align with policy. DIR 3 confirmed the facility’s P&P did not cover face-to-face assessment completed by nurses and did not give directions to nurses what to follow. During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the Code of Federal Regulation Title 42 (federal regulations), “Condition of Participation: Patient’s Rights,” dated 2/2020, was reviewed. The federal regulations indicated, “§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation.” DIR 3 and NM 2 both stated they (DIR 3 and NM 2) were not aware of this regulation. DIR 3 stated the current practice did not follow the regulations. DIR 3 also stated nurses should assess the patient, then call and inform the physician about the assessment (face-to-face assessment after initiation of seclusion/restraint) so that the physician could determine and update the treatment plan for the patient. During an interview on 6/27/2025 at 6:58 p.m. with the Director of Performance Improvement and Quality (DQM), DQM stated the following: QAPI provided oversight for facility’s policies and procedures process and management. The department directors and managers were responsible for the update of the policies in accordance with regulations, standards of care and current practice. It was a collaborative effort between QAPI committee and the department. During an interview on 6/27/2025 at 7:16 p.m. with DQM, DQM stated when policies do not align with facility’s current practice and follow federal regulations, it would put the facility out of compliance and there would be potential for patient safety issue. During an interview on 6/27/2025 at 8:09 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: GB (Governing Body, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) relied on QAPI and the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) to report quality of care and patient safety issues but at the end of the day, the oversight and accountability of the facility fell on the governing board. The CEO also stated GB was responsible for providing oversight on overall quality of care and patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Psychiatric Nursing Standards of Care,” dated 10/2021, the P&P indicated, “It is the policy of the Behavioral Health Unit that all nursing services rendered will be consistent with established nursing standards ... Role of the Registered Nurse: the Registered Nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. Nursing care may be directed to other licensed nursing staff or unlicensed nursing staff...” During a review of the facility’s policy and procedure (P&P) titled “Organizational Performance Improvement Plan,” dated 4/2025, the P&P indicated, “The purpose of the Organization Performance Improvement Plan at [the facility] is to ensure the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ... The primary goal of the Organizational Performance Improvement Plan is to continually and systemically plan, design, measure, assess and improve performance of hospital-wide key functions and processes relative to patient care; and to improve healthcare outcomes while reducing and preventing medical/health care errors ... provide for a hospital-wide program that assures the facility designs processes (with special emphasis on design of new or revisions in established services) well and systematically measures, assesses and improves its performance to achieve optimal patient health outcomes in a collaborative, cross-departmental, interdisciplinary approach.” During a review of the facility’s “Governing Board of Directors Bylaws of [the facility] (GB Bylaws),” approved by the GB on 10/19/2022, the GB Bylaws indicated, “The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital’s compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard’s rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided.” 2. During a review of Patient 9’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 6/5/2025, the Psych Eval indicated, Patient 9 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 9’s “Progress Note Non-Physician (nursing progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “at 1830 (6:30 p.m.), BHW (behavioral health worker [BHW 5]) doing rounds and heard a commotion in room (the patient room shared by Patient 9 and Patient 8). BHW (BHW 5) witness Patient (Patient 9) sitting on top of roommate (Patient 8), hitting him (Patient 8) in the face ... Patient (Patient 9) was detained by BHW ... escorted to seclusion room, two men assist for decrease stimulation ... [physician] informed of patient status and ordered Benadryl (usually used for allergic reaction, can cause drowsiness) 50 milligrams (mg, unit of measure) IM (Intramuscular injection, delivering medication directly into the muscle tissue), Haldol (medication to treat schizophrenia and acute [new onset] agitation [being upset, annoyed, angry and physically disturbed)] 5 mg IM, Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg IM STAT (as soon as possible). IM delivered as ordered.” During an interview on 6/24/2025 at 12:45 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated nurse would perform a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after initiation of seclusion and/or restraints. CN 3 also stated there was no follow up call with the physician after the face-to-face assessment was completed unless there were any abnormal findings identified. During an interview on 6/24/2025 at 12:56 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated nurses would only call physician if there was any issue identified during the face-to-face assessment. During a concurrent interview and record review on 6/26/205 at 10:19 a.m. with NM 2, Patient 9’s “Progress Note Non-Physician (nursing progress notes),” dated 6/14/2025, was reviewed. The “Progress Note Non-Physician” indicated, “Face to Face ... at 1930 (7:30 p.m.) Face to Face evaluation completed ... Patient (Patient 9) has even and unlabored breaths (normal, effortless breathing) and is calm during face-to-face evaluation ... Patient (Patient 9) is calm at this time.” NM 2 stated the face-to-face assessment was performed by the Registered Nurse (RN) 9 and RN 9 did not need to call the physician after face-to-face assessment because there was no need. During a concurrent interview and record review on 6/27/2025 at 10:20 a.m. with NM 2, Patient 9’s Individual Observation Record (15-min rounding record),” dated 6/14/2025, was reviewed. The “Individual Observation Record” indicated, Patient 9 was in “locked seclusion” from 6:53 p.m. to 9:18 p.m. (almost 2 hours 30 minutes) with behavior documented as “cooperative.” The “Individual Observation Record” also indicated RN 10 documented Patient 9 was calm and cooperative at 8 p.m. NM 2 stated the seclusion should have been discontinued at earlier time because Patient 9 was calm and cooperative. NM 2 stated the seclusion was not necessary. During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 6/2023, was reviewed. The P&P indicated, “The physician must conduct a face-to-face assessment of the patient’s need for restraints or seclusion within one hour after the initiation of the intervention ... 4. Evaluations, Documentations and Monitoring a. Behavioral Restraints i. A physician or other licensed independent practitioner must see (face to face) and evaluate the need for seclusion and restraints within one hour after the initiation of this intervention, the evaluation must be documented in the patient medical record.” The P&P did not indicate any procedures relating to having a Registered Nurse to perform face to face assessment. DIR 3 stated the following: the facility’s current practice allowed nurses to perform the face-to-face assessments for patients on seclusion and/or restraints. Current practice did not align with policy. DIR 3 confirmed the facility’s P&P did not cover face-to-face assessment completed by nurses and did not give directions to nurses what to follow. During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the Code of Federal Regulation Title 42 (federal regulations), “Condition of Participation: Patient’s Rights,” dated 2/2020, was reviewed. The federal regulations indicated, “§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation.” DIR 3 and NM 2 both stated they (DIR 3 and NM 2) were not aware of this regulation. DIR 3 stated the current practice did not follow the regulations. DIR 3 also stated nurses should assess the patient, then call and inform the physician about the assessment so that the physician could determine and update the treatment plan for the patient. During an interview on 6/27/2025 at 6:58 p.m. with the Director of Performance Improvement and Quality (DQM), DQM stated the following: QAPI provided oversight for facility’s policies and procedures process and management. The department directors and managers were responsible for the update of the policies in accordance with regulations, standards of care and current practice. It was a collaborative effort between QAPI committee and the department. During an interview on 6/27/2025 at 7:16 p.m. with DQM, DQM stated when policies do not align with the facility’s current practice and follow federal regulations, it would put the facility out of compliance and there would be potential patient safety issue. During an interview on 6/27/2025 at 8:09 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: GB relied on QAPI and the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) to report quality of care and patient safety issues, but at the end of the day, the oversight and accountability of the facility fell on the governing board. The CEO also stated the GB was responsible for providing oversight on overall quality of care and patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Psychiatric Nursing Standards of Care,” dated 10/2021, the P&P indicated, “It is the policy of the Behavioral Health Unit that all nursing services rendered will be consistent with established nursing standards ... Role of the Registered Nurse: the Registered Nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. Nursing care may be directed to other licensed nursing staff or unlicensed nursing staff...” During a review of the facility’s policy and procedure (P&P) titled “Organizational Performance Improvement Plan,” dated 4/2025, the P&P indicated, “The purpose of the Organization Performance Improvement Plan at [the facility] is to ensure the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ... The primary goal of the Organizational Performance Improvement Plan is to continually and systemically plan, design, measure, assess and improve performance of hospital-wide key functions and processes relative to patient care; and to improve healthcare outcomes while reducing and preventing medical/health care errors ... provide for a hospital-wide program that assures the facility designs processes (with special emphasis on design of new or revisions in established services) well and systematically measures, assesses and improves its performance to achieve optimal patient health outcomes in a collaborative, cross-departmental, interdisciplinary approach.” During a review of the facility’s “Governing Board of Directors Bylaws of [the facility] (GB Bylaws),” approved by the GB on 10/19/2022, the GB Bylaws indicated, “The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital’s compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard’s rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided.” 3. During a review of Patient 20’s “Psychiatric Evaluation (Psych Eval, a formal assessment of the patient done by a Psychiatrist [physician who specializes in mental health]),” dated 6/17/2025, the Psych Eval indicated, Patient 20 was admitted to the facility on a 5150 hold (allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for being a danger to others. The Psych Eval also indicated Patient 20 was hearing voices and had a history of schizophrenia (mental illness affecting how someone behaves, feels, and thinks). During an interview on 6/24/2025 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Patient 20 was trying to hit staff in the day room (activity room), was given emergency medications and placed on 4 point restraints (physical device applied to the person’s wrists and ankles to limit movement) in the seclusion room (involuntary [without permission] confinement of a patient alone in a room or area from which the patient is physically prevented from leaving). During an interview on 6/24/2025 at 12:48 p.m. with Nurse Manager (NM) 2 and Charge Nurse (CN) 1, CN 1 stated when a patient was placed on restraints, the nurse would call the physician for a restraint order. CN 1 also stated the nurse sees the patient immediately after restraint application and will complete a “Face to Face” assessment within an hour. NM 2 stated the nurses were not required to call the physician after (completing the face-to-face assessment), unless there was something abnormal (unusual) with the patient. During a review of Patient 20’s “Progress Note Non-Physician (nursing progress note),” dated 6/24/2025, the progress note indicated, “At around 0830 (8:30) a.m., Patient (Patient 20) was knocking hard on the back door of the nursing station, the patient’s 1:1 sitter (individual who stays with the patient as a safety precaution) redirected (guide an individual’s thoughts and behavior to a different action) him (Patient 20) not to do it and patient (Patient 20) became aggressive (behavior that is forceful and potentially hostile or threatening) and doing a fist fight to the 1:1 sitter...wanted to fight with the staff, doing a fist, approaching the staff, staff got hit on the face with the patient’s fist ...ordered to place patient on seclusion and restraint (4-point restraints). Ordered, Haldol (medication used to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] and agitation [being upset, annoyed, angry and physically disturbed]) 5 milligrams (mg- a unit of measure), Ativan (medication used for relaxation) 2 mg, Benadryl (medication used to cause sleepiness) 50 mg. Per pharmacy, out of stock for Ativan, replaced with Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg... order noted and carried out.” Patient 20 was placed on 4 point restraints in the seclusion room and had received intramuscular (IM, injection in the muscle) medications. During a concurrent interview and record review on 6/26/2025 at 9:56 a.m. with CN 3, Patient 20’s two “Restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)” orders, both dated 6/24/2025, were reviewed. Patient 20 had an order placed at 8:32 a.m. for “Emergency Medication Administration” for being a “Danger to others.” Patient 20 also had a second order placed at 8:55 a.m. for the use of “Keyed Polyurethane (type of restraint that is applied to the person’s wrists and ankles and uses a key and lock for application)” restraints for being a “Danger to others.” During a concurrent interview and record review on 6/26/2025 at 9:56 a.m. with CN 3, Patient 20’s “Medication Administration Record (MAR),” dated 6/24/2025, was reviewed. The MAR indicated, on 6/24/2025 at 8:44 a.m., Patient 20 received Haldol (medication used to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] and agitation [being upset, annoyed, angry and physically disturbed]) 5 milligrams (mg , a unit of measure) Intramuscular (IM, injection into the muscle), Benadryl (medication used to cause sleepiness) 50 mg IM and Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg. During an interview on 6/26/2025 at 10:25 a.m. with CN 3, CN 3 stated if the patient was in the seclusion room or on restraints, the nurse did not have to call the doctor again unless there was a change in condition. During an interview on 6/26/2025 at 10:42 a.m. with CN 3, CN 3 stated the physician did not document a “Face to Face” assessment. During a concurrent interview and record review on 6/26/2025 at 3:35 p.m. with CN 3, Patient 20’s “Progress Note Physician,” dated 6/24/2025 and 6/25/2025, were reviewed. CN 3 stated the Progress notes did not indicate the incident (use of 4-point restraints and seclusion room placement of patient 20) that occurred on 6/24/2025. The Progress notes did not also indicate the completion of a face-to-face assessment by the physician following the initiation of seclusion/restraints on Patient 20. During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of Behavioral Health and Nurse Manager (NM) 2, the “Code of Federal Regulation Title 42, ‘Condition of Participation: Patient’s Rights, §482.13(e)(14),’” dated 2/2020, was reviewed. DIR 3 acknowledged they (facility staff) were not following the regulation on the nurses consulting the physician for a face-to-face evaluation within 1 hour of the completion of a face-to-face evaluation by a Registered Nurse, and was not what was practiced (the notification of the physician). During an interview on 6/27/2025 at 6:58 p.m. with the Director of Performance Improvement and Quality (DQM), DQM stated the following: QAPI provided oversight for the facility’s policies and procedures, process, and management. The department directors and managers were responsible for the update of the policies in accordance with regulations, standards of care, and current practice. It was a collaborative effort between QAPI committee and the department. During an interview on 6/27/2025 at 7:16 p.m. with DQM, DQM stated that when policies did not align with the facility’s current practice and follow federal regulations, it would put the facility out of compliance and there would be potential for patient safety issue. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 6/2023, the P&P indicated, “The physician must conduct a face-to-face assessment of the patient’s need for restraint or seclusion within one hour after the initiation of the intervention.” During an interview on 6/27/2025 at 8:09 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: GB relied on QAPI and the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) to report quality of care and patient safety issues but at the end of the day, the oversight and accountability of the facility fell on the governing board/Governing Body. The CEO also stated the GB was responsible for providing oversight on overall quality of care and patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Psychiatric Nursing Standards of Care,” dated 10/2021, the P&P indicated, “It is the policy of the Behavioral Health Unit that all nursing services rendered will be consistent with established nursing standards ... Role of the Registered Nurse: the Registered Nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. Nursing care may be directed to other licensed nursing staff or unlicensed nursing staff...” During a review of the facility’s policy and procedure (P&P) titled “Organizational Performance Improvement Plan,” dated 4/2025, the P&P indicated, “The purpose of the Organization Performance Improvement Plan at [the facility] is to ensure the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ... The primary goal of the Organizational Performance Improvement Plan is to continually and systemically plan, design, measure, assess and improve performance of hospital-wide key functions and processes relative to patient care; and to improve healthcare outcomes while reducing and preventing medical/health care errors ... provide for a hospital-wide program that assures the facility designs processes (with special emphasis on design of new or revisions in established services) well and systematically measures, assesses and improves its performance to achieve optimal patient health outcomes in a collaborative, cross-departmental, interdisciplinary approach.” During a review of the facility’s “Governing Board of Directors Bylaws of [the facility] (GB Bylaws),” approved by the GB on 10/19/2022, the GB Bylaws indicated, “The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital’s compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard’s rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff provided and maintained an appropriate level of observation and monitoring for two of 30 sampled patients who required line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring, per physician order and in accordance with the facility’s policy and procedure on rounding (the process of regularly visiting patients to assess their condition) and monitoring, when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025. This deficient practice resulted in Patient 9 physically assaulting (to attack) Patient 8 on 6/14/2025. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault. This deficient practice also had the potential in putting other patients at risk for injury due to lack of monitoring. 2. Conduct a comprehensive assessment upon admission, that included assessing a patient’s risk of suicide (killing self), homicide (killing others), or violence (assault towards others) for one of 30 sampled patients (Patient 4), in accordance with the facility’s policy regarding “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Nursing Standards of Care.” This deficient practice had the potential to result in harm to Patient 4 and other patients on the unit due to lack of assessment. On 6/26/2025 at 3:05 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Director of Performance Improvement and Quality (DQM), Associate Administrator (AA), Quality Coordinator, Director (DIR 1) of Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at facility’s offsite campus (Campus 2), and Nurse Manager (NM 1) of BHU at Campus 2. The facility failed to ensure nursing staff provided and maintained appropriate level of observation and monitoring for patients requiring line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring per physician order when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025. This resulted in Patient 9 physically assaulting (attack) Patient 8 in the room. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault. On 6/25/2025 at 1:45 p.m., the Behavioral Health Worker (BHW) 5 stated that on 6/14/2025, he (BHW 5) was in the hallway and heard feet shuffling in the room where Patient 8 and Patient 9 were both in. He (BHW 5) went into the room and found Patient 9 was on top of Patient 8 on the ground hitting Patient 8. BHW 5 also stated the following: he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. Patient 8 was on 1:1 monitoring that day, but the sitter was flexed (sent home) earlier that day due to overstaffing and no one was assigned to replace the sitter. There was no line of sight for both patients (Patient 8 and Patient 9) because the door was closed. On 6/27/2025 at 11:09 p.m., the IJ was removed in the presence of DQM, AA, QC, DIR 1, and with the CEO via telephone. The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, education began on 6/25/2025 night shift with all BHU Mental Health Workers, Registered Nurses, Charge Nurses, and Staffing Coordinators at all three campuses (Campus 1, Campus 2 and Campus 3) and would continue every shift until all relevant staff have been trained. The education included reinforcing compliance with physician monitoring order and the facility’s policy related to monitoring for different levels of monitoring: standard level (every 15-minute rounding), line of sight and one-to-one (1:1). The IJ Removal Plan also listed the responsibilities of Charge Nurse, Registered Nurse, Behavior Health Workers, and Staffing Coordinators to ensure adequate staffing and monitoring is provided and maintained for all line of sight (a straight line along which an observer had unobstructed vision) and 1:1 monitoring patients. The BHU leadership would perform daily morning reviews of all line-of-sight and 1:1 patients to confirm appropriateness of level of monitoring, active physician order in place and staff assignment instituted appropriately. Findings: 1. During a review of Patient 8’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/16/2025, the Psych Eval indicated, Patient 8 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 8’s “Consultation Report,” dated 4/16/2025, the “Consultation Report” indicated, Patient 8 had past medical history of pseudoseizures (event that mimic seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness] but are not caused by abnormal electrical activity in the brain) and autism (neurodevelopmental disorder characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication). During a review of Patient 9’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 6/5/2025, the Psych Eval indicated, Patient 9 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 8’s “Progress Note Non-Physician (nurses progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “Patient (Patient 8) was attacked by his (Patient 8’s) roommate (Patient 9) approximately 1830 (6:30 p.m.). Patient (Patient 8) was witnessed falling back out of his (Patient 8’s) room into the hallway, noted hitting the back of his (Patient 8’s) head ... Patient (Patient 8) unable to follow command for PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system). Right pupil 3 mm (millimeters, unit of measure) reactive to light. Left pupil nonreactive (the pupil [the black circle in the center of the eye] doesn’t constrict [get smaller] in response to light or when focusing on a near object). Rapid Response (a system designed to quickly address a patient’s sudden clinical deterioration before it escalates into a medical emergency) was called at 1838 (6:38 p.m.) ... [physician] was notified ... CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head, transfer to telemetry floor [room number]. Pending report.” The “Progress Note Non-Physician” also indicated Patient 8 was transferred to facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor at 7:31 p.m. During an interview on 6/24/2025 at 12 p.m. with Patient 8, Patient 8 stated he (Patient 8) was in the room, and someone attacked him (Patient 8). Patient 8 stated, “he hit my face to my left eye.” During an interview on 6/24/2025 at 3:10 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated the following: there were different levels of monitoring aside from standard every 15-minutue rounding in BHU. A specific staff was assigned to a specific patient who needed one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring and the staff had to stay with the patient within arm’s length. For patients who needed line of sight (a straight line along which an observer had unobstructed vision) monitoring, staff would need to keep a close eye on the patients and maintain visual on the patients outside their regular every 15-minute rounding. During an interview on 6/25/2025 at 10:02 a.m. with the Director of Performance Improvement/ Quality (DQM), DQM stated Patient 8 and Patient 9 were both in the same room when the incident happened on 6/14/2025. During a concurrent observation and interview on 6/25/2025 at 10:03 a.m. with DQM, the facility’s security video footage dated 6/14/2025, was reviewed. The security video footage with no audio indicated the following: -At 6:23:27 p.m. a Behavioral Health Worker (BHW 5) was seen sitting in the hallway; -At 6:23:30 p.m. BHW 5 heard something and walked toward Patient 8 and Patient 9’s room. BHW 5 looked at the window on the door, then opened the door and walked in; -At 6:23:47 p.m. Patient 8 walked out from the room, limping then fell to the floor in the middle of hallway; -At 6:25:45 p.m. Patient 9 was taken out by two BHWs out from the room. During the same interview on 6/25/2025 at 10:03 a.m. with DQM, DQM confirmed the identities of BHW 5, Patient 8 and Patient 9. DQM also stated there was an altercation between Patient 8 and Patient 9 in the room. During a review of Patient 8’s “Progress Note Non-Physician (nurses progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “2005 (8:05 p.m.) patient (Patient 8) on unit (Telemetry unit) ... Patient (Patient 8) has multiple bruises to his (Patient 8’s) face and head.” During an interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated on 6/14/2025, he (BHW 5) was sitting in the hallway and saw Patient 8 and Patient 9 went to the room. BHW 5 stated, “I heard feet shuffling in the room. I got up, peeked into the window and saw Patient 9 was on top of Patient 8 on the ground hitting Patient 8. Patient 9 was aggressive to Patient 8.” During the same interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. BHW 5 also stated Patient 8 was on one to one (1:1) monitoring that day but his (Patient 8’s) assigned sitter was flexed earlier that day due to overstaffing and no one was assigned to replace the sitter. BHW 5 stated there was no line of sight for both patients (Patient 8 and Patient 9) because the door was closed. During an interview on 6/25/2025 at 2:29 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated the following: the charge nurse of the unit was responsible for making assignment for the shift. There was no specific person assigned to perform line of sight. Any staff not assigned as 1:1 monitoring would be watching patients who required line of sight monitoring. The staff would need to see those patients at all times. CN 3 also stated a physician order was required for starting and discontinuing any line of sight and 1:1 monitoring. During a concurrent interview and record review on 6/25/2025 at 2:52 p.m. with the Nurse Manager (NM) 2 of BHU, the facility’s Campus 1 BHU assignment, “[Unit] AM Shift Assignment,” dated 6/14/2025, was reviewed. The “[Unit] AM Shift Assignment” indicated, Patient 8 was 1:1 monitoring and Patient 9 was on line-of-sight monitoring. The “[Unit] AM Shift Assignment” did not indicate which nursing staff was assigned to Patient 8 and Patient 9 to perform the 1:1 monitoring and line of sight monitoring. NM 2 stated she (NM 2) could not tell which staff was assigned to perform line of sight monitoring because it was not written on the assignment. During a concurrent interview and record review on 6/25/2025 at 3:29 p.m. with the Quality and Performance Improvement Supervisor (QPS), Patient 8’s “Order Information for: Patient Monitoring (physician order),” dated 6/12/2025, was reviewed. The physician order indicated Patient 8 was placed on 1:1 sitter observation. QPS stated the order was active at the time of incident. QPS stated the order was discontinued on 6/14/2025 at 8:19 p.m. During a concurrent interview and record review on 6/25/2025 at 3:30 p.m. with QPS, Patient 9’s “Order Information for: Patient Monitoring (physician order),” dated 6/10/2025, was reviewed. The physician order indicated Patient 9 was placed on line of sight observation. QPS stated the order was active and only discontinued on 6/20/2025. During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 10/2021, the P&P indicated, “The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment ... Observation levels are designed to provide the right level of observation, precaution and oversight commensurate with physician and RN assessment of the safety needs of the patient in alignment with the current behavior and symptoms they are demonstrating ... Three levels of staff monitoring are provided ... Level II - moderate - line of sight ... Policy - A level of observation wherein the patient remains in staff view at all times. A specific staff member is assigned, and the line of observation is maintained by staff in person and not through video monitoring ... Level III - intensive - one to one ... Policy - consists of one to one staff observation with a patient never farther away than arm’s length. The patient remains within arm’s length at all times ... The RN is responsible for obtaining an MD order for an observation level that is line of sight or 1 to 1 ... When the patient’s status permits, the RN will notify the MD and get an order to down-grade the observation status to that of “least restrictive” in a manner to maintain the patient in an optimal level of safety.” During a review of the facility’s policy and procedure (P&P) titled, “Psychiatric Nursing Standards of Care,” dated 10/2021, the P&P indicated, “It is the policy of the Behavioral Health Unit that all nursing services rendered will be consistent with established nursing standards ... Role of the Registered Nurse: the Registered Nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. Nursing care may be directed to other licensed nursing staff or unlicensed nursing staff...” 2. During a review of Patient 4’s “Psych (Psychiatric, a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Nurse Admit Note,” dated 4/16/2025 at 11:38 p.m., the Psych Nurse Admit Note indicated Patient 4 was admitted to the facility on 4/16/2025 at 10:10 p.m. During a review of Patient 4’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/17/2025, the H&P indicated the following: Patient 4 with a past medical history including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responses, and social interactions), presents on voluntary status for auditory hallucinations (sensory experiences that seem real but are created by the mind, not by an eternal stimulus) but unable to elaborate further. Patient 4 was also observed responding to internal stimuli (anything that can trigger a physical or behavioral change), talking to unseen others. During a review of Patient 4’s nursing notes titled, “BH (Behavior Health) History,” dated 4/17/2025 at 12:11 a.m., the nursing notes indicated the following: Patient 4’s reason for admission: Stabilization (the process of preventing a patient’s condition from worsening, particularly during an emergency or while awaiting further treatment). Admission was voluntary for being gravely disabled (a person who is unable to provide for their basic needs due to a mental health disorder). During a concurrent interview and record review on 6/24/2025 at 3:30 p.m. with the House Supervisor (HS) 1, HS 1 stated the following: Patient 4 was admitted under voluntary status for responding to internal stimuli on 4/16/2025 at 10:10 p.m. HS 1 stated a comprehensive nursing assessment should be done on all patients within two hours of admission to the facility. Patient assessments should include assessments for suicidal ideations (thoughts of killing self), homicidal ideations (thoughts of killing others), and assault ideations (thought of violence to others). HS 1 was asked to review Patient 4’s initial nursing assessment. HS 1 verified that Patient 1 had not been assessed for suicidal, homicidal, or assault ideations upon admission within two hours, as indicated in the facility’s policy regarding psychiatric nursing standards of care. HS 1 stated it was important to conduct these assessments to develop plans of care and to provide appropriate treatment for patients. During a concurrent interview and record review on 6/25/2025 at 11:13 a.m. with Registered Nurse (RN) 2, RN 2 stated the following: All patients should be assessed for suicidal, homicidal and assault ideations upon admission. RN 2 verified that these assessments were not documented for Patient 4 in the initial or comprehensive nursing assessment dated 4/17/2025. During a review of the facility’s policy and procedure (P&P) titled, “Psychiatric Nursing Standards of Care,” dated 10/2021, the P&P indicated the following: A comprehensive nursing assessment will be initiated within two hours of patient admission. The assessment will include physical, psychological, social and cultural factors that impact upon daily care of the patient. Also include in the assessment will be the patient’s self-destructive and violence potential ...”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 43236 Based on observation, interview and record review, the facility failed to: 1. Ensure its nursing staff adhered to policy and procedure regarding staff conduct, when a Registered Nurse (RN) 1 pursued an inappropriate relationship with one (1) of 30 sampled patients (Patient 3) after their discharge from the facility. This deficient practice had the potential to compromise professional boundaries and undermine the therapeutic integrity of care provided during the inpatient stay. 2.Ensure patients’ family members were informed of seclusion (apart from others) and/or restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) episodes for two of 30 sampled patients (Patient 22 and Patient 23), in accordance with the facility’s policy and procedures regarding “Seclusion and Restraint,” and “Notification of Patient Admission and Subsequent Events,” when Patient 22 and Patient 23 were placed on 4-point (both arms and legs) restraints in the seclusion room (is a room where a person is involuntarily confined alone). This deficient practice had the potential to negatively affect Patient 22 and Patient 23’s wishes for treatment and care they would receive in the facility, when there is lack of designated patients’ family member’s participation in the care process. 3. Ensure one of 30 sampled patient’s (Patient 22) restraint monitoring intervention, was implemented and conducted every 15 minutes, in accordance with the facility’s policy and procedure regarding “Seclusion and Restraint,” when Registered Nurse (RN) 6 placed Patient 22 on 4 point (both ankles and wrists) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely). Subsequently, Patient 22 received Thorazine (medication used to treat mental health condition and regulates your mood) 100 milligram (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via intramuscular (IM, into the muscles). This deficient practice had potential for negative consequences for Patient 22’s safety due to lack of oversight (absence or inadequacy of monitoring) to identify adverse effects of restraint use such as poor circulation (blood flow), injury and/or death. 4.Ensure nursing staff adhered to the facility’s policy and procedure regarding “Rounding, Observation and Monitoring of Patients,” when staff did not perform the 15- minute rounding (observing patient location and behavior) for one of 30 sampled patients (Patient 21). This deficient practice had the potential for Patient 21’s safety to not be monitored and care needs to not be addressed. 5. Ensure nursing staff adhered to the facility’s policy and procedure regarding notification of the physician for change of condition for one of 30 sampled patients (Patient 10), when Patient 10 reported a bleeding left eyebrow to the Registered Nurse (RN) 5, but RN 5 did not notify the attending physician. This deficient practice resulted in delay for Patient 10 to receive diagnostic exams including a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) scan of head thus have the potential to delay treatment and care. 6. Ensure corrections to the medical records were documented appropriately, for one of 30 sampled patients (Patient 5), in accordance with the facility’s policy regarding documentation and corrections in the medical record, when staff wrote on top of original documentation which obscured the original documentation for Patient 5’s location on 4/30/2025 from 5:45 p.m. to 6:30 p.m. This deficient practice had the potential to result in inaccurate information and may lead to incorrect treatment plans which may harm the patient. Findings: 1. During a review of Patient 3’s “Face Sheet (front page of the chart that contains a summary of basic information about the patient),” not dated, the Face Sheet indicated Patient 3 was admitted to the facility’s behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 5/8/2025. During a review of Patient 3’s “Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]),” dated 5/8/2025, the 5150 hold paperwork indicated Patient 3 was detained due to being unable to care for herself. During a review of Patient 3’s “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition),” dated 5/11/2025, the 5250 hold paperwork indicated Patient 1’s involuntary legal hold was extended due to being unable to care for herself. During a review of the facility’s staffing assignments for Campus 2, the assignments indicated RN 1 was assigned to care for Patient 3 on 5/16/2025, 5/17/2025, and 5/18/2025. During a review of Patient 3’s “Discharge Summary (a comprehensive document summarizing a patient’s hospital stay, including their condition upon admission, the care they received, diagnoses, treatments, and follow-up instructions),” dated 5/21/2025 at 9:34 a.m., the Discharge Summary indicated Patient 3 was discharged from the facility on 5/21/2025. During an interview on 6/24/2025 at 3:30 p.m. with the Director (DIR) 1 of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility’s offsite campus (Campus 2) and the Quality Coordinator (QC), DIR 1 stated that on 6/1/2025, the house supervisor on shift at the time received a phone call from Patient 3 alleging RN 1 had an inappropriate relationship with her (Patient 3). The house supervisor notified DIR 1, who called Patient 3 back; after speaking with her (Patient 3), DIR 1 placed RN 1 on suspension. The QC stated RN 1 denied having a sexual relationship with Patient 3 while she (Patient 3) was admitted to the facility but admitted to having inappropriate contact with Patient 3 after her (Patient 3) discharge from the facility once presented with evidence. DIR 1 stated RN 1 admitted to sending Patient 3 money, visiting Patient 3 while she (Patient 3) was admitted to a different facility, and gifting Patient 3 a vape (electronic cigarette that can either be nicotine or marijuana). During a concurrent interview and record review on 6/25/2025 at 11:36 a.m. with the QC, mobile phone screenshots provided by Patient 3 to the facility, were reviewed. One screenshot was of a text message conversation between Patient 3 and a contact listed as RN 1, undated. The other screenshot appeared to be receipt of money via a mobile phone app from a contact listed as RN 1 on 5/25/2025, 5/26/2025, and 5/30/2025. The QC stated RN 1 confirmed that the text messages were from him, that RN 1 sent Patient 3 money, and that RN 1 gave Patient 3 “contraband (illegal goods).” During an interview on 6/26/2025 at 11:13 a.m. with DIR 1, DIR 1 confirmed RN 1 was terminated for violation of code of conduct and for having inappropriate boundaries with patients. DIR 1 stated this was a violation of nursing ethics and “you don’t do that.” During a review of RN 1’s “Personnel Action Report (PAR),” dated 6/3/2025, the PAR indicated RN 1’s employment at the facility was terminated involuntarily on 6/3/2025 for the reason “inappropriate relationship with patient.” During a review of the facility’s policy and procedure (P&P) titled, “Staff Conduct,” last reviewed 10/2021, the P&P indicated, “Expectations will include, but not necessarily be limited to the following: ... 7. Staff should not provide patients with drugs, alcohol, cigarettes, (other than during specified smoke breaks) or other personal and/or prohibited items. ... 9. Any form of unauthorized socialization with a patient within two (2) years of hospitalization is prohibited. Staff may resume their relationship with the patient in a fashion that is consistent with the relationship prior to hospitalization.” 2.a. During a review of Patient 22’s medical record titled, “History and Physical Exam (H&P, a formal and complete assessment of the patient and the problem),” dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief of complaint of status post (after) fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) with dizziness. During a review of Patient 22’s medical record titled, “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 6/13/2025, the psychiatric evaluation indicated Patient 22 was brought in from medical floor on a 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for grave disability (unable to care for one’s self) and danger to self. During a concurrent interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22’s, “Orders,” dated 6/16/2025, was reviewed. The Orders indicated Patient 22 had a physician’s order for 4-point (bilateral arms and bilateral legs) restraints for 4 hours, use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure), for being a danger to others. The HS 1 stated keyed polyurethane indicated Patient 22 was placed in seclusion (involuntary [without permission] confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) room. During the same interview on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22’s, “Notification of seclusion and/or restraint episode consent form,” dated 6/12/2025, was reviewed. The consent form indicated Patient 22’s request for the facility staff to notify Patient 22’s family member (FM) 1 regarding any episode of seclusion and/or restraint use. HS 1 stated there was no documentation in Patient 22’s clinical record that FM 1 was notified of restraints use and placement in seclusion room of patient 22. HS 1 further stated the family member should have been notified because Patient 22 requested according to the form and Patient 22’s wish should have been honored. During a review of the facility’s policy and procedures (P&P) titled, “Seclusion and Restraint,” reviewed in 6/2023, the P&P indicated, “A family member will be contacted by phone to notify the seclusion/restraint episode and patient condition, after obtaining the patient’s consent.” During a review of the facility’s policy and procedure (P&P) titled, “Notification of Patient Admission and Subsequent Events,” reviewed in 10/2021, the P&P indicated, “It is the policy of Behavioral Unit to make reasonable attempts to notify any person designated by a patient admitted for mental health services in the following areas ...Notification of Seclusion and/or Restraint Episode.” 2.b. During a review of Patient 23’s “History and Physical (H&P),” dated 5/9/2025, the H&P indicated Patient 23 was admitted for chief complaint, “Patient endorses suicidal ideation (thoughts of taking one’s own life).” During a concurrent interview and record review on 6/25/2025 at 3:48 p.m. with the House Supervisor (HS) 1, Patient 23’s “Orders,” dated 5/12/2025, were reviewed. The HS 1 stated Patient 23 had a physician restraint order for 4 hours and use of keyed polyurethane restraints due to being a danger to others. During a concurrent interview and record review on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, Patient 23’s “Notification of Seclusion and/or Restraint episode” dated 5/8/2025, was reviewed. The HS 2 stated Patient 23’s notification of seclusion and restraint consent form was signed by Patient 23 on admission. HS 2 further stated there was no documentation the nurse had informed the family member (FM) 2 regarding Patient 23 being on restraint and having been placed in the seclusion room. During the same interview on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, HS 2 stated the use of restraints was higher level of intervention, and it was important to notify the patient’s family in case of an injury or if anything were to happen. During a review of the facility’s policy and procedures (P&P) titled, “Seclusion and Restraint,” reviewed in 6/2023, the P&P indicated, “A family member will be contacted by phone to notify the seclusion/restraint episode and patient condition, after obtaining the patient’s consent.” During a review of the facility’s P&P titled, “Notification of Patient Admission and Subsequent Events,” reviewed in 10/2021, the P&P indicated, “It is the policy of Behavioral Unit to make reasonable attempts to notify any person designated by a patient admitted for mental health services in the following areas ...Notification of Seclusion and/or Restraint Episode.” 3. During a review of Patient 22’s medical record titled, “History and Physical Exam (H&P),” dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief of complaint of status post fall with dizziness. During a review of Patient 22’s medical record titled, “Psychiatric Evaluation,” dated 6/13/2025, the psychiatric evaluation indicated Patient 22 was brought in from medical floor on a 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for grave disability (someone is unable to provide for their basic personal needs due to a mental disorder) and danger to self. During a concurrent observation and interview on 6/24/2025 at 11:51 a.m. with the Director of Behavioral Unit (DIR) 1 in Campus 2 Unit 2 seclusion room, there was a bed and a camera inside. DIR 1 stated seclusion room criteria included patient on restraint, and someone (assigned facility staff) will stay with the patient in the room. During a concurrent observation and interview on 6/24/2025 at 12:19 p.m. with DIR 1 in Campus 2 Unit 1, there was a female staff sitting outside the room of Patient 22. DIR 1 stated Patient 22 had a 1:1 sitter (is a caregiver who provides direct observation and support to a patient). During a concurrent interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22’s “Order,” dated 6/16/2025, was reviewed. The HS 1 stated Patient 22 had an order for 4-point restraints, for 4 hours duration, and use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints due to being a danger to others. HS 1 further stated, keyed polyurethane restraints would be applied only in the seclusion room (is a room where a person is involuntarily confined alone). During the same interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22’s, “Progress Notes Non-Physician” and Medication Order,” dated 6/16/2025, were reviewed. HS 1 stated, Patient 22’s progress notes indicated Patient 22 was put on 4-point (both arms and legs) restraints. HS 1 also said Patient 22 received Thorazine and Benadryl via IM on 6/16/2025 at 8:16 a.m. During an observation on 6/26/2025 at 2:45 p.m. with the Associate Administrator (AA), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video: 1. 7:53 a.m.: Staff brought Patient 22 to the seclusion room unrestrained at this time 2. 7:58 a.m.: Patient 22 was put on restraints applied to both ankles and wrist During a concurrent observation, interview, and record review on 6/26/2025 at 3:07 p.m. with the AA, the Director of the Behavioral Health Unit (DIR) 1 and the Quality Coordinator (QC)., in the conference room, the security footage from 6/16/2025 was reviewed. The following events were observed at the indicated timestamps in the video: 1. 8:15 a.m.: Patient 22 received injection medications to right deltoid (triangular shoulder muscle) and to left buttocks 2. 8:18 a.m.: RN 6 (primary nurse) left the room 3. 8:26 a.m.-8:52 a.m. - Patient 22 was observed alone in the room with no staff 4. 8:53 a.m. RN 6 entered the room and quickly stepped out of the room During an interview on 6/27/2025 at 8:44 a.m. with the Registered Nurse (RN) 7, the RN 7 stated for restraint monitoring every 15 minutes, the RN would check for circulation (the continuous movement of blood though-out the body) by physically checking the pulse, ensuring the restraint was not too tight cutting off circulation, and check skin discolorations. RN 7 also said it was important to check patients on restraint because there could be changes of condition especially when they (the patients) were medicated as well. During a concurrent observation, interview, and record review on 6/27/2025 at 9:02 a.m. with AA, DIR 1 and the Quality Coordinator (QC), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video: 1. 8:53:57 a.m. RN 6 entered the room and walked out of the room at 8:54:00 (3 seconds) 2. 8:54-9:25 a.m. Patient alone in the room, no staff present 3. 9:26:23 -Behavior Mental Worker step in and out of the room 4. 9:28:50-9:29:26 a.m.: RN 6 went near the Patient 22 and just looked at her. 5. 9:30 -10:13:24 a.m.: RN 6 entered the room, approached the patient and appeared to be talking with Patient 22. 6. 10:14:10: RN 6 still in the room started to unlock and remove the keyed polyurethane restraint to ankles and wrist. Subsequently, other facility staff entered the room During the same interview on 6/27/2025 at 9:02 a.m. with DIR 1, DIR 1 stated a more thorough assessment could have been done for Patient 22 for safety concerns, an adverse event can occur, and circulation can be compromised. DIR 1 acknowledged RN 6 was seen with Patient 22 at 8:53 a.m., 9:28 a.m. and 10:13 a.m. DIR 1 acknowledged the time gaps Patient 22 was not monitored while restrained in the seclusion room. During the same interview on 6/27/2025 at 9:02 a.m. with DIR 1, Patient 22’s, “Progress Note Non-Physician,” dated 6/16/2025, was reviewed. DIR 1 stated Patient 22’s progress notes did not reflect what was done for the patient according to the video footage observed and the expectation would be documentation matched what they (the staff) were doing for the patient. During a review of facility’s policy and procedure (P&P) titled, “Seclusion and Restraint,” reviewed in 6/2023, the P&P indicated, “Patients in behavioral modification restraint shall be monitored continually by staff on face to face basis at arms-length for duration of seclusion, when audiovisuals are not available ...Patient in seclusion only shall be monitored continually by staff on face to face basis for the first hour. This is followed by observation at intervals not greater than every fifteen (15) minutes and continuous monitoring visual equipment in close proximity to the patient ...The flow sheet will include type of restraint, LOC and circulation checks every 15 minutes ...” 4. During a review of Patient 21’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]), dated 5/9/2025, the Psych Eval indicated Patient 21 was admitted to the facility on a 5150 hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for grave disability (individual cannot provide their own food, clothing, and shelter because of a mental health disorder). Patient 21 had a history of suicidal ideation (thoughts of self-harm) and urinary tract infection (UTI, an infection in the bladder/urinary tract). During an interview on 6/24/2025 at 12:23 p.m. with Behavioral Health Worker (BHW) 4, BHW 4 stated 15 minutes rounding was about checking on each patient’s location, behaviors, and ensuring safety on the unit. During a concurrent interview and record review on 6/27/2025 at 5:45 p.m. with Nurse Manager (NM) 2 and Director (DIR) 3 of the Behavioral Health Unit, Patient 21’s “Individual Observation Record,” dated 5/27/2025, was reviewed. NM 2 and DIR 3 acknowledged Patient 21’s location and behaviors on 5/27/2025 from 5:00 p.m. to 5:29 p.m., and from 8:18 p.m. to 8:44 p.m., were missing and not documented. DIR 3 stated there should be every 15 minutes rounding done for Patient 21. During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 10/2021, the P&P indicated, “All patients on the BHU (Behavioral Health Unit) are at a minimum under standard observation ...Policy-Assess and document at 15-minute intervals.” 5. During a review of Patient 10’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/16/2025, the Psych Eval indicated, Patient 10 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a concurrent observation and interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), the facility’s security video footage dated 4/20/2025, was reviewed. The security video footage indicated the following: -At 11:26 p.m.: Patient 10 was seen standing by the doorway of his (Patient 10’s) room holding a pair of green pants; -At 11:27 p.m.: a Behavioral Health Worker (BHW 10) was seen walking towards Patient 10 and handed Patient 10 a diaper. Patient 10 and BHW 10 exchanged some conversation; -At 11:27:25 p.m.: BHW 10 put hands on Patient 10’s left shoulder area and right arm and pushed Patient 10 into the room. Both BHW 10 and Patient 10 went into the room; -At 11:27:41 p.m.: BHW 11 was seen walking down the hallway and looked into Patient 10’s room but did not go inside; -At 11:27:49 p.m.: BHW 10 came out of Patient 10’s room; -At 11:27:56 p.m.: Patient 10 walked to the doorway and pointed his left eye to BHW 11 During the same interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), DQM confirmed Patient 10, BHW 10 and BHW 11’s identities from the video surveillance footage. DQM stated Patient 10 came out of the room with laceration on the left eyebrow. During the same interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), DQM stated the facility conducted an internal investigation and identified care was delayed because RN 5 did not notify the attending physician regarding Patient 10’s change of condition (left eyebrow wound). DQM stated, “the care was delayed.” DQM further said Patient 10’s physician was not notified that night. Physician was notified the next morning and a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) scan of head was ordered. During a review of Patient 10’s “Progress Note Non-Physician (nursing progress notes),” dated 4/20/2025, the “Progress Note Non-Physician,” indicated, at 3:17 a.m., Patient 10 went to the nursing station with bleeding at the corner of left eyebrow, Patient 10 informed RN 5 that “I got my pants wet and requested for another pair. The BHW (Behavioral Health Worker 10) put his hand on me, held me tight on my neck, and pushed me back from the door of my room to my bed. I hit myself somewhere, not sure if it was on my bed or on the wall. I had a scar on my left eyebrow since I was 9 years old. It started bleeding where the scar is.” During an interview on 6/26/2025 at 11:32 a.m. with Nurse Manager (NM) 2 of BHU, NM 2 stated RN 5 did not assess Patient 10’s wound (left eyebrow) when it was reported, and did not call the physician for Patient 10’s change of condition. During an interview on 6/27/2025 at 9:48 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3, DIR 3 stated the following: BHW 11 heard yelling and went to the room that day. He (BHW 11) noted there was a cut on Patient 10 but he (BHW 11) thought BHW 10 told the nurse already, so he (BHW 11) did not report. During a review of the facility’s policy and procedure (P&P) titled, “Physician Notification,” dated 10/2024, the P&P indicated, “the attending physician will be notified regarding patient issue in a timely manner ... the primary attending physician will immediately be notified of patient’s change in condition.” 6. During a review of Patient 5’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/27/2025, the H&P indicated the following: Patient 5 with a history of alcohol use disorder, seizure disorder (sudden burst of electrical activity in the brain), and psychosis (disconnection from reality). Patient 5 was brought in by ambulance from the streets after having a witnessed tonic-clonic seizure (a type of seizure that involves a loss of consciousness [a state where an individual loses awareness of themselves and their surroundings] and violent muscle contractions [the process where muscle fibers shorten to generate force, allowing for movement and other functions]) for about 5 minutes. During a review of a document for Patient 5 titled, “BHU (Behavior Health Unit) Rounding & Observation,” dated 4/30/2025, the document indicated Patient 5’s locations. Location Code: PR (indicates Patient Room), H (indicates Hallway), and SR (indicates Seclusion Room): -At 5:45 p.m. and 6 p.m., Location: The letter “H” was handwritten, in dark black ink, on top of original writing in lighter black ink. Two originally handwritten letters were obscured by the letter “H” and not legible. -At 6:15 p.m. and 6:30 p.m., Location: The letter “S” was handwritten, in dark black ink, on top of the original writing of two letters in a lighter black ink. One of the original letters was obscured by the letter “S” and other original letter was “R”. During a concurrent interview and record review on 6/25/2025 at 2:16 p.m. with the Nurse Manager (NM) 1 for Campus 2, NM 1 reviewed Patient 5’s rounding documentation titled, “BHU (Behavior Health Unit) Rounding & Observation,” dated 4/30/2025, and verified that there was previous writing underneath the “H” documented at 5:45 p.m. and 6 p.m., and the “S” documented at 6:15 p.m. and 6:30 p.m. The letters “H” and “S” appeared to be written on top of the letters “PR,” at 5:45 p.m., 6 p.m., 6:15 p.m., and 6:30 p.m. NM 1 stated that if a staff wanted to correct documentation, the staff needed to draw a line through the error, write error and initials of the staff making the correction, then write the correct documentation. The NM verified there was writing on top of existing writing and that the facility’s policy regarding documentation and corrections was not followed. During a review of the facility’s policy and procedure (P&P) titled, “Documentation, Corrections,” dated 2/2023, the P&P indicated the following: When an error is made ... corrections are allowed. All medical record entries are made as soon as possible after care, treatment or services provided. A medical record entry is never made in the medical record in advance of the care, treatment or service provided to the patient. Pre-dating or back dating an entry in the medical record is prohibited. Procedure: Corrections to the paper medical record are made following the process stated below: 1. Handwritten entries are made with permanent black ink ... 2. All entries in the medical record must be legible, dated, timed, and authenticated. 3. Do not write over original medical record entry to obscured what was originally written ... 4. Erasers and use of correction fluid or tape ...are prohibited. 5. Corrections of entries are done, as follows: a. Draw a SINGLE line through the mistake ... b. Write ERROR next to the single lined through mistake, then write the time, date, and sign/titled. c. Document the correct information above the error ... d. Use the current time, date, and then time, date, and sign/title for the new entry.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50515 Based on observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 16), the facility’s policy and procedure (P&P) for infection control was implemented when, Patient 16’s intravenous tubing (known as “piggyback,” a flexible tube that administers medication) was not labeled with a date for change of IV (Intravenous, into the vein) tubing, and IV site was not dated. This deficient practice had the potential to result in Patient 16 being exposed to infections such as phlebitis (infection of the veins) and/or bloodstream infection caused by prolonged use of IV tubing and IV insertion site. Finding: During a review of Patient 16’s “Face Sheet (a document containing a patient’s medical and demographic information),” undated, the face sheet indicated Patient 16 was admitted to the facility on 6/23/2025 at 6:56 p.m., with a medical diagnosis of lactic acidosis (a condition causing blood to be acidic). During an observation on 6/25/2025 at 11:00 a.m., in Patient 16’s room 211, Patient 16’s IV (Intravenous, into the vein) insertion site was observed with no insertion date label and the IV tubing piggyback (method of administering medication through an existing intravenous [IV]) line) antibiotic had no tubing label for change of tubing. During a concurrent observation and interview on 6/25/2025 at 11:12 a.m. with Patient 16’s registered Nurse (RN) 8 in room 211, RN 8 confirmed that Patient 16’s IV insertion site had no insertion date label, and the IV piggyback tubing had no label sticker to indicate the next change of tubing. RN 8 stated the IV insertion site to the left antecubital (area on the inside of the elbow) should be labeled with insertion date and nurse initials and the IV piggyback should have a label with date of next tubing change. RN 8 also said these are all measures to prevent infection. RN 8 further stated the IV tubing, and IV insertion site were changed every three days unless contraindicated and documented. During an interview on 6/26/2025 at 8:55a.m. with the Director of Medical/Surgical floor (DIR) 2, the DIR 2 stated, the standard of care for patients with IV access was for the insertion site to be assessed every shift for patency (condition of being open), date of insertion and documented in the patients’ medical record. DIR 2 also said that for IV piggyback medication tubing, they need to be labeled with next change of tubing date. DIR 2 further stated IV tubing should be changed every 72 hours for infection prevention. During a review of the facility’s policy and procedures (P&P) titled, “Intravenous Therapy,” reviewed 2/2023, the P&P indicated, “The peripheral IV site is to be changed every 72 hours to prevent infection and phlebitis from occurring. If the site is not changed, document reason(s) in the medical record. IV tubing, including piggy-back tubing will be changed every 72 hours with the following exceptions: 1. TPN (Total Parenteral Nutrition, a method of feeding a patient intravenously (through a vein) when they cannot get adequate nutrition through their digestive system) /Lipids (a liquid preparation of fat used in intravenous infusions to provide calories and essential fatty acids to patients unable to obtain adequate nutrition through oral intake) change every 24 hours.””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50516 Based on observation and interview, the facility failed to ensure one of three sampled campuses (Campus 1) Behavioral Health Unit (BHU), was kept clean and free of flies, in accordance with the facility’s policy regarding Infection control and prevention. This deficient practice had the potential to cause infections through contaminated areas and objects, which could negatively impact the patients’ and staff’s overall health. Findings: During a concurrent observation and interview on 6/24/2025 at 12:34 p.m. with Behavioral Health Worker (BHW) 4, in the seclusion room (involuntary [without permission] confinement of a patient in a room or area from which the patient is physically prevented from leaving), BHW 4 stated he (BHW 4) saw juice stains and sticky areas on the floor. BHW 4 stated Environmental Services (EVS, department responsible for maintaining a clean working environment) usually came and clean the room. BHW 4 looked at the bed and stated, “I think it’s juice on the mattress. It’s dirty right now and it does have to be clean.” BHW 4 stated there were wipes used to sanitize the bed, and anyone can go and clean the room. During a concurrent observation and interview on 6/24/2025 at 12:37 p.m. with BHW 4, in the seclusion room bathroom, BHW 4 verified the toilet with brown stains was not clean. BHW 4 also stated he (BHW 4) saw a fly in the room, and that there were “A couple of flies here and there.” BHW 4 stated he (BHW 4) noticed the flies this morning (6/24/2025) and did not notify anyone about the flies. During a concurrent observation and interview on 6/24/2025 at 12:48 p.m. with Nurse Manager (NM) 2 and Charge Nurse (CN) 1, in another seclusion room, NM 2 and CN 1 verified there were stains on the wall. NM 2 stated, “The whole unit looks dirty.” During an interview on 6/26/2025 at 11:53 a.m. with the Director (DIR) 4 of Infection Control, DIR 4 stated she (DIR 4) did not hear of any flies in the units recently. DIR 4 stated the plan to remove pests was to meet with EVS to coordinate a cleaning effort to see if the patient’s rooms, lounge, or patio areas had to be treated. DIR 4 said the nursing directors and charge nurses would take guidance from EVS, and effectiveness would be evaluated within 24 hours. DIR 4 stated flies could contaminate food surfaces and patient wounds. During an interview on 6/27/2025 at 9:12 a.m. with the Environmental Services Manager (ESM), ESM stated he (ESM) was always made aware of flies and other pests. ESM stated he and his (ESM) staff were not called about the flies. During an interview on 6/27/2025 at 5:20 p.m. with the Director of Behavioral Health (DIR) 3, DIR 3 stated humane care can be physical care and needs of the patient. DIR 3 stated “we should be on top of asking EVS to clean for soiled areas and after discharge, and for infection prevention.” DIR 3 stated, the areas “Should definitely be kept clean.” DIR 3 stated the danger of not having a clean environment “Could cause slips, falls, bugs, maybe another patient picking something up that should have been picked up by staff,” and was part of infection control. During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention and Control Plan,” dated 2/2025, the P&P indicated, “Develop and implement a preventative and corrective program designed to minimize infectious hazards, including reviewing and evaluating aseptic, isolation, and sanitation techniques ...Infection Prevention: The outcome objectives are to reduce the risk of preventable HAIs (Hospital Acquired Infections), reduce the risk of multi-drug resistant organisms, decrease patient suffering and inconvenience ...” During a review of the facility’s policy and procedure (P&P) titled, “Patients Rights,” dated 8/2022, the “P&P” indicated, “In addition, LPS (Lanterman-Petris-Short Conservatorship, is a legal process in California where a court appoints someone to care for and make decisions for an individual deemed “gravely disabled” due to a mental disorder. This mechanism allows for involuntary mental health treatment and placement, including medication and living arrangements, when the individual cannot provide for their basic needs) grants all patients these irrevocable rights: To dignity, privacy and humane care.””

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 43236 Based on interview and record review, the facility failed to: 1. Ensure its staff followed infection control policy and procedure (P&P) when the annual tuberculosis (TB, a serious infectious bacterial disease that primary affects the lung, is spread through the air, and can stay in the air for several hours) screening, was missing for one (1) of 10 sampled employees (Registered Nurse [RN] 5). This deficient practice had the potential to put the facility’s staff and patients at risk for acquiring (catching) TB. 2. Ensure its staff followed infection control policy and procedure (P&P), when evidence of either influenza (the flu, a contagious viral disease that affects the lungs and is spread through coughing and sneezing) vaccination administration or declination, was missing for one (1) of 10 sampled employees (Behavioral Health Worker [BHW] 10). This deficient practice had the potential to put the facility’s staff and patients at risk for acquiring influenza. Findings: 1. During a concurrent interview and record review on 6/27/2025 at 3:33 p.m. with the Director of Infection Control (DIR) 4, Registered Nurse (RN) 5’s employee health records, were reviewed. RN 5 had a positive QuantiFERON test (a blood test used to help detect TB infection) on 5/16/2019. The most recent TB (tuberculosis, a serious infectious bacterial disease that primary affects the lung, is spread through the air, and can stay in the air for several hours) symptom screening listed for RN 5, was on 10/12/2023. DIR 4 stated that RN 5 was noncompliant and did not complete their annual TB symptom (signs of having a disease) screening in 2024. Additionally, DIR 4 stated RN 5’s employment at the facility was terminated on 4/24/2025. During the same interview on 6/27/2025 at 3:33 p.m. with the Director of Infection Control (DIR) 4, DIR 4 stated it was important for the facility to know their employees’ TB status because they wanted to be able to catch if their employees convert from negative to positive TB status (go from not having TB to having TB), or from latent TB (when TB bacteria is present in the body but the immune system keeps them under control, preventing that person from feeling sick or spreading TB to other people) to active TB (when the immune system can’t keep TB from multiplying and growing in the body, so that person feels sick and can spread TB to other people); if they were showing symptoms, the employees could have potentially given TB to their co-workers or their patients. During a review of the facility’s policy and procedure (P&P) titled, “Employee Health Program,” last reviewed 11/2024, the P&P indicated, “Annual Tuberculosis (TB) Screening: a. Employees with documented history of negative tuberculin skin test (TST) will undergo an annual TST and TB symptom questionnaire. b. Employees with documented history of positive TST will complete an annual TB symptom questionnaire.” 2. During a concurrent interview and record review on 6/27/2025 at 4:45 p.m. with the Director of Infection Control (DIR) 4, BHW 10’s employee health records, were reviewed. DIR 4 stated there was no evidence in the records that BHW 10 had either received the 2024 flu vaccine or declined it. Additionally, DIR 4 stated BHW 10’s employment at the facility was terminated on 4/24/2025. During the same interview on 6/27/2025 at 4:45 p.m. with the Director of Infection Control (DIR) 4, DIR 4 stated that it was still important for staff to sign a declination form so that they understood the risk they were taking on if they declined the vaccine, such as flu transmission to themselves, to other patients, and to other employees, and also so that employees understood that they must wear a mask if they declined the vaccine to prevent transmission of influenza. During a review of the facility’s policy & procedure (P&P) titled, “Healthcare Personnel Influenza Vaccination,” last reviewed 5/2020, the P&P indicated, “All personnel will be required to either accept or decline the influenza vaccine annually in order to comply with California Health and Safety Code, Section 1288.5 and any local, state and federal laws ... All healthcare personnel will be offered the influenza vaccine annually at no cost. Healthcare personnel are defined as employees, contract staff, licensed independent practitioners, and volunteers at [the facility] ... Healthcare personnel who choose to decline the vaccine will sign a declination form and will be required to wear a surgical mask while in the Hospital Board designated Mask Zones from November 1st through April 30th of each year.” 1”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 42937 Based on interview, and record review, the facility failed to ensure two of 30 sampled patients’ (Patient 28 and Patient 29) inter-disciplinary treatment plan was developed and implemented when: 1. Patient 28’s inter-disciplinary treatment plan (a structured, individualized document that outlines the care team objectives, intervention and the strategies to achieve specific health goals) for anemia (a condition where the body doesn’t have enough healthy red blood cells or hemoglobin to carry sufficient oxygen to the body’s tissues) was not developed and implemented by nursing staff within 8 hours of admission (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding Multidisciplinary treatment plan. This deficient practice had the potential for the care needs and risks of Patient 28 to not be identified and addressed which may result in patient harm. 2. Patient 29’s inter-disciplinary treatment plan (a structured, individualized document that outlines the care team objectives, intervention and the strategies to achieve specific health goals) for hypertension (high blood pressure) was not developed and implemented by nursing staff within 8 hours of admission (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding Multidisciplinary treatment plan. This deficient practice had the potential for the care needs and risks of Patient 29 to not be identified and addressed which may result in patient harm. Findings: 1. During a review of Patient 28’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 06/20/2025, the Psych eval record indicated that Patient 28 was placed on a 5150 hold (a 72-hour involuntary psychiatric hold) for being gravely disabled (GD, when a person is no longer able to provide for their own food, clothing, or shelter because of a mental health disorder). The Psych eval indicated Patient 28 was discovered with altered mental status (AMS, a change in a person’s normal level of consciousness, awareness, or cognitive function [the mental processes that enable someone to perceive, process, and understand information, make decisions, and learn]), wandering around in public with his (Patient 28) pants down, and unable to meet basic needs independently for survival, and at risk for failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity). The Psych eval also indicated Patient 28 had a medical history of anemia (a condition where the body doesn’t have enough healthy red blood cells or hemoglobin to carry sufficient oxygen to the body’s tissues). During a concurrent interview and record review on 06/27/2025 at 4:30 p.m. with Performance Improvement Registered Nurse (PIRN), Patient 28’s medical record titled, “Interdisciplinary Master Treatment Plan,” dated 06/23/2025, was reviewed. Patient 28’s medical record indicated that a treatment plan for anemia was not developed and implemented. PIRN stated that the admitting nurse did not initiate a treatment plan for anemia. PIRN also said Patient 28 had history of anemia and was on ferrous sulfate (an iron supplement used to treat or prevent low blood levels of iron such as those caused by anemia) medication since admission. During an interview on 6/27/2025 at 5:19 p.m. with the Director of Behavioral Health (DIR) 3, DIR 3 stated upon review of the facility’s electronic medical record (EMR, a digital version of a patient’s medical chart) system, it was found that the EMR in the behavioral health unit (BHU, a specialized unit that provide care for individuals with mental health conditions) did not have the option for the nurse to create an anemia treatment plan. DIR 3 said the BHU leadership would reach out to the information technology (the department responsible for managing and maintaining the facility’s technology infrastructure, including software, and data) department to fix that problem. During a review of the facility’s Policy and Procedure titled, “Multidisciplinary Treatment Plan,” with last revised date of 12/2023, the P&P indicated the following: Policy: Each patient admitted to the Behavioral Health Unit at College Medical Center shall have an individualized written treatment plan which is based on interdisciplinary clinical assessments. The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Treatment planning takes place prior to the first treatment team meeting for the patient and is reviewed at the first treatment meeting and in regular treatment reviews. All members of the multidisciplinary treatment team shall be present during the meetings, including but not limited to nursing, social work, discharge planning, recreational therapy, the attending psychiatrist and the patient (if possible). Patients and families are involved in the treatment planning process by providing input and receiving ongoing feedback. Procedure: Multi-disciplinary Treatment Team: Within eight (8) hours of admission, nursing staff shall begin to develop a treatment plan based on an assessment of the patient’s presenting problems, emotional, cultural, behavioral, physical, spiritual and sensory deficits. 2. During a review of Patient 29’s “Consultation Report,” dated 06/20/2025, the consultation report indicated that Patient 29’s blood pressure was elevated, was anxious (a feeling of unease, worry, or fear), and currently on psychiatric hold with suicidal) thoughts of taking one’s own life) gesture. Patient 29 had hypertension (high blood pressure) history. During a concurrent interview and record review on 06/27/2025 at 4:40 p.m. with Performance Improvement Registered Nurse (PIRN), Patient 29’s medical record titled, “Interdisciplinary Master Treatment Plan,” dated 06/20/2025, was reviewed. Patient 29’s medical record also indicated that a treatment plan for hypertension was not developed and implemented. PIRN stated that the admitting nurse did not initiate a treatment plan for hypertension. PIRN said Patient 29 had history of hypertension and was on medication for hypertension. PIRN stated the admitting nurse should have initiated a treatment plan for hypertension. During a review of the facility’s Policy and Procedure (P&P) titled, “Multidisciplinary Treatment Plan”, with last revised date of 12/2023, the P&P indicated the following: Policy: Each patient admitted to the Behavioral Health Unit at College Medical Center shall have an individualized written treatment plan which is based on interdisciplinary clinical assessments. The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Treatment planning takes place prior to the first treatment team meeting for the patient and is reviewed at the first treatment meeting and in regular treatment reviews. All members of the multidisciplinary treatment team shall be present during the meetings, including but not limited to nursing, social work, discharge planning, recreational therapy, the attending psychiatrist and the patient (if possible). Patients and families are involved in the treatment planning process by providing input and receiving ongoing feedback. Procedure: Multi-disciplinary Treatment Team: Within eight (8) hours of admission, nursing staff shall begin to develop a treatment plan based on an assessment of the patient’s presenting problems, emotional, cultural, behavioral, physical, spiritual and sensory deficits.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to provide adequate number of Behavioral Health Workers (BHW, same as Mental Health Workers, non-licensed staff helping with unit rounding and assist patients with daily activities) to perform line of sight (a straight line along which an observer had unobstructed vision) monitoring in the Behavioral Health Unit (inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), in accordance with the facility’s policy on rounding and observation, for three of four sampled shifts (Shift 1, 2 and 3) at Unit S on 4/20/2025 and 6/14/2025. This deficient practice had the potential to result in insufficient monitoring of patients in BHU and putting patients at risk for injury. On 4/20/2025, a Behavioral Health Worker (BHW 10) pushed Patient 10, and Patient 10 sustained a left eyebrow injury. On 6/14/2025, Patient 9 hit Patient 8 in the room. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and bruises on face and head following the assault (an intentional act that causes another person to reasonably fear imminent harmful or offensive contact). Findings: During an interview on 6/24/2025 at 3:10 p.m. with the Nurse Manager (NM 2) of BHU, NM 2 stated the following: there were different levels of monitoring aside from standard every 15-minutue rounding in BHU. A specific staff was assigned to a specific patient who needed one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring and the staff had to stay with the patient within arm’s length. For patients who needed line of sight (a straight line along which an observer had unobstructed vision) monitoring, staff would need to keep a close eye on the patients and maintain visual on the patients outside their regular every 15-minute rounding. During an interview on 6/26/2025 at 3:41 p.m. with the Staffing Coordinator (SC), SC stated the following: she (SC) had been preparing staffing for BHU at Campus 1 for 2 years. Each unit would staff with three BHWs at minimal each shift and would staff up based on the acuity of the unit. Patients requiring one to one (1:1) monitoring and line of sight monitoring would be high acuity (the severity of a patient’s illness or injury, and the level of care they require). One additional BHW would be added to each patient who was on 1:1 and/or line of sight monitoring. Staffing Coordinators would obtain census, number of patients on 1:1 and line of sight monitoring from the charge nurse when preparing for the staffing. During a concurrent interview and record review on 6/26/2025 at 3:53 p.m. with SC, the facility’s BHU “Unit S, AM Shift Assignment (Shift 1),” dated 4/20/2025, was reviewed. The “Unit S, AM Shift Assignment” indicated, there were five (5) BHWs staffed for census of 20 patients with 10 patients requiring line of sight monitoring. SC stated the following: based on the census and number of patients requiring line of sight, Unit S would need thirteen (13) BHWs to cover rounding and line of sight monitoring. 5 BHWs would not be enough to cover half of the patients who required line of sight monitoring. During a concurrent interview and record review on 6/26/2025 at 3:55 p.m. with SC, the facility’s BHU “Unit S, PM Shift Assignment (Shift 2),” dated 4/20/2025, was reviewed. The “Unit S, PM Shift Assignment” indicated, there was one licensed vocational nurse (LVN) working as BHW and three (3) BHWs staffed for census of 20 with 10 patients requiring line of sight monitoring. SC stated the following: based on the census and number of patients requiring line of sight, Unit S would need thirteen (13) BHWs to cover rounding and line of sight monitoring. With the one LVN who worked as BHW that night, there were only four (4) staff to do rounding and line of sight monitoring, which was not enough. SC further stated there was potential risk for patient hurting another patient, someone could get hurt and staff could feel stressed due to short staffing. During a review of Patient 10’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/16/2025, the Psych Eval indicated, Patient 10 was a 77-year-old admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 10’s “Progress Note Non-Physician (nursing progress notes),” dated 4/20/2025, the “Progress Note Non-Physician,” indicated, at 3:17 a.m., Patient 10 went to nursing station with bleeding at corner of left eyebrow, Patient 10 informed RN 5 that “I got my pants wet and requested for another pair. The BHW (Behavioral Health Worker 10) put his hand on me, held me tight on my neck, and pushed me back from the door of my room to my bed. I hit myself somewhere, not sure if it was on my bed or on the wall. I had a scar on my left eyebrow since I was 9 years old. It started bleeding where the scar is.” The “Progress Note Non-Physician,” also indicated RN 5 spoke with BHW 10 with BHW 10 stating, “This guy came talking shit to me. He put his hand on me, and I tried to defend myself by pulling my arm away from him. and he (Patient 10) lost his balance.” During a concurrent interview and record review on 6/26/2025 at 4:06 p.m. with SC, the facility’s BHU “Unit S, AM Shift Assignment” (Shift 3), dated 6/14/2025, was reviewed. The “Unit S, AM Shift Assignment” indicated, there were five (5) BHWs staffed for census of 20 patients with 4 (four) patients requiring line of sight monitoring and two (2) patients requiring one to one monitoring. The “Unit S, AM Shift Assignment” also indicated four (4) BHWs were canceled and one BHW was flexed at 2 p.m. SC stated the following: based on the census and number of patients requiring line of sight, Unit S would need nine (9) BHWs to cover rounding, line of sight and 1:1 monitoring. SC further stated five (5) BHWs was not enough to cover all the line-of-sight monitoring. The four (4) BHWs should not have been canceled. During a review of Patient 8’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/16/2025, the Psych Eval indicated, Patient 8 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 8’s “Consultation Report,” dated 4/16/2025, the “Consultation Report” indicated, Patient 8 had past medical history of pseudoseizures (event that mimic seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness] but are not caused by abnormal electrical activity in the brain) and autism (neurodevelopmental disorder characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication). During a review of Patient 9’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 6/5/2025, the Psych Eval indicated, Patient 9 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnoses including but not limited to a 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 9’s “Order Information for: Patient Monitoring (physician order),” dated 6/10/2025, the physician order indicated, Patient 9 was placed on line of sight observation starting 6/10/2025. During a review of Patient 8’s “Order Information for: Patient Monitoring (physician order),” dated 6/12/2025, the physician order indicated, Patient 8 was placed on 1:1 sitter observation starting 6/12/2025. During a review of Patient 8’s “Progress Note Non-Physician (nurses progress notes),” dated 6/14/2025, the “Progress Note Non-Physician” indicated, “Patient (Patient 8) was attacked by his (Patient 8’s) roommate (Patient 9) approximately 1830 (6:30 p.m.). Patient (Patient 8) was witnessed falling back out of his (Patient 8’s) room into the hallway noted hitting the back of his (Patient 8’s) head ... Patient (Patient 8) unable to follow command for PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system). Right pupil 3 mm (millimeters, unit of measure) reactive to light. Left pupil nonreactive (the pupil [the black circle in the center of the eye] doesn’t constrict [get smaller] in response to light or when focusing on a near object). Rapid Response (a system designed to quickly address a patient’s sudden clinical deterioration before it escalates into a medical emergency) was called at 1838 (6:38 p.m.) ... [physician] was notified ... CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head, transfer to telemetry floor [room number]. Pending report.” The “Progress Note Non-Physician” also indicated Patient 8 was transferred to the facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor at 7:31 p.m. During an interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated on 6/14/2025, he (BHW 5) was sitting in the hallway and saw Patient 8 and Patient 9 went to the room. BHW 5 stated, “I heard feet shuffling in the room. I got up, peeked into the window and saw Patient 9 was on top of Patient 8 on the ground hitting Patient 8. Patient 9 was aggressive to Patient 8.” During the same interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. BHW 5 also stated Patient 8 was on one to one (1:1) monitoring that day (6/14/2025), but his (Patient 8’s) assigned sitter was flexed earlier that day due to overstaffing and no one was assigned to replace the sitter. BHW 5 stated there was no line of sight for both patients (Patient 8 and Patient 9) because the door was closed. During an interview on 6/25/2025 at 2:29 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated the following: the charge nurse of the unit was responsible for making assignment for the shift. There was no specific person assigned to perform line of sight. Any staff not assigned as 1:1 monitoring would be watching patients who required line of sight monitoring. The staff would need to see those patients at all times. CN 3 also stated a physician order was required for starting and discontinuing any line of sight and 1:1 monitoring. During a concurrent interview and record review on 6/25/2025 at 2:52 p.m. with the Nurse Manager (NM) 2 of BHU, the facility’s Campus 1 BHU assignment, “Unit S, AM Shift Assignment,” dated 6/14/2025, was reviewed. The “Unit S, AM Shift Assignment” indicated, Patient 8 was 1:1 monitoring and Patient 9 was on line of sight monitoring. The “[Unit] AM Shift Assignment” did not indicate which nursing staff was assigned to Patient 8 and Patient 9 to perform the 1:1 monitoring and line of sight monitoring. NM 2 stated she (NM 2) could not tell which staff was assigned to perform line of sight monitoring because it was not written on the assignment. During an interview on 6/27/2025 at 9:37 a.m. with the Director (DIR) 3 of BHU, DIR 3 stated the BHU unit did not assign line of sight monitoring per patient per staff before. DIR 3 stated, “we did not have the staff.” DIR 3 further stated there was no policy or staffing grid to guide the staffing coordinators on how to staff BHWs to the unit. During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 10/2021, the P&P indicated, “The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment ... Observation levels are designed to provide the right level of observation, precaution and oversight commensurate with physician and RN assessment of the safety needs of the patient in alignment with the current behavior and symptoms they are demonstrating ... Three levels of staff monitoring are provided ... Level II - moderate - line of sight ... Policy - A level of observation wherein the patient remains in staff view at all times. A specific staff member is assigned and the line of observation is maintained by staff in person and not through video monitoring ... Level III - intensive - one to one ... Policy - consists of one to one staff observation with a patient never farther away than arm’s length. The patient remains within arm’s length at all times ... The RN is responsible for obtaining an MD order for an observation level that is line of sight or 1 to 1 ... When the patient’s status permits, the RN will notify the MD and get an order to down-grade the observation status to that of “least restrictive” in a manner to maintain the patient in an optimal level of safety.” During a review of the facility’s policy and procedure (P&P) titled, “Scope of Service,” dated 10/2021, the P&P indicated, “Management of Patients ... 1. Nursing care is delivered based on acuity of the patient, skill level of the nurse and available resources ... Note: Augmentation of nursing resources, beyond core staffing will be based on the acuity of the patients and the nursing skill level.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48186 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation (CoP) for Governing Body as evidenced by: 1. The facility’s Governing Body (a group of people who are legally responsible for the management and direction of an organization) failed ensure that the Quality Assurance Performance Improvement (is a data driven and proactive approach to quality improvement) Department analyze the cause, and develop a correction plan to address a delay of care for one of 30 sampled patients (Patient 1) who had a decline in condition (worsening of symptoms) after sustaining a fall (an unplanned change in position where a patient lands on the floor or another lower surface) on 5/2/2024 at 10:15 a.m. Nursing staff documented Patient 1 was alert prior to the fall and after the fall from 5/2/2024 at 10:00 p.m., Patient 1 was lethargic (a symptom that involves an unusual decrease in consciousness), was manifesting confusion (symptoms that involve disruptions in memory, ability to think and focus, awareness), and disorientation (the condition of having lost one’s sense of direction) and yet, there was no notification to physician or call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to immediately assess and treat the patient) that was done by nursing staff. This deficient practice had the potential for reoccurrence of a patient’s decline in condition (when clinical symptoms worsen) not being addressed immediately by staff thus leading to life-threatening events such as cardiac arrest (when the heart stops beating), etc. and compromising patient safety. (Refer to A-0063) 2. The Governing Body failed to ensure the Nursing Services Department ensure nursing staff notified the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) (Campus 1) that one of 30 sampled patients (Patient 3) had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not), sustained a head injury, and was refusing medical care. This deficient practice resulted in Patient 3 being discharged from the ED, without being seen and medically cleared by an ED Physician for a possible head injury (post-assault [when an individual inflicts physical contact that causes bodily harm and/or injury]) and without being evaluated for psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), which could have resulted in unresolved psychosis and complications from a brain bleed such as death. (Refer to A-0063) 3. The Governing Body failed to ensure the facility’s Security Services Department ensure one of 30 sampled patients (Patient 3) was free from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when the security guard (SO 1) physically assaulted (when someone physically attacks another person causing bodily harm) Patient 3. This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh) above the left eye. (Refer to A-0063) 4. The facility failed to protect Patient 3 from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) from a contracted service from a security guard (SO)1. This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh). (Refer to A-0083) 5. The facility allowed contracted staff to continue to work at the facility despite one Security guard (SO3) not having received CPI (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) training, and two security guards (SO 1 and SO 2) with expired CPI training. This deficient practice resulted in SO 1 not using appropriate de-escalation technique (methods used to reduce the intensity of a volatile situation) and punched Patient 3 ten times in the face resulting in Patient 3’s injury. This deficient practice also had the potential for SO 2 and SO 3 to forget how to use a safe and appropriate de-escalation technique, which may result in other physical altercations with patients that may lead to patient abuse. (Refer to A-0083) 6. The facility failed to ensure the Security Services, a contracted service (a service that is performed by an independent contractor or service provider, under a formal, legally binding agreement), had a valid and un-expired contract agreement to provide and maintain a safe care environment in the facility. This deficient practice had the potential for the contracted security services staff to not uphold their job requirements and responsibilities as required by the facility, placing the patients at risk for an unsafe care environment. (Refer to A-0083) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48186 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 1. The facility failed to ensure the staff removed a ligature (a thing used for tying) risk item for one of 30 sampled patients (Patient 9), in accordance with the facility’s policy and procedure regarding contrabands (any item that is prohibited or could be dangerous to patients, staff or visitors. Example: Belts and shoelaces), when Patient 9 was allowed to wear a sweater with a drawstring in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders). This deficient practice resulted in putting Patient 9 and other patients in an unsafe environment when the drawstring (considered as a contraband) could be used to harm self or others. (Refer to A-0144) 2. The facility failed to ensure one of 30 sampled patients (Patient 20), who was at risk for suicide (a mental state in which it is likely that a person will try to end their own life), was monitored every 15 minutes, in accordance with the facility’s policy and procedure regarding rounding (visit patients to assess their needs, review their care, and ensure safety) on and monitoring patients. This deficient practice had the potential to result in an unsafe care due to lack of purposeful rounding, which may lead to Patient 20 harming self that could cause injury and/or death. (Refer to A-0144) 3. The facility failed to ensure one of 30 sampled patients (Patient 3) was free from abuse (the improper treatment of a person), when Patient 3 was physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff. This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh) above the left eye. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48186 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Quality Assurance and Performance Improvement (QAPI) as evidenced by: 1. The facility’s Quality Assurance and Performance Improvement (QAPI, a data driven and proactive approach to quality care) Committee failed to ensure that an adverse event (an undesirable or harmful outcome) involving one of 30 sampled patients (Patient 1), was analyzed to determine the cause of the event and then develop and implement preventive actions to ensure patient safety and prevent re-occurrence, in accordance with the facility’s policy and procedure regarding Organizational Performance Improvement Plan. Patient 1 received delayed intervention for a head bleed with a decline in condition (after an unwitnessed fall) which included symptoms of lethargy (a symptom that involves an unusual decrease in consciousness), confusion, eyes not opening to painful stimuli, all of which were not reported by nursing staff to the physician. This deficient practice had the potential to result in life-threatening situations and jeopardize patients’ safety, which may lead to death, when the events that led to Patient 1’s delayed care are not analyzed for the causes, and preventive actions to prevent re-occurrence of the same incident involving a decline in patient’s condition, are not properly addressed. (Refer to A-0286) 2. The facility’s Quality Assurance and Performance Improvement (QAPI, a data driven and proactive approach to quality care) Committee failed to keep track of its abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) reports record made to the regulatory agency, when one of 30 sampled patient’s (Patient 7) report of an alleged physical abuse for being hit 15 times by two staff on 4/7/2017, was not available for review. This deficient practice had the potential for the facility not being able to identify abuse patterns, intervene early to protect potential victims, and develop prevention strategies to improve patient care. This deficient practice also had the potential to result in putting the facility non-compliant with mandatory reporting requirement of State and Federal regulatory agency and delay the investigation process by State regulatory agency. (Refer to A-0286) 3. The facility failed to ensure 10 out of 28 policy and procedure (P&P) sampled, were reviewed and addressed by Quality Assurance Performance Improvement (QAPI, a data-driven and proactive approach to quality improvement program) Committee, to ensure these P&Ps were not outdated and that P&Ps were reviewed by the facility’s governing body every three years. This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to outdated policies that might not reflect up to date best practices. (Refer to A-0309) The cumulative effect of these deficient practices resulted in the facility’s inability to deliver quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48186 Based on observation, interview and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 1. The facility failed to ensure one of 30 sampled Patients (Patient 1), Patient 1’s decline in condition, becoming lethargic (a symptom that involves an unusual decrease in consciousness) and unresponsive to pain (the patient does not respond spontaneously) with abnormal changes in the vital signs (increased blood pressure, when the force of blood flowing through the blood vessels continues to be higher than 130/80 mm Hg, millimeters of mercury, a unit of measurement), after sustaining an unwitnessed fall (an unplanned change in position where a patient lands on the floor or a lower surface) the day before, was communicated in a timely manner to the physicians, in accordance with the facility’s policy and procedure regarding assessment and physician notification. This deficient practice resulted in delayed intervention for Patient 1’s brain bleed and resulted in a call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stop], or death). This deficient practice also resulted in Patient 1 intubation (surgically inserting a tube into the patient’s windpipe to aid in breathing) and being transferred to the intensive care unit (ICU, for critically ill or injured patients that is staffed by specially trained medical personnel) in the same facility, and then being transferred out to a higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates) facility for surgery. (Refer to A-0395) 2. The facility failed to ensure for two of 30 sampled patients (Patients 25 and 28), the following: 2.a. Patient 25’s pressure injury (PI, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the right and left buttock had a wound care treatment order and wound care treatment provided, in accordance with the facility’s policy and procedure. This deficient practice resulted in Patient 25’s delayed treatment which may result in Patient 25’s PI to deteriorate and for the patient to suffer from pain and wound infection. (Refer to A-0395) 2.b. Patient 28’s high blood pressure (BP, amount of force blood uses to move through the body, with a normal range less than 120/80 mmHg]) readings were not communicated to the physician in accordance with the facility’s policy and procedure regarding physician notification. This deficient practice had the potential to cause a delay in determining Patient 28’s change of condition and/or a delay in the provision of emergent treatment needed which could worsen Patient 28’s condition that may result in complications such as stroke (clot in the brain), and/or death. (Refer to A-0395) 3. The facility failed to ensure nursing staff develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for high fall (an unplanned change in position where a patient lands on the floor or a lower surface) risk prevention and care for one of thirty (30) sampled patients (Patient 1), in accordance with the facility’s policy and procedures regarding care plan development. This deficient practice had the potential to result in Patient 1’s treatment and care goals not being met by not identifying the patient’s needs and risks for potential fall. (Refer to A-0396) 4. The facility failed to ensure one of 30 sampled patient’s (Patients 16), individualized nursing care plans (provides a means of communication among health care providers) to address Patient 16’s issues regarding Hypertension (high blood pressure) and Skin Impairment (damaged skin), was developed and implemented, in accordance with the facility’s policy and procedure regarding care plan development. This deficient practice had the potential to result in delayed provision of care to the patient by not identifying Patients 16’s needs and risks. (Refer to A-0396) 5. The facility failed to notify the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) (Campus 1) that one of 30 sampled patients (Patient 3) had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not), a head injury (sustained after a fall [an unexpected descent to the floor or another lower surface with or without injury to the patient]), and was refusing medical care. This deficient practice resulted in Patient 3 being discharged from the Emergency Department (ED), without being seen and cleared by an ED Physician for a possible head injury (post [after]-assault [when an individual inflicts physical contact that causes bodily harm and/or injury]) and without being evaluated for psychosis, which could have resulted in unresolved psychosis and complications from a brain bleed such as death. (Refer to A-0398) 6. The facility failed to ensure one of 30 sampled Patients (Patient 1), who was identified as high risk for fall, received “hourly rounding (purposeful rounding by staff with the goal to protect patients and promote patient safety on the 4 P’s: Pain, Potty, Positioning, and possessions),” in accordance with the facility’s procedure regarding rounding and monitoring of patients. This deficient practice likely resulted in Patient 1’s fall (an unexpected descent to the floor or onto another surface with or without injury to the patient) on 5/2/2024 at 10:15 a.m. and sustaining a head bleed, which required transfer to a high-level care (a hospital capable of providing diagnostic or interventional care beyond the capacity of the hospital from which a patient originates) facility for surgery. (Refer to A-0398) 7. The facility failed to ensure nursing staff assessed a patient and notified a physician in a timely manner, regarding an injury involving one of 30 sampled patients (Patient 7), after a hands-on protocol (using one or both hands to immobilize a patient) per Crisis Prevention Institute (CPI, a program that teaches people how to prevent and respond to crises) was used to restrain (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) Patient 7 to his (Patient 7) bed on 4/6/2017 (night shift). This deficient practice resulted in delay of treatment and care as physician was contacted only the next morning when Patient 7 was found with redness on left side of head and swelling in the left orbit (the bony cavity of the skull that houses the left eye). (Refer to A-0398) 8. The facility failed to ensure nursing staff removed a ligature (a thing used for tying) risk item, in accordance with the facility’s policy and procedure regarding contrabands (any item that is prohibited or could be dangerous to patients, staff or visitors. Example: Belts and shoelaces, etc.), for one of 30 sampled patients (Patient 9), when Patient 9 was allowed to wear a sweater with a drawstring in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders). This deficient practice resulted in putting Patient 9 and other patients’ safety at risk when the drawstring could be used as a ligature to harm self or others. (Refer to A-0398) 9. The facility failed to ensure for three of 30 sampled patients (Patients 25, 24, and 23), Patients 25, 24, and 23’s nursing care provided by the Licensed Vocational Nurse (LVN, an entry level health care provider who is responsible for basic nursing care under the direction of a registered nurse) was supervised by the Registered Nurse (RN, a licensed professional responsible for providing patient care, education and support to the patient), in accordance with the facility’s policy and procedure regarding RN oversight, when the LVNs’ patient care documentation was not reviewed and verified by the RNs to indicate the care was completed, accurate, and provided under the RNs’ supervision. This deficient practice had the potential for Patients 25, 24, and 23 to receive incomplete and inaccurate care which may cause negative impact on the overall provision of care and may lead to patient harm and/or death. (Refer to A-0398) 10. The facility failed to ensure one of 30 sampled Patient’s (Patient 1) PRN (as needed) medication, Hydralazine (prescribed medication used to treat high blood pressure) was administered as ordered by the physician and in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice had the potential to result in worsening of Patient 1’s condition with further increase in blood pressure that may result in complications such as seizure (abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness [describes a person’s awareness and understanding of what is happening in their surroundings), stroke (a clot in the brain), and/or death. (A-0405) 11. The facility failed to ensure nursing staff performed safe medication administration for one of 30 sampled patients (Patient 10), in accordance to the facility’s policy and procedure regarding medication administration, when a Licensed Vocational Nurse (LVN) 1 allowed Patient 10 walk away with two medication ointment in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders). This deficient practice had the potential to result in Patient 10 not receiving prescribed medication correctly. This deficient practice may also cause additional complications such as Patient 10 swallowing it or giving the medication to other patients in BHU who might end up using the medications inappropriately. (Refer to A-0405) 12. The facility failed to ensure one of 30 sampled patient’s (Patient 14) Valproic acid (also known as Depakene, medication used to treat seizure disorders (abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness [describes a person’s awareness and understanding of what is happening in their surroundings], mental/mood conditions, and to prevent migraine headaches), was administered in accordance with the physician’s order. This deficient practice had the potential for Patient 14’s behavioral condition such as agitation (a feeling of irritability and severe restlessness) to remain unresolved and may also lead to prolonged hospitalization. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to deliver quality health care in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 46333 Based on observation, interview and record review, the facility’s Governing Body failed to ensure the following: 1. The facility’s Governing Body (a group of people who are legally responsible for the management and direction of an organization) failed ensure that the Quality Assurance Performance Improvement (is a data driven and proactive approach to quality improvement) Department analyze the cause, and develop a correction plan to address a delay of care for one of 30 sampled patients (Patient 1) who had a decline in condition (worsening of symptoms) after sustaining a fall (an unplanned change in position where a patient lands on the floor or another lower surface) on 5/2/2024 at 10:15 a.m. Nursing staff documented Patient 1 was alert prior to the fall and after the fall from 5/2/2024 at 10:00 p.m., Patient 1 was lethargic (a symptom that involves an unusual decrease in consciousness), was manifesting confusion (symptoms that involve disruptions in memory, ability to think and focus, awareness), and disorientation (the condition of having lost one’s sense of direction) and yet, there was no notification to physician or call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to immediately assess and treat the patient) that was done by nursing staff. This deficient practice had the potential for reoccurrence of a patient’s decline in condition (when clinical symptoms worsen) not being addressed immediately by staff thus leading to life-threatening events such as cardiac arrest (when the heart stops beating), etc. and compromising patient safety. 2. The Governing Body failed to ensure the Nursing Services Department ensure nursing staff notified the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) (Campus 1) that one of 30 sampled patients (Patient 3) had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not), sustained a head injury, and was refusing medical care. This deficient practice resulted in Patient 3 being discharged from the ED, without being seen and medically cleared by an ED Physician for a possible head injury (post-assault [when an individual inflicts physical contact that causes bodily harm and/or injury]) and without being evaluated for psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), which could have resulted in unresolved psychosis and complications from a brain bleed such as death. 3. The Governing Body failed to ensure the facility’s Security Services Department ensure one of 30 sampled patients (Patient 3) was free from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when the security guard (SO 1) physically assaulted (when someone physically attacks another person causing bodily harm) Patient 3. This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh) above the left eye. Findings: 1. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/30/2024, the “H&P” indicated, Patient 1, “presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [essential nutrient for body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ...” During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1’s “Progress Notes (the part of a medical record where healthcare professionals record details to document a patient’s clinical status or achievements during treatment),” dated 5/2/2024, was reviewed. The progress note indicated on 5/2/2024 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 “reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one’s sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position.” During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1’s “Progress Notes,” dated 5/3/2024 at 8:00 a.m., was reviewed. The progress notes indicate Patient 1 was “drowsy and lethargic (a symptom that involves an unusual decrease in consciousness); eyes are not open to pain, but pt (Patient 1) is grunting (to make a short, low sound instead of speaking) and moving hands to sternal rub (a technique to test an unconscious person’s responsiveness).” The DMS verified that there was no progress note by any physician that Patient 1 was assessed for a change in condition (drowsy and lethargic, eyes do not open to pain) until 5/3/2024 at 10:59 p.m., when a progress note by MD 1, date of service/time was 5/3/2024 at 10:59 p.m. indicated, “24 hour event: rapid response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to immediately assess and treat the patient) was called on the patient (Patient 1) at approximately 6 p.m. neurologically (the branch of medicine that deals with problems affecting the brain) twitching in all extremities was noted and neurology was called.” During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1’s “Neurological Assessment (evaluates brain and functioning),” dated from 4/24/2024 through 5/3/2024 was reviewed and indicated the following: - On 4/29/2024 at 9:16 p.m. (date of admission to the facility), Patient 1’s level of consciousness (LOC, is a state of awareness, alertness, and wakefulness) was identified as alert. - On 4/30/2024 at 9:08 a.m., Patient 1’s level of consciousness was identified as alert. - On 5/1/2024 at 8:00 a.m., Patient 1’s level of consciousness was identified as alert. - On 5/1/2024 at 10:00 p.m., Patient 1’s level of consciousness was identified as alert. - On 5/2/2024 at 10:15 a.m. (when Patient 1 had an unwitnessed fall [an unplanned change in position where a patient lands on the floor or another lower surface] inside the patient room), Patient 1’s level of consciousness was identified as lethargic (a symptom that involves an unusual decrease in consciousness), marked by confusion (symptoms that involve disruptions in memory, ability to think and focus, awareness), and disorientation (the condition of having lost one’s sense of direction). - On 5/2/2024 at 10:00 p.m., Patient 1’s level of consciousness was identified as lethargic, confusion/disorientation. - On 5/3/2024 at 8:00 a.m., Patient 1’s level of consciousness was identified as lethargic; the right and left pupils are brisk and regular (normal pupil behavior). - On 5/3/2024 at 10:00 p.m. Patient 1’s level of consciousness was identified as obtunded (diminished responsiveness); the right and left pupils are sluggish (abnormalities of pupils’ behavior correlate with an underlying serious problem with brain functioning). During an interview and record review with the DMS on 10/29/2024 at 4:55 p.m. Patient 1’s “Neurological Assessment,” was reviewed. DMS verified that Patient 1 had a condition change. The DMS stated, “The nurse (RN 1) should have notified the doctor and monitored the patient more frequently than every 4 hours.” The DMS verified that the neurological assessment indicated Patient 1’s condition declined from 5/2/2024 at 10:15 a.m. (when Patient 1 fell) and continued to decline, over 24 hours, until 5/3/2024 at 6:00 p.m. when a Rapid Response was called. During a review of Patient 1’s Computed Tomography scan (CT scan, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body’s internal structures), dated 5/3/2024 at 6:31 p.m., the CT scan results indicated, Patient 1 had “Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement).” During a concurrent interview and record review on 10/29/2024 at 4:45 p.m. with the DMS, Patient 1’s “flow sheet (track patient health data over a period of time),” for vitals dated from 5/3/2024 at 8:00 a.m., at 1200 p.m., and at 7:15 p.m., was reviewed. Patient 1’s vital signs (measurements of the body’s most basic functions, such as temperature, pulse rate, respiration rate, and blood pressure) were as follows: On 5/3/2024 at 8:00 a.m., Patient’s 1 blood pressure (BP, measures the blood pushing against the blood vessel walls when the heart beats) was elevated, 179/92. The blood pressure was not addressed. DMS confirmed that PRN (as needed) Hydralazine (prescribed medication used to treat high blood pressure) that was prescribed to administered if the systolic BP (the first number in measurement of the pressure the blood pressure) over 160s, was not given. The DMS verified that the BP was not reassessed until (4 hours later) at 12:00 p.m., when the systolic BP continued to be elevated at 160. The DMS confirmed that the elevated BP was also not addressed at 12 p.m. On 5/3/2024 at 7:15 p.m., Patient 1’s BP increased to 205/100. During an interview and record review with the DMS on 10/29/2024 at 5:00 p.m., Patient 1’s “Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient) Team Assessment” report, was reviewed. The report indicated a rapid response started at 6:13 p.m. on 5/3/2024. The report indicated, Patient 1 was lethargic (a symptom that involves an unusual decrease in consciousness) and with AMS (altered mental status, a change in mental function), CT scan was ordered and confirmed subdural hematoma (a type of bleeding near the brain that can happen after a head injury).” Patient 1 had to be intubated (placing a tube into the patient windpipe to aid in breathing). During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN, nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam) 1, RN 1 stated, on 5/2/2024 at 8:00 a.m., CNA 1 reported that she found Patient 1 on the floor. RN 1 stated on 5/3/2024, he (RN 1) was precepting (provides supervision during clinical practice) for RN 2. RN 1 stated he (RN 1) was responsible to review RN 2’ assessment of Patient 1 and sign off on documentation completed by RN 2. During the same interview on 10/30/2024 at 9:56 a.m. with RN 1, RN 1 further stated that on 5/3/2024 at 8:00 a.m., Patient 1 required a sternal rub (a technique to test an unconscious person’s responsiveness). RN 1 stated a sternal rub was done to apply some pain to see if the patient (Patient 1) would respond. RN 1 confirmed that he (RN 1) was not able to get Patient 1 to respond verbally, Patient 1 was grunting and moving hands. RN 1 stated, “When patient has a condition change, the MD (physician) should have been notified, and a rapid response should be called immediately.” During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN) 2, RN 2 stated, “In the (Medical Surgical) unit, the CNA would take patients’ blood pressure, and the RN will review the BP within an hour.” RN 2 stated when a blood pressure was abnormal, the CNA would inform the RN immediately. RN 2 stated, “I do not recall if the CNA (CNA 1) notified of Patient 1’s blood pressure of 179.” During a concurrent interview and record review on 11/1/2024 at 4:00 p.m. with the Director of Performance Improvement/Risk Manager (DPIQ), the facility’s “Quality Council (a group of senior management within given operational units who plan, implement, facilitate and monitor the quality process)” minutes (an official record of actions the board or committee took at a meeting), dated 6/18/2024, was reviewed. The minutes indicated the presentation was regarding cases that were reported to the California Department of Public Health (CDPH). The first case was in regard to Patient 1 incident. The minutes indicated, “Patient fall resulted hematoma (a collection of blood within the skull) and transferred out for higher level of care. All appropriate documentation was provided to the surveyor. We do not foresee any issues. We identified an issue internally with the care plan and will look into that.” DPIQ stated after the investigation was completed there was identification of a need for rounding. DPIQ confirmed that there was no corrective plan presented in the Quality Council meeting. During a concurrent interview and record review on 11/1/1024 at 5:07 p.m. with the Improvement/Associate Administrator (AA), the facility’s “Governing Board of Directors Meeting Minutes (a log of recording that acts as an official log of corporate deliberations and helps facilitate an organization’s books and obligations)” for July 2024, was reviewed. The AA stated what was presented to the governing body (GB) was the patient fell; there was fall intervention in place, which was a falling star signage and a yellow armband. AA stated what was reported was the “false,” such as there was no fall care plan in place and there was no two times assessment for pain. AA stated we presented the “false,” but did not present the “fixed.” The corrective plan (a document that outlines the steps to address the root cause of a problem) was not presented to the Governing Body. AA stated that the responsibility to assure the incident of delay in care for a subdural hematoma (type of bleeding near the brain that can happen after a head injury) for Patient 1 being identified and thoroughly investigated and that a corrective plan was developed and presented to GB was the responsibility of the Quality Assurance Performance Improvement (QAPI, a data-driven and proactive approach to quality improvement), and the body that had oversight was the GB. During a review of the facility’s policy and procedure (P&P) titled, “Governing Board,” dated September 2023, the P&P indicated, “To state the composition, structure, and membership of the Governing Board of [name of facility] ...The Governing Board identifies those responsible for the provision of care, treatment, and services. The Governing Board is ultimately responsible for the quality of care provided by (Name of the Facility). To fulfill this function the Governing Board assures: Effective functioning of activities related to performance improvement by providing a mechanism which shall be defined in the Performance Improvement Plan ... Risk management functions related to patient care and safety.” During a review of the facility’s “Governing Board of Directors Bylaws of (name of the facility),” dated October 2024, the Bylaws indicated, “The purpose for the establishment and operation of the Board of Directors is to serve as the governing body of the Hospital, and in connection therewith, the Board of Directors shall be responsible for the operation of the Hospital.” 2. During a review of Patient 3’s Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not). During an interview on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ stated the following: On 8/12/2024 at approximately 2:56 a.m., the physical altercation (physical aggression that may or may not result in an injury) between Security Officer 1 (SO 1) and Patient 3 occurred in the facility’s new Emergency Department that was still under construction at the time. SO 1 was working in the new ED at the entrance. Patient 3 tried to rip off the construction barrier on the wall. Patient 3 was agitated (a state of severe restlessness or uneasiness) and got into a verbal altercation (a verbal argument) with SO 1, then Patient 3 spat on SO 1. SO 1 and Patient 3 got into a physical altercation. Patient 3 was taken by staff inside the Emergency Room. The DPIQ validated SO 1 punching Patient 3 to the head (10 times) and that the verbal interactions on facility video between SO 1 and Patient 3 appeared to be a verbal argument prior to the physical altercation. During a concurrent interview and record review on 10/30/2024 at 3:30 p.m. with the Director of Emergency Department (DED), Patient 3’s medical record, was reviewed. The DED verified the following from the medical record: The Medical Screening Exam (MSE, an exam performed by a physician to determine whether a medical condition exist) and physician note were missing from the medical record. There was no notification to the ED Physician from nursing staff about Patient 3’s physical altercation (with SO 1), head laceration (a deep cut or tear in skin or flesh), auditory hallucinations (when someone hears voices or noises that don’t exist in reality) and refusal of medical care. Patient 3 left the facility in the custody of the police without being seen by an ED Physician and without receiving medical clearance (the process of evaluating someone’s health condition to determine if they are fit for a specific activity or procedure) for psychosis or a head injury (post [after] physical assault). During the same interview on 10/30/2024 at 3:30 p.m., the DED stated the following: Patient 3 was seen in the Emergency Department on 8/12/2024 following a physical altercation with a member of facility security staff (SO 1). There should have been a notification from nursing staff to the ED Physician that Patient 3 was having auditory hallucinations, had a head laceration following a physical altercation, and was refusing care. It was important to notify the ED Physician so that patient (Patient 3) could get the appropriate medical care. Patient 3 should not have left without being seen by a physician and being medically cleared for psychosis or a head injury (post physical assault). Nursing staff documented refusal of care, but the ED physician should have documented Patient 3’s refusal to be seen in Patient 3’s medical record. During an interview on 10/31/2024 at 3:22 p.m. with the Emergency Department (ED) Physician, Medical Doctor 4 (MD 4), MD 4 stated the following: After the triage nurse triaged a patient (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) in the ED, the ED physician sees the patient and performs a MSE. A patient who presents with a head laceration, possible danger to others (condition of a person whose behavior or significant threats support a reasonable expectation that there is a substantial risk that he will inflict physical harm upon another person in the near future) and is identified as having auditory hallucinations, must be seen by a physician and must be medically cleared for psychosis or a head injury (post physical assault), by a physician prior to being discharged. During the same interview on 10/31/2024 at 3:22 p.m. with MD 4, MD 4 said a patient presenting with auditory hallucinations should be evaluated by the ED physician to determine a need for a Psychiatric Emergency Team (PET, a team of licensed mental health clinicians) evaluation. When patients are discharged in the custody of the police, the ED Physician must medically clear all patients to ensure they do not have a medical event after they leave the ED. For head trauma, the standard of care treatment is to have a Computed Tomography (CT, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body’s internal structures) scan completed to rule out a brain bleed, because a brain bleed can stop someone from breathing and kill them. During the same interview on 10/31/2024 at 3:22 p.m. with MD 4, MD 4 stated if a patient refuses care, staff notifies the ED physician, and the ED physician must explain and document that the risk and benefits (risks and benefits of healthcare-relevant decisions) have been explained to the patient. Documentation of the MSE or refusal in the MD progress note should be completed within 24 hours of seeing the patient. The ED Physician has the ultimate responsibility for the patient, and the interdisciplinary team (a group of healthcare professionals with various areas of expertise who work together toward the goals of their patients), such as the Charge Nurse or Registered Nurse, should communicate changes or refusals to the ED physician. During a review of Patient 3’s “ED note - Nursing (ED nursing note),” dated 8/12/2024 at 2:45 a.m., the ED nursing note indicated, “patient (Patient 3) was brought in by [staff] in cuffs (a device used to secure a person’s wrists or ankles to limit their movement) into chair in emergency department (ED), patient (Patient 3) was yelling and screaming, threatening all staff and refusing care ... [staff] was able to see cut above [Patient 3’s] left eye, cleaned and dressed with 4 X 4’s dressing (a topical dressing for local management of bleeding wounds such as cuts, lacerations and abrasions) refusing triage and Medical Doctor (MD) exam, vital signs (measurements of the body’s most basic functions, such as temperature, pulse rate, respiration rate, and blood pressure) and other care, kept screaming, in police department custody.” During a review of patient 3’s “ED note - Nursing (ED nursing note),” dated 8/12/2024 at 3:21 a.m., the ED nursing note indicated the following: “Patient (Patient 3) complained of auditory hallucination ... unwitnessed altercation but patient (Patient 3) has laceration above left eye... called [local] police department immediately... police department arrived and took patient into custody.” During an interview on 10/31/2024 at 4:35 p.m. with the DPIQ, the DPIQ stated the following: Once Patient 3 was taken into custody by the police, the facility was unaware of what happened to Patient 3. During an interview on 11/1/2024 at 5:14 p.m. with the Performance Improvement Associate Administrator (AA), the AA stated the following: He (AA) was a Governing Board (a group of people who are legally responsible for the management and direction of an organization) member for the facility. Patient 3’s event was identified as an adverse event (an undesirable medical outcome that occurs in a patient as a result of medical care or treatment). Patient 3’s adverse event was reported to the Governing Board in an emergency meeting. The facility did not keep meeting minutes (a formal written record of a meeting’s discussions, decisions, and actions) for the emergency Governing Board meeting, but there should have been meeting minutes. He (AA) would be responsible for presenting Patient 3’s adverse event Root Cause Analysis (RCA, a structured process for identifying the underlying causes of a problem or event, and then developing solutions to prevent it from happening again) Corrective Action Plan (a document that outlines the steps to address the root cause of a problem) to the Governing Board for approval and that was not done. Patient 3’s adverse event was not discussed or presented during the last Governing Board meeting on October 22, 2024. Adverse events should be brought to the attention of the Governing Board immediately, even if the RCA was not completed. It was important for Patient 3’s adverse event and RCA Corrective Action Plan to be reported to the Governing Board because the Governing Board needs to approve the Corrective Active Plan to ensure it was appropriate. The Governing Board had the ultimate responsibility for patient safety to provide oversight and input as necessary. The AA verified there were no meeting minutes to validate the Governing Board was aware of Patient 3’s adverse event. There was no documentation of the Governing Board’s oversight for Patient 3’s RCA Corrective Action Plan to ensure the RCA Action Plan was appropriate and patient safety was upheld. During a review of the facility’s policy and procedure (P&P) titled, “Physician Notification,” dated 3/2023, the P&P indicated the following: “The physician of record will be notified regarding patient issues in a timely manner ... The physician of record and or hospitalist will be notified of patient’s change in condition.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Right to Refuse Care,” dated 4/2018, the P&P indicated the following: “ ...In the event that a patient refuses care or services, the physician should be notified. it is the physician’s responsibility to explain the consequences of refusal and to present alternatives if any are appropriate ...” During a review of the facility’s policy and procedures (P&P) titled, “Medical Screening Examinations,” dated 2/2020, the P&P indicated the following: “ ...Any patient who presents to [the facility] requesting emergency services is entitled to and will receive a Medical Screening Examination performed by licensed providers for the determination of whether an emergency condition exists .... Emergency Medical Condition: A medical condition manifesting itself by acute (sudden and severe in onset) symptoms of sufficient severity, (including severe pain, psychiatric disturbances and/or symptoms) such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions or serious dysfunction or serious dysfunction of any bodily organ ...” During a review of the facility’s policy and procedures (P&P) titled, “Emergency Department Standards of Practice and Care,” dated 8/2020, the P&P indicated: “ ...Important Aspects of Patient Care: ...E. Assessment and patient needs are communicated to the healthcare provider(s) who is responsible for the care and treatment of the patient: 1. Members of the multidisciplinary team ... 3. Progress/nursing notes ...” During a review of the facility’s policy and procedures (P&P) titled, “Standard of Care Procedures,” dated 10/2020, the P&P indicated: “ ...Procedure: ...M. Head injuries 1. A patient who arrives at the Emergency Department with a head injury will be evaluated for the following care: ...Notify the Emergency Department Physician ...” During a review of the facility’s policy and procedures (P&P) titled, “Triage,” dated 8/2020, the P&P indicated: “...Policy: ...B. Triage assessment and the assignment of an acuity rating do not fulfill the legal requirement of the patient receiving a medical screening examination (MSE) by the physician. C. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires medical screening of individuals seeking emergency care to determine whether an emergency medical condition exists. Stabilization of the patient, to the best of the hospital’s capabilities, is required prior to discharge or transfer ...” During a review of the facility’s policy and procedure (P&P) titled, “Governing Board,” dated September 2023, the P&P indicated, “To state the composition, structure, and membership of the Governing Board of [name of facility] ...The Governing Board identifies those responsible for the provision of care, treatment, and services. The Governing Board is ultimately responsible for the quality of care provided by (Name of the Facility). To fulfill this function the Governing Board assures: Effective functioning of activities related to performance improvement by providing a mechanism which shall be defined in the Performance Improvement Plan ... Risk management functions related to patient care and safety.” During a review of the facility’s “Governing Board of Directors Bylaws of (name of the facility),” dated October 2024, the Bylaws indicated, “The purpose for the establishment and operation of the Board of Directors is to serve as the governing body of the Hospital, and in connection therewith, the Board of Directors shall be responsible for the operation of the Hospital.” 3. During a review of Patient 3’s Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was Registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries), on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not). During an observation and interview on 10/29/2024 at 3:21 p.m. with the Security Officer 3 (SO 3). The SO 3 was observed by the entrance of the Emergency Department (Campus 1) entrance. The SO 3 stated he (SO 3) was employed by the facility for 3 months and he (SO 3) did not receive Crisis Prevention Intervention (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) training. During a concurrent interview and record review on 10/29/2024 at 3:30 p.m. with the Security Officer 2 (SO 2), the SO 2 stated the following: If a patient was agitated (a state of severe restlessness or uneasiness) or aggressive (ready or likely to attack or confront), CPI techniques should be used to de-escalate (reduce the intensity of (a conflict or potentially violent situation) the patient. He (SO 2) was due for a new CPI training. SO 2 verified his (SO 2) CPI card was expired and that the expiration date listed on the CPI card was 2/15/2024. During an interview on 10/29/2024 at 4:05 p.m. with the Security Manager (SM), the SM stated the following: Security Officer staff are required to have CPI training within 60 days of hire, or they are unable to work. If a patient is aggressive, the security staff should not take the patient down [to the floor], they should only physically intervene if facility staff calls for back-up assistance. Security should never physically assault a patient. It is important for staff to be CPI trained to understand proper use of de-escalation techniques and restraints (direct physical contact that prevents or significantly restricts someone’s freedom of movement) when dealing with aggressive or combative (ready or eager to fight) patients. All security staff are required to have CPI training. Security staff must maintain current CPI certification and renew CPI annually. During a review of facility (Campus 1) video footage (no audio) on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement Quality Management (DPIQ), the DPIQ verified the following on the video footage: - At 2:56 a.m. Patient 3 walked into the hallway where Security Officer 1 (SO 1) was posted. No other staff or persons were present. Patient 3 exited the facility doors and entered again and began walking the hallway past SO 1. - At 2:57 a.m., Patient 3 started touching the wall. SO 1 approached Patient 3 and there was a verbal interaction. SO 1 walked with Patient 3 to a corner and Patient 3 was no longer observed on camera. SO 1 followed Patient 3 to the corner and performed multiple kicking motions towards Patient 3’s direction. - At 2:58 a.m., SO 1 and Patient 3 were visibly arguing face to face, less than one arm’s length away. SO 1 pushed Patient 3 away using his (SO 1’s) arm. Patient 3 punched SO 1 and there was a physical altercation (a confrontation, tussle or physical aggression that may or may not result in injury) where SO 1 wrestled (grabbed and pushed using body weight and slammed to the ground) Patient 3 to the ground. SO 1 punched Patient 3 in the face multiple times (using blunt force with SO 1’s right first), while Patient 3 was on the floor with SO 1 restraining him (Patient 3) by placing his (SO 1’s) body weight on Patient 3. There was blood on the floor. - At 2:59 a.m., Patient 3 remained restrained on the floor by SO 1, with SO 1’s knee on patient 3’s lower body and arm on Patient 3’s upper body. SO 1 removed hand cuffs from pocket to apply to Patient 3. During an interview on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ stated the following: The physical altercation between SO 1 and Patient 3 occurred 8/12/2024 in the facility’s new Emergency Department (ED) that was still under construction at the time. SO 1 was working in the new ED at the entrance. Patient 3 tried to rip off the construction barrier on the wall. Patient 3 was agitated and got into a verbal altercation (a verbal argument) with SO 1, then Patient 3 spat at SO 1. SO 1 and Patient 3 got into a physical altercation. The DPIQ validated the punching by SO1 on Patient 3 and that the verbal interactions on facility video between SO 1 and Patient 3 appeared to be an argument prior to the physical altercation. During an interview on 10/30/2024 at 2:11 p.m. with the Security Manager (SM), the SM stated the following: On 8/12/2024, SO 1 and Patient 3 were involved in a physical altercation. Patient 3 was agitated, pulling things off the wall and SO 1 intervened aggressively. SO 1 started kicking Patient 3. Patient 3 was in SO 1’s face and punched him (SO 1). SO 1 tackled Patient 3 to the ground then punched him (Patient 3) multiple times in the face. SO 1 was at fault for the physical altercation (a confrontation, tussle or physical aggression that may or may not result in injury) and physically assaulting Patient 3. SO 1 did not follow CPI guidelines. SO 1 should have made attempts to de-escalate Patient 3. SO 1 should not have placed Patient 3 in handcuffs, this was not CPI protocol. SO 1 should have called for back-up on the radio (provided to all security staff) or called a code gray (a hospital emergency response that indicates a dangerous or combative person in the hospital, or criminal activity), when Patient 1 was agitated and combative. It was staff to patient abuse when SO 1 tackled Patient 3 to the floor and punched him (Patient 3) in the face. Following the facility investigation which started 8/12/2024, SO 1 was suspended at the start of the next shift at 3:30 p.m. SO 1 did not return to work and was terminated for not utilizing proper CPI techniques, when SO 1 did not de-escalate Patient 3 and physically abused Patient 3. During a concurrent interview and record review on 10/30/2024 at 5:21 p.m. with the DPIQ, the DPIQ verified the following: SO 1’s CPI card expired 7/5/2023. SO 1 was a Lead Security Officer. There is no CPI policy. The DPIQ provided a booklet titled “Crisis Prevention Institute: Non-violent Crisis Intervention Training.” During an interview on 11/1/2024 at 5:14 p.m. with the Performance Improvement Associate Administrator (AA), the AA stated the following: He (AA) was a Governing Board (a group of people who are legally responsible for the management and direction of an organization) member for the facility. Patient 3’s event was identified as an adverse event (an undesirable medical outcome that occurs in a patient as a result of medical care or treatment). Patient 3’s adverse event was reported to the Governing Board in an emergency meeting. The facility did not keep meeting minutes (a formal written record of a meeting’s discussions, decisions, and actions) for the emergency Governing Board meeting, but there should have been meeting minutes. He (AA) would be responsible for presenting Patient 3’s adverse event Root Cause Analysis (RCA, a structured process for identifying the underlying causes of a problem or event, and then developing solutions to prevent it from happening again) Corrective Action Plan (a document that outlines the steps to address the root cause of a problem) to the Governing Board for approval and that was not done. Patient 3’s adverse event was not discussed or presented during the last Governing Board meeting on October 22, 2024. Adverse events should be brought to the attention of the Governing Board immediately, even if the RCA was not completed. It was important for Patient 3’s adverse event and RCA Corrective Action Plan to be reported to the Governing Board because the Governing Board needs to approve the Corrective Active Plan to ensure it is appropriate. The Governing Board had the ultimate responsibility for patient safety to provide oversight and input as necessary. The AA verified there were no meeting minutes to validate the Governing Board was aware of Patient 3’s adverse event. There was no documentation of the Governing Board’s oversight for Patient 3’s RCA Corrective Action Plan to ensure the RCA Action Plan was appropriate and patient safety was upheld. During a review of Patient 3’s “Emergency Documentation,” dated 8/12/2024 at 3:21 a.m., the Emergency Documentation indicated: “patient was having auditory hallucinations (when someone hears voices or noises that don’t exist in reality) ...unwitnessed altercation but patient (3) has laceration (a deep cut or tear in skin or flesh) above left eye ... [SO 1] placed patient (3) in cuffs ...” During a review of the document provided by the facility titled, “Position description: Security Officer,” no date, the document indicated the following: “ ...Qualifications: Must complete CPI within 60 days of hire ...” During a review of the document provided by the facility titled, “Position description: Lead Security Officer,” no date, indicated the following: “ ...Qualifications: Must complete CPI within 60 days of hire ...” During a review of the booklet provided by the facility titled “Crisis Prevention Institute: Non-violent Crisis Intervention Training,” no date, the booklet indicated the following: “Manage your own emotional responses to distress behavior; Use the Decision Making Matrix in the moment of Risk Behavior to determine Safety Interventions that represent a reasonable, proportionate, least restrictive, and last resort course of action; Use safety intervention strategies to maximize safety and minimize harm to self or others ...” During a review of the facility’s policy and procedures (P&P) titled, “Management of Violent Patients,” dated 5/2022, the P&P indicated the following: “ ...IV. Procedure: A. Utilizing current Assault Prevention Techniques/Training, any or all of the following measures may be taken: ...b. Conditions which may lead to violence: ...vi. Psychiatric Disorders (a mental illness that involves significant changes in a person’s thoughts, emotions, or behaviors that are difficult to control) ... 2. a. ...vii. Staff should alert hospital security as soon as possible of anytime a patient starts to escalate (becomes more intense or serious) or becomes violent. b. Patients who are agitated but cooperative may be amendable to verbal de-escalation techniques: i. Respect personal space- Maintain a distance of two arm’s lengths and provide personal space for easy exit for either party; ii. Do not be provocative- Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient ...” During a review of the facility’s policy and procedure (P&P) titled, “Assaultive Behavior,” dated 10/2021, the P&P indicated the following: “ ...D. A patient who strikes at or actually strikes another person, including patients, visitors or staff, will be assessed for seclusion and/or restraints. A Code Gray must be called, to secure additional assistance, if needed ...” During a review of the facility’s policy and procedure (P&P) titled, “Code Gray,” dated 10/2021, the P&P indicated the following: “ ...A. In the event of a psychiatric emergency (defined as an aggressive patient who does not respond to verbal limits and/or is posing a safety risk) the charge nurse will be alerted. She/he will make the determination whether a Code Gray is to be paged ...” During a review of the facility’s policy and procedures (P&P) titled, “Employee File Requirements,” dated 11/2022, the P&P indicated the following: “ ...All staff whose job description requires Crisis Prevention and Intervention (CPI) must complete the recertification training no later than the end of the month in which it expires. New hires have 60 days from the date of hire to complete the training ...” During a review of the facility’s policy and procedure (P&P) titled, “Governing Board,” dated September 2023, the P&P indicated, “To state the composition, structure, and membership of the Governing Board of [name of facility] ...The Governing Board identifies those responsible for the provision of care, treatment, and services. The Governing Board is ultimately responsible for the quality of care provided by (Name of the Facility). To fulfill this function the Governing Board assures: Effective functioning of activities related to performance improvement by providing a mechanism which shall be defined in the Performance Improvement Plan ... Risk management functions related to patient care and safety.” During a review of the facility’s “Governing Board of Directors Bylaws of (name of the facility),” dated October 2024, the Bylaws indicated, “The purpose for the establishment and operation of the Board of Directors is to serve as the governing body of the Hospital, and in connection therewith, the Board of Directors shall be responsible for the operation of the Hospital.””

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 46333 Based on interview and record review, the Governing Body failed to ensure patient care and services rendered under contract with an outside entity (Security Services) were provided in a safe and effective manner, for one of 30 sampled patients (Patients 3), when: 1. The facility failed to protect Patient 3 from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) from contracted service from the security guard (SO)1. This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh). 2.a. The facility allowed contracted staff to continue to work at the facility despite one Security guard (SO3) not having received CPI (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) training, and two security guards (SO 1 and SO 2’s) with expired CPI training. This deficient practice resulted in SO 1 not using appropriate de-escalation technique (methods used to reduce the intensity of a volatile situation) and punched Patient 3 ten time in the face resulting in Patient 3’s injury. This deficient practice also had the potential for SO 2 and SO 3 to forget how to use a safe and appropriate de-escalation technique, which may result in other physical altercations with patients that may lead to patient abuse. 2.b. The facility failed to ensure the Security Services, a contracted service (a service that is performed by an independent contractor or service provider, under a formal, legally binding agreement), had a valid and un-expired contract agreement to provide and maintain a safe care environment in the facility. This deficient practice had the potential for the contracted security services staff to not uphold their job requirements and responsibilities as required by the facility, placing the patients at risk for an unsafe care environment. Findings: 1. During a review of Patient 3’s Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was Registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries), on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not). During a concurrent interview and record review on 10/29/2024 at 3:30 p.m. with the Security Officer 2 (SO 2), the SO 2 stated the following: If a patient was agitated (a state of severe restlessness or uneasiness) or aggressive (ready or likely to attack or confront), CPI techniques should be used to de-escalate (reduce the intensity of a conflict or potentially violent situation) the patient. During an interview on 10/29/2024 at 4:05 p.m. with the Security Manager (SM), the SM stated the following: Security Officer staff are required to have CPI training within 60 days of hire, or they are unable to work. If a patient is aggressive, the security staff should not take the patient down [to the floor], they should only physically intervene if facility staff calls for back-up assistance. Security should never physically assault a patient. It is important for staff to be CPI trained to understand proper use of de-escalation techniques and restraints (direct physical contact that prevents or significantly restricts someone’s freedom of movement) when dealing with aggressive or combative (ready or eager to fight) patients. All security staff are required to have CPI training. Security staff must maintain a current CPI certification and renew CPI annually. During a review of facility (Campus 1) video footage (no audio) on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement Quality Management (DPIQ), the DPIQ verified the following on the video footage: - At 2:56 a.m. Patient 3 walked into the hallway where Security Officer 1 (SO 1) was posted. No other staff or persons were present. Patient 3 exited the facility doors and entered again and began walking the hallway past SO 1. - At 2:57 a.m., Patient 3 started touching the wall. SO 1 approached Patient 3 and there was a verbal interaction. SO 1 walked with Patient 3 to a corner and Patient 3 was no longer observed on camera. SO 1 followed Patient 3 to the corner and performed multiple kicking motions towards Patient 3’s direction. - At 2:58 a.m., SO 1 and Patient 3 were visibly arguing face to face, less than one arm’s length away. SO 1 pushed Patient 3 away using his (SO 1’s) arm. Patient 3 punched SO 1 and there was a physical altercation where SO 1 wrestled (grabbed and pushed using body weight and slammed to the ground) Patient 3 to the ground. SO 1 punched Patient 3 in the face multiple times (using blunt force with SO 1’s right first), while Patient 3 was on the floor with SO 1 restraining him (Patient 3) by placing his (SO 1’s) body weight on Patient 3. There was blood on the floor. - At 2:59 a.m., Patient 3 remained restrained on the floor by SO 1, with SO 1’s knee on patient 3’s lower body and arm on Patient 3’s upper body. SO 1 removed hand cuffs from pocket to apply to Patient 3. During an interview on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ validated the punching by SO1 on Patient 3 and that the verbal interactions on facility video between SO 1 and Patient 3 appeared to be an argument prior to the physical altercation. During an interview on 10/30/2024 at 2:11 p.m. with the Security Manager (SM), the SM stated the following: On 8/12/2024, SO 1 and Patient 3 were involved in a physical altercation. Patient 3 was agitated, pulling things off the wall and SO 1 intervened aggressively. SO 1 started kicking Patient 3. Patient 3 was in SO 1’s face and punched him (SO 1). SO 1 tackled Patient 3 to the ground then punched him (Patient 3) multiple times in the face. SO 1 was at fault for the physical altercation (a confrontation, tussle or physical aggression that may or may not result in injury) and physically assaulting Patient 3. SO 1 did not follow CPI guidelines. SO 1 should have made attempts to de-escalate Patient 3. SO 1 should not have placed Patient 3 in handcuffs, this is not CPI protocol. SO 1 should have called for back-up on the radio (provided to all security staff) or called a code gray (a hospital emergency response that indicates a dangerous or combative person in the hospital, or criminal activity), when Patient 1 was agitated and combative. It was staff to patient abuse when SO 1 tackled Patient 3 to the floor and punched him (Patient 3) in the face. Following the facility investigation which started 8/12/2024, SO 1 was suspended at the start of the next shift at 3:30 p.m. SO 1 did not return to work and was terminated for not utilizing proper CPI techniques, when SO 1 did not de-escalate Patient 3 and physically abused Patient 3. During a review of the facility’s policy and procedures (P&P) titled, “Management of Violent Patients,” dated 5/2022, the P&P indicated the following: “ ...IV. Procedure: A. Utilizing current Assault Prevention Techniques/Training, any or all of the following measures may be taken: ...b. Conditions which may lead to violence: ...vi. Psychiatric Disorders (a mental illness that involves significant changes in a person’s thoughts, emotions, or behaviors that are difficult to control) ... 2. a. ...vii. Staff should alert hospital security as soon as possible of anytime a patient starts to escalate (becomes more intense or serious) or becomes violent. b. Patients who are agitated but cooperative may be amendable to verbal de-escalation techniques: i. Respect personal space- Maintain a distance of two arm’s lengths and provide personal space for easy exit for either party; ii. Do not be provocative- Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient ...” During a review of the facility’s policy and procedure (P&P) titled, “Assaultive Behavior,” dated 10/2021, the P&P indicated the following: “ ...D. A patient who strikes at or actually strikes another person, including patients, visitors or staff, will be assessed for seclusion and/or restraints. A Code Gray must be called, to secure additional assistance, if needed ...” During a review of the facility’s policy and procedure (P&P) titled, “Code Gray,” dated 10/2021, the P&P indicated the following: “ ...A. In the event of a psychiatric emergency (defined as an aggressive patient who does not respond to verbal limits and/or is posing a safety risk) the charge nurse will be alerted. She/he will make the determination whether a Code Gray is to be paged ...” During a review of the facility’s policy and procedure (P&P) titled, “Governing Board,” dated September 2023, the P&P indicated, “To state the composition, structure, and membership of the Governing Board of [name of facility] ...The Governing Board identifies those responsible for the provision of care, treatment, and services. The Governing Board is ultimately responsible for the quality of care provided by (Name of the Facility). To fulfill this function the Governing Board assures: Effective functioning of activities related to performance improvement by providing a mechanism which shall be defined in the Performance Improvement Plan ... Risk management functions related to patient care and safety.” During a review of the facility’s “Governing Board of Directors Bylaws of (name of the facility),” dated October 2024, the Bylaws indicated, “The purpose for the establishment and operation of the Board of Directors is to serve as the governing body of the Hospital, and in connection therewith, the Board of Directors shall be responsible for the operation of the Hospital.” 2.a. During a review of Patient 3’s “Emergency Documentation,” dated 8/12/2024 at 3:21 a.m., the Emergency Documentation indicated: “patient (Patient 3) was having auditory hallucinations ...unwitnessed altercation but patient (3) has laceration (a deep cut or tear in skin or flesh) above left eye ... [SO 1] placed patient (3) in cuffs ...” During a concurrent interview and record review on 10/30/2024 at 5:21 p.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ verified the following: SO 1’s Crisis Prevention Intervention (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) card expired 7/5/2023. SO 2’s CPI card expired 2/15/2024 and renewed 10/30/2024 (after the survey team identified SO 2 was working without CPI training on 10/29/2024). SO 3 was a new hire (hired 7/1/2024) working without CPI training on 10/29/2024. The DPIQ stated the following: CPI for security staff should be completed within 60 days of hire and maintained per policy. SO 1 was a Lead Security Officer. There was no CPI policy. The DPIQ provided a booklet titled “Crisis Prevention Institute: Non-violent Crisis Intervention Training.” During a review of the document provided by the facility titled, “Position description: Security Officer,” no date, the document indicated the following: “ ...Qualifications: Must complete CPI within 60 days of hire ...” During a review of the document provided by the facility titled, “Position description: Lead Security Officer,” no date, the document indicated the following: “ ...Qualifications: Must complete CPI within 60 days of hire ...” During a review of the booklet provided by the facility titled “Crisis Prevention Institute: Non-violent Crisis Intervention Training,” no date, the Booklet indicated the following: “Manage your own emotional responses to distress behavior; Use the Decision Making Matrix in the moment of Risk Behavior to determine Safety Interventions that represent a reasonable, proportionate, least restrictive, and last resort course of action; Use safety intervention strategies to maximize safety and minimize harm to self or others ...” During a review of the facility’s policy and procedures (P&P) titled, “Management of Violent Patients,” dated 5/2022, the P&P indicated the following: “ ...IV. Procedure: A. Utilizing current Assault Prevention Techniques/Training, any or all of the following measures may be taken: ...b. Conditions which may lead to violence: ...vi. Psychiatric Disorders (a mental illness that involves significant changes in a person’s thoughts, emotions, or behaviors that are difficult to control) ... 2. a. ...vii. Staff should alert hospital security as soon as possible of anytime a patient starts to escalate (becomes more intense or serious) or becomes violent. b. Patients who are agitated but cooperative may be amendable to verbal de-escalation techniques: i. Respect personal space- Maintain a distance of two arm’s lengths and provide personal space for easy exit for either party; ii. Do not be provocative- Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient ...” During a review of the facility’s policy and procedure (P&P) titled, “Assaultive Behavior,” dated 10/2021, the P&P indicated the following: “ ...D. A patient who strikes at or actually strikes another person, including patients, visitors or staff, will be assessed for seclusion and/or restraints. A Code Gray must be called, to secure additional assistance, if needed ...” During a review of the facility’s policy and procedure (P&P) titled, “Code Gray,” dated 10/2021, the P&P indicated the following: “ ...A. In the event of a psychiatric emergency (defined as an aggressive patient who does not respond to verbal limits and/or is posing a safety risk) the charge nurse will be alerted. She/he will make the determination whether a Code Gray is to be paged ...” During a review of the facility’s policy and procedure (P&P) titled, “Employee File Requirements,” dated 11/2022, the P&P indicated the following: “ ...All staff whose job description requires Crisis Prevention and Intervention (CPI) must complete the recertification training no later than the end of the month in which it expires. New hires have 60 days from the date of hire to complete the training ...” During a review of the facility’s policy and procedure (P&P) titled, “Governing Board,” dated September 2023, the P&P indicated, “To state the composition, structure, and membership of the Governing Board of [name of facility] ...The Governing Board identifies those responsible for the provision of care, treatment, and services. The Governing Board is ultimately responsible for the quality of care provided by (Name of the Facility). To fulfill this function the Governing Board assures: Effective functioning of activities related to performance improvement by providing a mechanism which shall be defined in the Performance Improvement Plan ... Risk management functions related to patient care and safety.” During a review of the facility’s “Governing Board of Directors Bylaws of (name of the facility),” dated October 2024, the Bylaws indicated, “The purpose for the establishment and operation of the Board of Directors is to serve as the governing body of the Hospital, and in connection therewith, the Board of Directors shall be responsible for the operation of the Hospital.” 2.b. During a concurrent interview and record review on 11/1/2024 at 10:45 a.m. with Executive Director of Human Resources (HRD), the HRD stated Security Officer 3 (SO 3) was a contracted employee with a hire date of 7/1/2024. The HRD stated SO 3’s job description (a written document that outlines the responsibilities and qualifications for a job position) was not in the employee’s file. During a concurrent interview and record review, on 11/1/2024 at 11:13 a.m., with the HRD, the HRD stated SO 2 was a contracted employee with a hire date of 1/6/2023. The HRD stated SO 2’s job description was not in the employee’s file. During a concurrent interview and record review on 11/1/2024 at 12:16 p.m. with the HRD, the HRD provided the “Security Service Agreement,” Contract with a start of service date on 1/15/2020, and a termination date of 12/31/2023. The HRD stated “that is the last contract we have on file.” The HRD verified that the security service agreement contract was expired since 12/31/2023. During a concurrent interview on 11/1/2024 at 12:53 p.m. with the Director of Performance Improvement/Risk Manager (DPIQ), the DPIQ stated the Executive Director of Support Services (EDSS) was responsible in reviewing the security contract. During an interview on 11/1/2024 at 2:50 p.m. with the HRD, the HRD confirmed SO 2 and SO 3 did not have the security officer job description. During an interview on 11/1/2024 at 5:40 p.m. with the Performance Improvement Associate Administrator (AA), the AA stated the facility’s Governing Body (GB) had the ultimate responsibility and authority in the hospital including oversight of contracted services. The AA stated it was important to have a valid contract with the contracted services (Security Services) to ensure there was accountability in providing patient safety. The AA stated the facility’s GB had oversight regarding ensuring there was no expired Security Services contract because providing patient safety was their responsibility. During a concurrent interview and record review on 11/1/2024 at 7:16 p.m. with the Executive Director of Human Resources (HRD), HRD stated the importance of having the job description for the contracted security officers in the HR records was to have a list of the expectations, responsibilities, obligations of the contracted security staff. HRD stated it was important to know the role that the security officer will be performing in the facility under the terms of the contractual agreement. During a review of the facility’s policy and procedure (P&P) titled, “Organizational Performance Improvement Plan,” reviewed on 04/2024, the P&P indicated, “The organizational program, established by the medical staff, with support and approval from the Governing Board, has the responsibility for monitoring every aspect of patient care and service (including contracted services), from the time the patient enters the hospital through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes ...” During a review of the facility’s policy and procedure (P&P) titled, “Independent Contractors and Contracting Arrangements,” revised on 08/2020, the P&P indicated, “Purpose to ensure that all independent contractors and employees of contractors who perform duties within [Name of the facility] are qualified to perform such duties; are consistently performing in a competent manner; ...1. Description of duties. 2. Current licensure and Certification... 4. Resume documenting experience to perform duties. 5. Attendance document from General Hospital Orientation and if appropriate, annual re-orientation. 6. 90 day and annual evaluation of performance done by contracting [name of facility] manager .... Companies that provide labor within [Name of Facility] are required to keep the above records for review at any time by [name of facility] or regulatory agency, except for insurance certificates that are kept in Administration. All required documentation must be current. Failure to provide current licensure or certification will result in immediate suspension of the contract pending investigation... No employee of a contracting company may perform duties for which they do not have current proof of competency ... [Name of facility] reviews all contracting company’s employee records performing duties at [name of facility] on an annual basis. Representative of [name of Facility] may review contracting company’s records at any time with or without notice.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to: 1. Ensure the staff removed a ligature (a thing used for tying) risk item for one of 30 sampled patients (Patient 9) accordance with the facility’s policy and procedure regarding contrabands (any item that is prohibited or could be dangerous to patients, staff or visitors. Example: Belts and shoelaces), when Patient 9 was allowed to wear a sweater with a drawstring in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders). This deficient practice resulted in putting Patient 9 and other patients in an unsafe environment when the drawstring (considered as a contraband) could be used to harm self or others. 2. Ensure one of 30 sampled patients (Patient 20), who was at risk for suicide (a mental state in which it is likely that a person will try to end their own life), was monitored every 15 minutes, in accordance with the facility’s policy and procedure regarding rounding (visit patients to assess their needs, review their care, and ensure safety) on and monitoring patients. This deficient practice had the potential to result in an unsafe care due to lack of purposeful rounding, which may lead to Patient 20 harming self that could cause injury and/or death. Findings: 1. During a review of Patient 9’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 10/24/2024, the Psych Eval indicated, Patient 9 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] evaluation and treatment) due to being gravely disabled (inability to care self) with admitting diagnosis of paranoid schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). The Psych Eval also indicated Patient 9 had auditory (hearing) hallucinations (when someone hears voices or noises that don’t exist in reality) of evil voices commanding her (Patient 9) to kill someone. During a concurrent observation and interview on 10/30/2024 at 9:07 a.m. with the Charge Nurse (CN) 4 of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) in Patient 9’s room, Patient 9 was observed lying in bed wearing a white sweater. There was a drawstring on the hood of Patient 9’s white sweater. CN 4 stated Patient 9 should not have any clothing with drawstring in it because it was dangerous. CN 4 stated drawstring was not allowed in the BHU because it would pose a ligature (a thing used for tying or binding tightly) risk on patients. During a concurrent interview and record review on 10/30/2024 at 9:39 a.m. with the Registered Nurse (RN) 7, Patient 9’s “Patient Valuables/ Belongings (belongings list, inventory of a patient’s belongings brought to the hospital),” dated 10/24/2024, was reviewed. The belongings list indicated, “clothing description with white sweater, grey graphic tee, and cheetah pants.” RN 7 stated staff would look for any drawstring or any items on patient’s clothing upon admission that could possibly pose a risk for harm. RN 7 stated if there was drawstring on the clothing, the drawstring should be cut or removed from the unit and kept in the contraband room. RN 7 stated, “Drawstring was a definite ‘No’ on the floor because of the ligature risk.” During an interview on 11/1/2024 at 9:35 a.m. with the Nurse Manager (NM) 1 of Behavioral Health Unit, NM 1 stated drawstring on clothing was considered as contraband (prohibited items) and it was a ligature risk because patients could use the drawstring to harm self or others. During a review of the facility’s policy and procedure (P&P) titled, “Identification and Securing of Contraband,” dated 5/2021, the P&P indicated, “To preserve the safety of patients, employees and visitors of the hospital by identifying and preventing prohibited items (contraband) from entering the hospital facilities ... What to do with contraband: immediately dispose, place in personal vehicle of patient/visitor or place in [facility] locker. Identified contraband will not be allowed to be brought into the facility ... hanging risk (ropes, electrical wires ...string/rope/cord longer than eight inches).” 2. During a review of Patient 20’s “Consultation Report,” dated 10/29/2024, the report indicated Patient 20 was admitted to the facility with a diagnosis of Suicidal ideation (a mental state in which it is likely that a person will try to end their own life or feeling that people would be better off without them). During a review of Patient 20’s “Columbia-Suicide Severity Rating Scale (CSSRS, a suicidal ideation and behavior rating scale intended to help establish a person’s immediate risk of suicide.),” dated 10/29/2024, Patient 20’s CSSRS indicated Patient 20 had a low suicidal risk. During an interview on 10/29/2024 at 2:06 p.m. with Charge Nurse 3 (CN 3), CN 3 stated the patients that were admitted in the Behavioral Health Unit (BHU, a specialize unit that provides services for people with mental health) would be monitored every 15 minutes. CN 3 said the Behavioral Health Worker (BHW) would do patient rounding (visit patients to assess their needs, review their care, and ensure safety) every 15 minutes and would document the patient’s location and the patient’s behavior observed during the patient rounding. During an interview on 10/30/2024 at 9:09 a.m. with Mental Health Worker 1 (MHW 1 [also known as BHW]), MHW 1 stated, “Rounds (patient rounding) are every 15 minutes.” MHW 1 stated they document the location and behavior of the patient. MHW 1 stated hazards (example: contrabands such as shoelaces, belts, etc.) in the room that could harm the patient were being checked too during the patient’s rounding. During a concurrent interview and record review on 10/31/2024 at 11:46 a.m. with Nurse Manager 1 (NM 1), NM 1 verified Patient 20 had a physician’s order, dated 10/29/2024 at 4:33 pm, for 15 minutes rounding monitoring for suicide, harm to self. During a concurrent interview and record review on 10/31/2024 at 11:55 a.m. with Nurse Manager 1 (NM 1), NM 1 verified Patient 20’s “Individual Observation Record,” had missed documentation of patient rounding every 15 minutes on the following dates and times: -Patient 20 was monitored on 10/29/2024 at 5:02 p.m., the next monitoring was at 5:29 pm (a total of 27 minutes since Patient 20 was last seen); -Patient 20 was monitored on 10/30/2024 at 12:00 a.m., the next monitoring was at 12:29 a.m. (a total of 29 minutes since Patient 20 was last seen); -Patient 20 was monitored on 10/30/2024 at 5:31 a.m., the next monitoring was at 5:59 a.m. (a total of 28 minutes since Patient 20 was last seen); -Patient 20 was monitored on 10/30/24 at 3:05 a.m., the next monitoring was at 3:29 a.m. (a total of 24 minutes since Patient 20 was last seen); -Patient 20 was monitored on 10/30/2024 at 2:00 p.m., the next monitoring was at 2:28 p.m. (a total of 28 minutes since Patient 20 was last seen); - Patient 20 was monitored on 10/31/2024 at 12:34 a.m., the next monitoring was at 12:59 a.m. (a total of 25 minutes since Patient 20 was last seen); -Patient 20 was monitored on 10/31/2024 at 3:01 a.m., the next monitoring was at 3:29 a.m. (a total of 28 minutes since Patient 20 was last seen); and, -Patient 20 was monitored on 10/31/2024 at 8:59 a.m., the next monitoring was at 9:29 a.m. (a total of 30 minutes since Patient 20 was last seen). During the same interview on 10/31/2024 at 11:55 a.m. with Nurse Manager (NM) 1, NM 1 stated patient rounding every 15 minutes was important to monitor for patient safety. NM 1 stated, “Anything can happen in 15 minutes, patient can hurt the roommate, spontaneously die, make weapons ...It is important to check for patient’s chest rise and fall, location, and demeanor.” NM 1 said the BHW were responsible for doing the 15-minute patient rounding and documenting the rounds. NM 1 stated when a patient needs further intervention the RN would assess the patient. During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 10/2021, the P&P indicated the following: - “It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety.” - “The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment.” - “Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes.” - “All patients on the BHU are at a minimum under standard observation.””

“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: 48186 Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 3) was free from abuse (the improper treatment of a person), when Patient 3 was physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff. This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh) above the left eye. On 10/31/2024 at 1:07 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Performance Improvement and Quality Management (DPIQ), Associate Administrator (AA), the Chief Nursing Officer (CNO), and the Chief Executive Officer (CEO). The facility was informed that facility nursing staff failed to ensure Patient 3 was free from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Security Officer 1 (SO 1) physically assaulted (physical attack that causes physical harm/injury) Patient 3. Patient 3 suffered a left eye laceration (post [after] assault) and had to be treated in the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries). SO 1 did not follow hospital policy, when Crisis Prevention and Intervention Program (CPI, strategies for de-escalating [reduce the intensity] violent, hostile [aggressive], or anxious [feeling of fear or uneasiness] behavior) techniques were not used to de-escalate Patient 3 who was agitated (a feeling of irritability or severe restlessness). Additionally, SO 1 did not have an active CPI Certification at the time of Patient 3’s physical assault by SO 1, as required per hospital policy. On 11/1/2024 at 6:05 p.m., the facility submitted an acceptable Immediate Jeopardy Removal Plan (IJRP, includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The IJRP included the following: 1. Memorandum to all staff A memorandum addressing the critical importance of maintaining Crisis Prevention and Intervention (CPI) certification for all staff. Any lapse in CPI certification will result in immediate suspension until recertification is completed. Directors have been instructed to monitor and verify the certification status of their team members to ensure compliance and minimize operational disruptions. 2. Suspension of all staff who have direct interaction with patients Effective 11/01/2024, any staff member with an expired CPI certification will be placed on immediate suspension until they complete recertification. To facilitate this, additional CPI training session have been scheduled for the upcoming week alongside the regular scheduled CPI training sessions. These extra training sessions will ensure ample opportunity for all staff who needed recertification to fulfill this requirement. 3. Immediate Education on De-escalation Techniques Education immediately commenced on 11/01/2024 for hospital staff. Education will continue daily for staff until all scheduled staff have been trained. The following topics were included in the training: A. Behaviors that may indicate or pose a threat to the safety of staff, other patients and visitors include: - Provocative behavior (intended to cause a reaction such as anger or annoyance) - Angry demeanor - Loud, aggressive speech - Tense posturing (e.g., gripping arm rails tightly, clenching fists) - Frequently changing body position, pacing - Aggressive acts (e.g., pounding walls, throwing objects, hitting oneself) - Staff should alert hospital security as soon as possible of anytime a patient starts to escalate or becomes violent. B. De-escalation techniques include: - Respect personal space-Maintain a distance of two arm’s lengths and provide space for easy exit for either party. - Do not be provocative - Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient. - Establish Verbal contact -The first person to contact the patient should be the leader. - Speak slowly and calmly. - Use concise, simple language - elaborate and technical terms are hard for an impaired person to understand. - Identify feelings and desires -“What are you hoping for?” - Listen closely to what the patient is saying-After listening, restate what the patient said to improve mutual understanding (e.g., “tell me if I have this right ... “). - Agree or agree to disagree -(a) agree with clear specific truths; (b) agree in general: “Yes, everyone should be treated respectfully”; (c) agree with minority situations: “There are others who would feel like you.” C. If the patient is assaultive and presenting a physical danger, do not fight the patient and seek safe shelter. Immediately call for help (code grey) or by yelling for staff and/or dialing 3111. When a safe number of staff are present and if less restrictive means are ineffective (verbal de-escalation), as decided by the lead RN, or physician, staff will swarm the patient and each will work to restrain (to limit the movement of a patient to keep them safe or prevent them from harming others) the patient utilizing CPI techniques. On 11/1/2024 at 9:44 p.m., the IJ was removed, in the presence of the DPIQ, the AA, and the CNO, after the elements of the IJRP were verified onsite, by the survey team, through observation, interviews and record reviews. Findings: During a review of Patient 3’s Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was Registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries), on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not). During an observation and interview on 10/29/2024 at 3:21 p.m. with the Security Officer 3 (SO 3). The SO 3 was observed by the entrance of the Emergency Department (Campus 1) entrance. The SO 3 stated he (SO 3) was employed by the facility for 3 months and he (SO 3) did not receive Crisis Prevention Intervention (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) training. During a concurrent interview and record review on 10/29/2024 at 3:30 p.m. with the Security Officer 2 (SO 2), the SO 2 stated the following: If a patient was agitated (a state of severe restlessness or uneasiness) or aggressive (ready or likely to attack or confront), CPI techniques should be used to de-escalate (reduce the intensity of (a conflict or potentially violent situation) the patient. He (SO 2) was due for a new CPI training. SO 2 verified his (SO 2) CPI card was expired and that the expiration date listed on the CPI card was 2/15/2024. During an interview on 10/29/2024 at 4:05 p.m. with the Security Manager (SM), the SM stated the following: Security Officer staff were required to have CPI training within 60 days of hire, or they were unable to work. If a patient was aggressive, the security staff should not take the patient down [to the floor], they should only physically intervene if facility staff called for back-up assistance. Security should never physically assault a patient. It was important for staff to be CPI trained to understand proper use of de-escalation techniques and restraints (direct physical contact that prevents or significantly restricts someone’s freedom of movement) when dealing with aggressive or combative (ready or eager to fight) patients. All security staff were required to have CPI training. Security staff must maintain current CPI certification and renew CPI annually. During a review of facility (Campus 1) video footage (no audio) on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement Quality Management (DPIQ), the DPIQ verified the following on the video footage: At 2:56 a.m. Patient 3 walked into the hallway where Security Officer 1 (SO 1) was posted. No other staff or persons were present. Patient 3 exited the facility doors and entered again and began walking the hallway past SO 1. - At 2:57 a.m., Patient 3 started touching the wall. SO 1 approached Patient 3 and there was a verbal interaction. SO 1 walked with Patient 3 to a corner and Patient 3 was no longer observed on camera. SO 1 followed Patient 3 to the corner and performed multiple kicking motions towards Patient 3’s direction. - At 2:58 a.m., SO 1 and Patient 3 were visibly arguing face to face, less than one arm’s length away. SO 1 pushed Patient 3 away using his (SO 1’s) arm. Patient 3 punched SO 1 and there was a physical altercation where SO 1 wrestled (grabbed and pushed using body weight and slammed to the ground) Patient 3 to the ground. SO 1 punched Patient 3 in the face multiple times (using blunt force with SO 1’s right first), while Patient 3 was on the floor with SO 1 restraining him (Patient 3) by placing his (SO 1’s) body weight on Patient 3. There was blood on the floor. - At 2:59 a.m., Patient 3 remained restrained on the floor by SO 1, with SO 1’s knee on patient 3’s lower body and arm on Patient 3’s upper body. SO 1 removed hand cuffs from pocket to apply to Patient 3. During an interview on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ stated the following: The physical altercation between SO 1 and Patient 3 occurred 8/12/2024 in the facility’s new Emergency Department (ED) that was still under construction at the time. SO 1 was working in the new ED at the entrance. Patient 3 tried to rip off the construction barrier on the wall. Patient 3 was agitated and got into a verbal altercation (a verbal argument) with SO 1, then Patient 3 spat at SO 1. SO 1 and Patient 3 got into a physical altercation. The DPIQ validated the punching by SO1 on Patient 3 and that the verbal interactions on facility video between SO 1 and Patient 3 appeared to be an argument prior to the physical altercation. During an interview on 10/30/2024 at 2:11 p.m. with the Security Manager (SM), the SM stated the following: On 8/12/2024, SO 1 and Patient 3 were involved in a physical altercation. Patient 3 was agitated, pulling things off the wall and SO 1 intervened aggressively. SO 1 started kicking Patient 3. Patient 3 was in SO 1’s face and punched him (SO 1). SO 1 tackled Patient 3 to the ground then punched him (Patient 3) multiple times in the face. SO 1 was at fault for the physical altercation (a confrontation, tussle or physical aggression that may or may not result in injury) and physically assaulting Patient 3. SO 1 did not follow CPI guidelines. SO 1 should have made attempts to deescalate Patient 3. SO 1 should not have placed Patient 3 in handcuffs, this is not CPI protocol. SO 1 should have called for back-up on the radio (provided to all security staff) or called a code gray (a hospital emergency response that indicates a dangerous or combative person in the hospital, or criminal activity), when Patient 1 was agitated and combative. It was staff to patient abuse when SO 1 tackled Patient 3 to the floor and punched him (Patient 3) in the face. Following the facility investigation which started 8/12/2024, SO 1 was suspended at the start of the next shift at 3:30pm. SO 1 did not return to work and was terminated for not utilizing proper CPI techniques, when SO 1 did not de-escalate Patient 3 and physically abused Patient 3. During a concurrent interview and record review on 10/30/2024 at 5:21 p.m. with the DPIQ, the DPIQ verified the following: SO 1’s CPI card expired 7/5/2023. SO 2’s CPI card expired 2/15/2024 and renewed 10/30/2024 (after the survey team identified SO 2 was working without CPI training on 10/29/24). SO 3 was a new hire (hired 7/1/2024) working without CPI training on 10/29/24. The DPIQ stated the following: CPI for security staff should be completed within 60 days of hire and maintained per policy. SO 1 was a Lead Security Officer. There was no CPI policy. The DPIQ provided a booklet titled “Crisis Prevention Institute: Non-violent Crisis Intervention Training.” During a review of Patient 3’s “Emergency Documentation,” dated 8/12/2024 at 3:21 a.m., the document indicated: “patient (Patient 3) was having auditory hallucinations (when someone hears voices or noises that don’t exist in reality) ...unwitnessed altercation but patient (3) has laceration above left eye ... [SO 1] placed patient (3) in cuffs ...” During a review of the document provided by the facility titled, “Position description: Security Officer,” no date, the document indicated the following: “ ...Qualifications: Must complete CPI within 60 days of hire ...” During a review of the document provided by the facility titled, “Position description: Lead Security Officer,” no date, the document indicated the following: “ ...Qualifications: Must complete CPI within 60 days of hire ...” During a review of the booklet provided by the facility titled “Crisis Prevention Institute: Non-violent Crisis Intervention Training,” no date, the booklet indicated the following: “Manage your own emotional responses to distress behavior; Use the Decision Making Matrix in the moment of Risk Behavior to determine Safety Interventions that represent a reasonable, proportionate, least restrictive, and last resort course of action; Use safety intervention strategies to maximize safety and minimize harm to self or others ...” During a review of the facility’s policy and procedure (P&P) titled, “Management of Violent Patients,” dated 5/2022, the P&P indicated the following: “ ...IV. Procedure: A. Utilizing current Assault Prevention Techniques/Training, any or all of the following measures may be taken: ...b. Conditions which may lead to violence: ...vi. Psychiatric Disorders (a mental illness that involves significant changes in a person’s thoughts, emotions, or behaviors that are difficult to control) ... 2. a. ...vii. Staff should alert hospital security as soon as possible of anytime a patient starts to escalate (becomes more intense or serious) or becomes violent. b. Patients who are agitated but cooperative may be amendable to verbal de-escalation techniques: i. Respect personal space- Maintain a distance of two arm’s lengths and provide personal space for easy exit for either party; ii. Do not be provocative- Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient ...” During a review of the facility’s policy and procedures (P&P) titled, “Assaultive Behavior,” dated 10/2021, the P&P indicated the following: “ ...D. A patient who strikes at or actually strikes another person, including patients, visitors or staff, will be assessed for seclusion and/or restraints. A Code Gray (a hospital emergency response that indicates a dangerous or combative person in the hospital, or criminal activity) must be called, to secure additional assistance, if needed ...” During a review of the facility’s policy and procedures (P&P) titled, “Code Gray ,” dated 10/2021, the P&P indicated the following: “ ...A. In the event of a psychiatric emergency (defined as an aggressive patient who does not respond to verbal limits and/or is posing a safety risk) the charge nurse will be alerted. She/he will make the determination whether a Code Gray is to be paged ...” During a review of the facility’s policy and procedures (P&P) titled, “Employee File Requirements,” dated 11/2022, the P&P indicated the following: “ ...All staff whose job description requires Crisis Prevention and Intervention (CPI) must complete the recertification training no later than the end of the month in which it expires. New hires have 60 days from the date of hire to complete the training ...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven and proactive approach to quality care) Committee failed to: 1. Ensure that an adverse event (an undesirable or harmful outcome) involving one of 30 sampled patients (Patient 1), was analyzed to determine the cause of the event and then develop and implement preventive actions to ensure patient safety and prevent re-occurrence, in accordance with the facility’s policy and procedure regarding Organizational Performance Improvement Plan. Patient 1 received delayed intervention for a head bleed with a decline in condition (after an unwitnessed fall) which included symptoms of lethargy (a symptom that involves an unusual decrease in consciousness), confusion, eyes not opening to painful stimuli, all of which were not reported by nursing staff to the physician. This deficient practice had the potential to result in life-threatening situations and jeopardize patients’ safety, which may lead to death, when the events that led to Patient 1’s delayed care were not analyzed for the causes and preventive actions to prevent re-occurrence of the same incident involving a decline in patient’s condition were not properly addressed. 2. Keep track of its abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) reports record made to the regulatory agency, when one of 30 sampled patient’s (Patient 7) report of an alleged physical abuse for being hit 15 times by two staff on 4/7/2017, was not available for review. This deficient practice had the potential for the facility not being able to identify abuse patterns, intervene early to protect potential victims, and develop prevention strategies to improve patient care. This deficient practice also had the potential to result in putting the facility non-compliant with mandatory reporting requirement of state regulatory agency and delay the investigation process by state regulatory agency. Findings: 1. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/30/2024, the “H&P” indicated, Patient 1, “presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [essential nutrient for body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ...” During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1’s “Progress Notes (the part of a medical record where healthcare professionals record details to document a patient’s clinical status or achievements during treatment),” dated 5/2/2024, was reviewed. The progress note indicated on 5/2/2024 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 “reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one’s sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position.” During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1’s “Progress Notes,” dated 5/3/2024 at 8:00 a.m., was reviewed. The progress notes indicate Patient 1 was “drowsy and lethargic (a symptom that involves an unusual decrease in consciousness); eyes are not open to pain, but pt (Patient 1) is grunting (to make a short, low sound instead of speaking) and moving hands to sternal rub (a technique to test an unconscious person’s responsiveness).” The DMS verified that there was no progress note by any physician that Patient 1 was assessed for a change in condition (drowsy and lethargic, eyes do not open to pain) until 5/3/2024 at 10:59 p.m., when a progress note by MD 1, date of service/time was 5/3/2024 at 10:59 p.m. indicated, “24 hour event: rapid response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to immediately assess and treat the patient) was called on the patient (Patient 1) at approximately 6 p.m. neurologically (the branch of medicine that deals with problems affecting the brain) twitching in all extremities was noted and neurology was called.” During a review of Patient 1’s Computed Tomography (CT scan, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body’s internal structures) scan, dated 5/3/2024 at 6:31 p.m., CT scan results indicated, Patient 1 had “Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement).” During an interview and record review with the DMS on 10/29/2024 at 4:55 p.m. Patient 1’s “Neurological Assessment,” was reviewed. DMS verified that Patient 1 had a condition change. The DMS stated, “The nurse (RN 1) should have notified the doctor and monitored the patient (Patient 1) more frequently than every 4 hours.” During a concurrent interview and record review on 10/29/2024 at 4:45 p.m. with the DMS, Patient 1’s “flow sheet (track patient health data over a period of time),” for vitals dated from 5/3/2024 at 8:00 a.m., at 12:00 p.m., and at 7:15 p.m., was reviewed. Patient 1’s vital signs were as follows: On 5/3/2024 at 8:00 a.m., Patient’s 1 blood pressure (BP, measures the blood pushing against the blood vessel walls when the heart beats) was elevated, 179/92. The blood pressure was not addressed. DMS confirmed that PRN (as needed) Hydralazine (prescribed medication used to treat high blood pressure) that was prescribed to be administered if the systolic BP (the first number in measurement of the pressure the blood pressure) was over 160s, was not given. The DMS verified that the BP was not reassessed until (4 hours later) at 12:00 p.m., when the systolic BP continued to be elevated at 160. The DMS confirmed that the elevated BP was also not addressed at 12:00 p.m. On 5/3/2024 at 7:15 p.m., Patient 1’s BP increased to 205/100. During an interview and record review with the DMS on 10/29/2024 at 5:00 p.m., Patient 1’s “Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient) Team Assessment” report indicated a rapid response started at 6:13 p.m. on 5/3/2024. The report indicated, Patient 1 was lethargic (a symptom that involves an unusual decrease in consciousness) and with AMS (altered mental status, a change in mental function), CT scan was ordered and confirmed subdural hematoma (a type of bleeding near the brain that can happen after a head injury).” Patient 1 had to be intubated (placing a tube into the patient windpipe to aid in breathing). During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN, nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam) 1, RN 1 stated, on 5/2/2024 at 8:00 a.m., CNA 1 reported that she (CNA 1) found Patient 1 on the floor. RN 1 stated on 5/3/2024 he (RN 1) was precepting (provides supervision during clinical practice) for RN 2. RN 1 stated he (RN 1) was responsible to review RN 2’ assessment of Patient 1 and sign off on documentation completed by RN 2. RN 1 further stated that on 5/3/2024 at 8:00 a.m., Patient 1 required a sternal rub (a technique to test an unconscious person’s responsiveness). RN 1 stated a sternal rub was done to apply some pain to see if the patient (Patient 1) will respond. RN 1 confirmed that he (RN 1) was not able to get Patient 1 to respond verbally, Patient 1 was grunting (to make a short, low sound instead of speaking) and moving hands. RN 1 stated, “When patient has a condition change, the MD (physician) should have been notified, and a rapid response should be called immediately.” During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN) 2, RN 2 stated, “In the (Medical Surgical) unit, the CNA would take patients’ blood pressure, and the RN will review the BP within an hour.” RN 2 stated when a blood pressure is abnormal, the CNA will inform the RN immediately. RN 2 stated, “I do not recall if the CNA (CNA 1) notified of Patient 1’s blood pressure of 179.” During a concurrent interview and record review on 10/30/2024 at 4:00 p.m. with the Director of Medical Surgical (DMS), Patient 1’s “Assessment” flowsheet (track patient health data over a period of time), was reviewed. The flowsheet indicated Patient 1 was identified on the Morse Scores (Assessment tool that predicts the likelihood that a patient will fall (an unplanned change in position where a patient lands on the floor or another lower surface): ranging from 0-24 indicate no risk, 25-50 indicate low risk and higher than 50 indicate high risk) at 50 which was high fall risk. DMS stated the individualized fall prevention for Patient 1 was “the bed was in low position, wheels (bed) are locked, and the patient (Patient 1) was restrained.” After reviewing with DMS purpose of restraint in the hospital setting, DMS stated, “the patient (Patient 1) was also on hourly rounding.” During a concurrent interview and record review on 10/30/2024 at 4:15 p.m. with the Director of Medical Surgical (DMS), Patient 1’s electronic medical record titled, “Hourly Rounding (purposeful rounding by staff with the goal to protect patients and promote patient safety on the 4 P’s: Pain, Potty, Positioning, and possessions),” was reviewed. The Hourly Rounding form indicated, “Rounding every hour from 6 a.m. - 10 p.m. and rounding every two hours from 10 p.m. -6 a.m.” The form had staff’s initials hourly and every two hours for night shift (10 p.m. -6 a.m.) on 4/30/2024 and 5/1/2024, but on 5/2/2024 (date that Patient 1 fell), the form was left blank. The form had Patient 1’s identification labeled with date of birth, medical record number, physician name and other identification numbers. DMS stated although she (DMS) did not see a deficiency in practice that staff did not complete hourly rounding on 5/2/2024, which was the date that Patient 1 fell, DMS stated staff should have signed the form and initiated a fall care plan (provides a framework for evaluating and providing patient care needs related to the nursing process). DMS further stated the purpose of hourly rounding was to “make sure that staff are going in the room and checking on patients.” During an interview on 11/1/2024 at 11:39 a.m. with Director of Performance Improvement/Risk Manager (DPIQ), DPIQ validate that although the facility’s Medical Surgical (provides caring, to all patients for illness, surgery or testing and observation) and telemetry (patients undergo continuous heart monitor) unit are implementing the hourly rounding process, DPIQ stated “there is no policy or procedure regarding hourly rounding process because this is something that nursing established.” DPIQ further stated, the Quality Assurance Performance department does not know who or when the “Hourly Rounding” process was established. During a concurrent interview and record review on 11/1/2024 at 4:00 p.m. with Director of Performance Improvement/Risk Manager (DPIQ), the facility’s “Quality Council” minutes, dated 6/18/2024, was reviewed. The minutes indicated the presentation was regarding cases that were reported to the California Department of Public Health (CDPH). The first case was in regard to Patient 1’s fall. The minutes indicated, “Patient fall resulted hematoma (a collection of blood within the skull) and transferred out for higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which the patient originates). All appropriate documentation was provided to the surveyor. We do not foresee any issues. We identified an issue internally with the care plan and will look into that.” There was no corrective plan documented in the Quality Council minutes. DPIQ stated after the investigation was completed there was identification of a need for rounding. DPIQ confirmed that there was no corrective plan presented in the Quality Council meeting. During a review of the facility’s policy and procedure (P&P) titled, “Organizational Performance Improvement Plan,” dated April 2024, the P&P indicated, “The purpose of the Organizational Performance Improvement Plan at (name of the facility) is to ensure that the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ...Organizational Goals of Performance Improvement: The primary goal of the Organizational Performance Improvement Plan is to continually and systematically plan, design, measure, assess and improve performance of hospital wide key functions and processes relative to patient care; and to improve healthcare outcomes while reducing and preventing medical/health care errors. To achieve this goal, the plan strives to ...The status of identified problems and action plans is tracked to assure improvement or problem resolution at the department and organization levels. Information from departments/services and the findings of discrete performance improvement activities and adverse patient events are used to detect trends, patterns of performance or potential problems that affect more than one department/service ... Important key aspects of care to the health and safety of patients are identified. Included are those that ...place patients at risk of serious consequences of deprivation of substantial benefit if care is not provided correctly or not provided when indicated; or care provided is not indicated, or those tending to produce problems for patients, their families or staff ... The following methodology known as the FOCUS-PDCA approach to performance improvement is utilized by (name of the facility) to find, organize, clarify, understand and select the process for improvement - to Plan, Do, Check and Act.” 2. During a review of Patient 7’s Face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance), undated, the face sheet indicated, “Patient 7 was admitted to the facility on 4/4/2017 with chief complaint of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration).” During a review of Patient 7’s Progress Notes Non-Physicians (nursing progress notes), dated 4/7/2017, the nursing progress notes indicated, “in the morning, patient (Patient 7) came to nurse’s station stating he (Patient 7) wants to file a report. He (Patient 7) stated, ‘staff jumped me (Patient 7) last night!’ he (Patient 7) said he (Patient 7) was hit 15 times by two staff. Red spatter found on mattress and wall. Patient (Patient 7) has redness on left side of head and swelling left orbit (bony cavity that contains the eye).” The nursing progress notes also indicated physician was notified after Patient 7’s report. During a concurrent interview and record review on 11/1/2024 at 4:53 p.m. with the Director (DBHU) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders), Mental Health Worker (MHW) 6’s “Employee Warning Notice (disciplinary record, facility’s disciplinary record with its employee),” dated 4/7/2017, was reviewed. The disciplinary record indicated, MHW 6 was placed on suspension on 4/7/2017 due to alleged abuse report. DBHU stated it was the facility’s process to put the staff on investigatory suspension when the staff was involved in an alleged abuse until investigation was over. During an interview on 11/1/2024 at 5:09 p.m. with the Director (DBHU) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders), DBHU stated the following: from facility’s internal investigation, Patient 7 had aggressive behavior despite staff attempt to de-escalate (reduce the intensity of a conflict or potentially violent situation). Three Mental Health Workers (MHW 6, 7, and 8) had to use hands on per Crisis Prevention Institute (CPI, a program that teaches people how to prevent and respond to crises) protocol to restrain (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) Patient 7 on his (Patient 7’s) bed. Patient 7’s nurse was called in to talk to Patient 7. DBHU stated that Patient 7’s nurse should have performed assessment on Patient 7 after the assaultive behavior (violent behavior that could cause physical harm) for any injury. Patient 7’s nurse should have notified the physician about the incident for any further instruction. DBHU stated Patient 7’s nurse did not document the incident, assessment or notification to Patient 7’s physician. Patient 7 was found with injury at left side of head and swelling at left eye next morning by following shift nurse. During an interview on 11/1/2024 at 5:15 p.m. with DBHU, DBHU stated any alleged abuse case would be reported to Quality Department which will handle the reporting to state regulatory agency. DBHU stated she (DBHU) did not know if reporting to the state regulatory agency was done for Patient 7. During an interview on 11/1/2024 at 8:35 p.m. with the Director of Performance Improvement Quality Management (DPIQ), DPIQ stated the facility should report all alleged physical abuse to state regulatory agency. DPIQ stated she (DPIQ) did not know if Patient 7’s alleged abuse case was ever reported to the state regulatory agency since it was in 2017. During a review of the facility’s policy and procedure titled, “Mandated Adverse Event Reporting to the [state] Department of Public Health,” dated 12/2023, the P&P indicated, “to comply with the mandated reporting requirements of [state] Health and Safety Code 1279.1(b) and to support the improvement of patient safety and quality improvement initiatives ... it shall be the policy of the organization to report an adverse event ... to the [state] department of Public Health no later than five days after the event has been detected ... an adverse event as defined under the Code includes any of the following ... criminal events including the following ... the death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds ... it will be the responsibility of the Quality Management Department to develop and submit the report to [state] department of Public Health, as well as serve as liaison with [state] department of Public Health during the subsequent investigation process.””

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure 10 out of 28 policy and procedure (P&P) sampled, were reviewed and addressed by Quality Assurance Performance Improvement (QAPI, a data-driven and proactive approach to quality improvement program) Committee, to ensure these P&Ps were not outdated and that P&Ps were reviewed by the facility’s governing body every three years. This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to outdated policies that might not reflect up to date best practices. Findings: During a concurrent interview and record review on 11/1/2024 at 5:07 p.m. with the Performance Improvement /Associate Administrator (AA), the facility’s policy and procedures (10 outdated P&Ps), were reviewed. AA stated, “P&Ps should be reviewed every three years by governing body.” The P&Ps that were reviewed and were validated to be outdated by AA were the following: - Facility’s policy and procedures (P&P) titled, “Skin Assessment,” dated 11/2020, the P&P indicated the policy was last reviewed 11/2020. - Facility’s policy and procedures (P&P) titled, “Patient Valuables and Belongings,” dated 8/2020, the P&P indicated the policy was last reviewed 8/2020. - Facility’s policy and procedures (P&P) titled, “Identification and Securing of Contraband (any item that is prohibited or could be dangerous to patients, staff or visitors),” dated 5/2021, the P&P indicated the policy was last reviewed 5/2021. - Facility’s policy and procedures (P&P) titled, “Rounding (visit patients to assess their needs, review their care, and ensure safety), Observation and Monitoring of Patients,” dated 5/2021, the P&P indicated the policy was last reviewed 10/2021. - Facility’s policy and procedures (P&P) titled, “Medical Screening Examinations (MSE, the initial exam performed when a patient presents to a dedicated emergency department and requests care),” dated 2/2020, the P&P indicated the policy was last reviewed 2/2020. - Facility’s policy and procedures (P&P) titled, “Psychiatric Evaluation (a clinical assessment of a person’s mental health)/Medical Clearance (the process of evaluating someone’s health condition to determine if they are fit for a specific activity or procedure) of Emergency Department (ED) patients,” dated 6/2020, the P&P indicated the policy was last reviewed 6/2020. - Facility’s policy and procedures (P&P) titled, “Patient Right to Refuse Care,” dated 4/2018, the P&P indicated the policy was last reviewed 4/2018. - Facility’s policy and procedures (P&P) titled, “Emergency Department: Standards of Care Procedures,” dated 10/2020, the P&P indicated the policy was last reviewed 10/2020. - Facility’s policy and procedures (P&P) titled, “Standards of Practice and Care,” dated 6/2020, the P&P indicated the policy was last reviewed 6/2020. - Facility’s policy and procedures (P&P) titled, “Transportation of the ED Patient,” dated 5/2021, the P&P indicated the policy was last reviewed 5/2021. During a review of the facility’s policy and procedure (P&P) titled, “Governing Board,” dated September 2023, the P&P indicated, “Governing Board -Responsibilities: Establishing mechanisms designed to ensure adherence to relevant statutory and regulatory requirements. Formulating, periodically reviewing, revising, and approving key policies in collaboration with organizational leaders. a. Policies will be reviewed and approved within established time frames. b. The Board will require collaboration among organizational leaders in establishment and/or revision of such policies.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to: 1. Ensure one of 30 sampled Patients (Patient 1), Patient 1’s decline in condition, becoming lethargic (a symptom that involves an unusual decrease in consciousness) and unresponsive to pain (the patient does not respond spontaneously) with abnormal changes in the vital signs (increased blood pressure, when the force of blood flowing through the blood vessels continues to be higher than 130/80 mm Hg, millimeters of mercury, a unit of measurement), after sustaining an unwitnessed fall (an unplanned change in position where a patient lands on the floor or a lower surface) the day before, was communicated in a timely manner to the physicians in compliance with the facility’s policy and procedure regarding assessment and physician notification. This deficient practice resulted in delayed intervention for Patient 1’s brain bleed and resulted in a call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stop], or death). This deficient practice also resulted in Patient 1 intubation (surgically inserting a tube into the patient’s windpipe to aid in breathing) and being transferred to the intensive care unit (ICU, for critically ill or injured patients that is staffed by specially trained medical personnel) in the same facility, and then being transferred out to a higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates) facility for surgery. 2. Ensure for two of 30 sampled patients (Patients 25 and 28), the following: 2.a. Patient 25’s pressure injury (PI, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the right and left buttock had a wound care treatment order and wound care treatment provided in accordance with the facility’s policy and procedure. This deficient practice resulted in Patient 25’s delayed treatment which may result in Patient 25’s PI to deteriorate and for the patient to suffer from pain and wound infection. 2.b. Patient 28’s high blood pressure (BP, amount of force blood uses to move through the body, with a normal range less than 120/80 mmHg]) readings were not communicated to the physician in accordance with the facility’s policy and procedure regarding physician notification. This deficient practice had the potential to cause a delay in determining Patient 28’s change of condition and/or a delay in the provision of emergent treatment needed which could worsen Patient 28’s condition that may result in complications such as stroke (clot in the brain), and/or death. On 10/30/2024 at 5:21 p.m., the survey team called an immediate jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Performance Improvement Associate Administrator (AA), and the Director of Performance Improvement/Risk Manager (DPIQ). The IJ was related to the facility’s failure to ensure that Patient 1’s decline in condition, such as becoming lethargic (a symptom that involves an unusual decrease in consciousness) and unresponsive to pain (the patient does not respond spontaneously) with abnormal changes in the vital signs (increased blood pressure, when the force of blood flowing through the blood vessels continues to be too high), after sustaining an unwitnessed fall the day before, was not communicated to the physicians in compliance with the facility’s policy and procedure. This failure resulted in delayed intervention for Patient 1’s brain bleed and resulted in a call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stops beating], or death). Also, resulted in Patient 1’s intubation (surgically inserting a tube into the patient’s windpipe to aid in breathing) and being transferred to the intensive care unit (ICU, for critically ill or injured patients that is staffed by specially trained medical personnel) in the same facility, and then being transferred out to a higher level of care (a hospital capable of providing diagnostic or interventional care beyond the capacity of the hospital from which the patient originates) facility for surgery. On 11/1/2024 at 1:16 p.m., while onsite, the IJ was removed after verifying and confirming the facility’s implementation of the IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, in the presence of the following facility members: Chief Nursing Officer (CNO), Performance Improvement Associate Administrator (AA), and the Director of Performance Improvement/Risk Manager (DPIQ). The IJ Removal Plan included the following: 1. Multidisciplinary Leadership Team Meeting & Policy Updates On 10/30/2024, the following leaders met to discuss the clinician notification process: - Chief Executive Officer - Chief Nursing Officer - Associate Administrator - Director of Medical/Surgical Services - Quality Director. During the meeting, it was identified there was a need to update two policies to provide staff with guidance on timely physician notification, documentation, and data required to ensure patient safety and prevent clinical deterioration (a sudden or serious worsening of a patient’s condition). Policy #1: Physician Notification The below nursing education elements will be reflected in “Physician Notification” A. The primary attending physician will immediately be notified of patient’s change in condition. B. Include details in your communication with the provider (e.g., vitals, symptoms observed, time the decline was observed, any relative context, etc.) Policy #2: Documentation Patient Care Record The below nursing education elements will be reflected in the “Documentation Patient Care Record.” A. Patients are immediately reassessed whenever a significant change in condition or in vital signs (blood pressure, heart rate, temperature, respiratory rate, or oxygen saturation) occurs outside the baseline for the patient. B. When a significant change occurs, the attending physician shall be immediately contacted and notification documented along with any pertinent details (e.g., vitals, symptoms observed, time the decline observed, any relative context, etc.). 2. Nursing Education Education was started for both night and day shift on the morning of 10/31/2024 to ensure staff have a comprehensive understanding of the updates. Education will continue daily for staff until all scheduled staff have been trained. The following have been used in the nursing education to ensure timely communication and intervention when necessary. Strict adherence is required to ensure patient safety and prevent clinical deterioration. Physician Notification: 1. Identify a decline in patient clinical condition or abnormal vitals: Monitor patients for any signs of clinical decline, such as changes in mental status, and significant changes in vital signs (blood pressure, heart rate, temperature, respiratory rate, or oxygen saturation) outside the baseline for the patient. Reassessment is required within 60 minutes and if vital signs remain significant further reassessments and level of care to be determined by the physician. 2. Notify the physician: Immediately contact the physician responsible for the patient’s care upon identifying any of the following: - Deterioration in the patient’s condition - Abnormal vital signs Include specific details in your communication: - Vitals or symptoms observed. - The time the decline or abnormality was noticed. - Any relevant context (e.g., falls, recent procedures, etc.). If the attending does not respond within 20 minutes by phone and the need is urgent, the staff will contact the following medical staff in the order listed below: - Consulting physician listed in patient record - Department medical director - Chief Medical Officer - Chief of staff If at any time, the patient’s status continues to decline, a rapid response protocol should be initiated. Documentation Patient Care Record: 1. Document the licensed provider notification: Record each notification in the patient’s medical record, including: - Time of notification: When you contacted the physician. - Method (e.g., phone, in-person). - Details of nursing assessment of patient condition (as stated above). - Physician’s response: Record the orders provided or the physician’s response. - Next steps: carry out physician orders and additional monitoring required. 3. Physician memorandum (memo) was created on 10/30/2024 and distributed to all medical staff members the following day. The memo references the hospital’s Rules & Regulations Section 5.1, outlining the requirement for progress notes to accurately reflect providers’ patient assessments. Additionally, the memo emphasizes that documentation must include the results of these assessments, noting any significant changes in patient condition or level of care. 4. EHR (Electronic Health Record) Cerner Standing Communication Order: Verify Change in Condition - Completed 11/01/2024A new standing communication order has been implemented for all new admissions, triggering a required task at 0500 and 1700. At these times, the required task will prompt nursing staff to verify whether there was a change in the patient’s condition during the shift. If “yes” is selected, the physician notification form will automatically appear and will be required to be completed by the RN. In addition, an automatic report will generate daily showcasing whether or not the required task was completed. Moreover, this report will be sent to directors daily for leadership oversight and follow-up. Beginning 11/01/2024, in-person education on the new EHR verification of change in condition process will occur daily for licensed staff until all scheduled staff have been trained. Findings: 1. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/30/2024, the “H&P” indicated, Patient 1, “presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transport oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [an essential nutrient necessary for blood pressure control and body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ...” During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1’s “Progress Notes (the part of a medical record where healthcare professionals record details to document a patient’s clinical status or achievements during treatment),” dated 5/2/2024, was reviewed. The progress note indicated on 5/2/24 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 “reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one’s sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position.” During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1’s “Progress Notes,” dated 5/3/2024 at 8:00 a.m., was reviewed. The progress notes indicate Patient 1 was”drowsy and lethargic (a symptom that involves an unusual decrease in consciousness); eyes are not open to pain, but pt (Patient 1) is grunting (short, low sound instead of speaking) and moving hands to sternal rub (a technique to test an unconscious person’s responsiveness).” The DMS verified that there was no progress note by any physician that Patient 1 was assessed for a change in condition (drowsy and lethargic, eyes do not open to pain) until 5/3/2024 at 10:59 p.m., when a progress note by MD 1, date of service/time was 5/3/2024 at 10:59 p.m. indicated, “24 hour event: rapid response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stop], or death) was called on the patient (Patient 1) at approximately 6 p.m. neurologically (the branch of medicine that deals with problems affecting the brain) twitching in all extremities was noted and neurology was called.” During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1’s “Neurological Assessment (evaluates brain and functioning),” dated from 4/24/2024 through 5/3/2024, was reviewed and indicated the following: - On 4/29/2024 at 9:16 p.m. (date of admission to the facility), Patient 1’s level of consciousness (LOC, is a state of awareness, alertness, and wakefulness) was identified as alert. - On 4/30/2024 at 9:08 a.m., Patient 1’s level of consciousness was identified as alert. - On 5/1/2024 at 8:00 a.m., Patient 1’s level of consciousness was identified as alert. - On 5/1/2024 at 10:00 p.m., Patient 1’s level of consciousness was identified as alert. - On 5/2/2024 at 10:15 a.m. (when Patient 1 had an unwitnessed fall inside the patient room), Patient 1’s level of consciousness was identified as lethargic (a symptom that involves an unusual decrease in consciousness), confusion (symptoms that involve disruptions in memory, ability to think and focus, awareness), and disorientation (the condition of having lost one’s sense of direction). - On 5/2/2024 at 10:00 p.m., Patient 1’s level of consciousness was identified as lethargic, confusion/disorientation. - On 5/3/2024 at 8:00 a.m., Patient 1’s level of consciousness was identified as lethargic; the right and left pupils are brisk and regular (normal pupil behavior). - On 5/3/2024 at 10:00 p.m. Patient 1’s level of consciousness was identified as obtunded (diminished responsiveness); the right and left pupils are sluggish (abnormalities of pupils’ behavior correlate with an underlying serious problem with brain functioning). During an interview and record review on 10/29/2024 at 4:55 p.m. with the DMS, Patient 1’s “Neurological Assessment,” was reviewed. DMS verified that Patient 1 had a condition change. The DMS stated, “The nurse (RN 1) should have notified the doctor and monitor the patient more frequently than every 4 hours.” The neurological assessment indicated Patient 1’s condition declined from 5/2/2024 at 10:15 a.m. (when Patient 1 fell) and continued to decline, over 24 hours, until 5/3/2024 at 6:00 p.m. when a Rapid Response was called. During a review of Patient 1’s Computerized Tomography scan (CT scan, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body’s internal structures), dated 5/3/2024 at 6:31 p.m., the CT scan results indicated, Patient 1 had “Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement).” During a concurrent interview and record review on 10/29/2024 at 4:45 p.m. with the DMS, Patient 1’s “flow sheet (track patient health data over a period of time),” for vitals dated from 5/3/2024 at 8:00 a.m., at 1200 p.m., and at 7:15 p.m., were reviewed. Patient 1’s vital signs were as follows: - On 5/3/2024 at 8:00 a.m., Patient’s 1 blood pressure (BP, measures the blood pushing against the blood vessel walls when the heart beats) was elevated, 179/92. The blood pressure was not addressed. DMS confirmed that PRN (as needed) Hydralazine (prescribed medication used to treat high blood pressure) that was prescribed to be administered if the systolic BP (the first number in measurement of the pressure the blood pressure) over 160s, was not given. - The DMS verified that the BP was not reassessed until (4 hours later) at 12:00 p.m., when the systolic BP continued to be elevated at 160. The DMS confirmed that the elevated BP was not addressed again. On 5/3/2024 at 7:15 p.m., Patient 1’s BP increased to 205/100. During an interview and record review with the DMS on 10/29/2024 at 5:00 p.m., Patient 1’s “Rapid Response Team Assessment” report indicated a rapid response started at 6:13 p.m. on 5/3/2024. The report also indicated, Patient 1 was lethargic and with AMS (altered mental status, a change in mental function), CT scan was ordered, and confirmed subdural hematoma (a type of bleeding near the brain that can happen after a head injury).” Patient 1 had to be intubated (placing a tube into the patient windpipe to aid in breathing). During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN, nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam) 1, RN 1 stated, on 5/2/2024 at 8:00 a.m., CNA 1 reported that she (CNA 1) found Patient 1 on the floor. RN 1 stated on 5/3/2024 he (RN 1) was precepting (provides supervision during clinical practice) for RN 2. Stated he (RN 1) was responsible to review RN 2’ assessment of Patient 1 and sign off on documentation completed by RN 2. RN 1 further stated that on 5/3/2024 at 8:00 a.m., Patient 1 required a sternal rub. RN 1 stated a sternal rub was done to apply some pain to see if the patient (Patient 1) will respond. RN 1 confirmed that he (RN 1) was not able to get Patient 1 to respond verbally, Patient 1 was grunting and moving hands. RN 1 stated, “When patient has a condition change, the MD (physician) should have been notified, and a rapid response should be called immediately.” During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN) 2, RN 2 stated, “In the (Medical Surgical) unit, the CNA would take patients’ blood pressure, and the RN will review the BP within an hour.” RN 2 stated when a blood pressure was abnormal, the CNA will inform the RN immediately. RN 2 stated, “I do not recall if the CNA (CNA 1) notified of Patient 1’s blood pressure of 179.” During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Re-assessment,” dated March 2023, the P&P indicated, “To ensure that all patients receive the appropriate assessment (including Initial/screening and reassessment) provided by qualified individuals within the organizational setting. The assessment process will be a continuous collaborative effort with all departments functioning as a team. Patient assessment is a multidisciplinary function. The importance of input by various members of the health care team is valued and supported by the organization ... Reassessment will occur at points in time when there are changes in the level of care, the patient’s condition, and/or the patient’s diagnosis ... Reassessment procedures determine and document the patient’s response to the care provided.” During a review of the facility’s policy and procedure (P&P) titled, “Physician Notification,” dated March 2023, the P&P indicated, “The physician of record (POR) will be notified regarding patient issues in a timely manner ... The POR and/or hospitalist will be notified of patient’s change in condition.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated July 2023, the P&P indicated, “Medications not eligible for scheduled dosing times are medications that require exact or precise timing of administration, based on diagnosis type, treatment requirements, or therapeutic goals: Medications prescribed on an as needed basis ...Medications are administered only with legitimate and appropriate orders ... Before administering a medication, the authorized individual administering the medication will complete the following: Verify that the medication selected for administration is correct based on the medication order and product label ... For as needed (prn) medications, the nurse will assess the patient condition and document the need for the medication prior to administration. The patient will be monitored for patient response appropriately, and reassessment will occur per hospital policy.” 2.a. During a review of Patient 25’s “History and Physical Exam (H&P, a full, complete assessment of a patient’s medical history and current condition),” dated 10/17/2024, the H&P indicated Patient 25 was discharged from the medical unit (a hospital floor/unit used to provide medical examinations, treatments, medical services or procedures to the patients) and was admitted to the Behavioral Health Unit (BHU, unit that provides services for patients with mental health and substance abuse issues) on a 5150 hold (California law that allows a person to be involuntary detained for up to 72 hours for psychiatric evaluation and treatment) for grave disability (unable to provide for their basic needs like food, clothing, shelter due to a mental health disorder). The H&P further indicated Patient 25’s medication regimen from the medical unit was to be continued in the BHU. During a review of Patient 25’s “Nurse Admission Report,” dated 10/16/2024, the report indicated Patient 25 had Pressure Injury (PI, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the right and left buttocks. During a concurrent interview and record review on 10/30/2024 at 11:10 a.m., with Charge Nurse 1 (CN 1), CN 1 verified Patient 25’s “Wound Care Nurse Progress Note,” dated 10/14/2024, was from Patient 25’s admission in the medical unit. The note indicated Patient 25 had a right ischium (bony part of the buttock) unstageable pressure injury (full thickness skin and tissue loss where the base of the wound is covered by dead tissue) measuring 7.0 x (by) 4.0 x 1.0 centimeter (cm-a unit of measurement) and a left ischium unstageable PI measuring 3.0 x 3.0 cm. CN 1 stated Patient 25 had a pending wound care consult for the BHU admission (Patient 25 had been admitted to BHU for a total of 16 days). During the same interview and record review on 10/30/2024 at 11:10 a.m. with CN 1, CN 1 verified that the BHU physician entered a “Wound Care Order,” for Patient 25 on 10/16/2024. The order indicated for Patient 25 to have Leptospermum honey (Medihoney, natural immunomodulatory and antimicrobial agent) 4”x5” wound patch, 1 topical (applied directly to a part of the body) dressing every 24 hours for 30 days. CN 1 verified there was no instruction on where the Medihoney wound patch would be applied. CN 1 stated the wound care order should specify the wound site for wound treatment. During concurrent interview and record review on 10/30/2024 at 11:30 a.m., with CN 1, Patient 25’s “Nursing Progress Notes,” dated 10/17/2024, 10/18/2024, and 10/29/2024, were reviewed. The notes indicated the following: - On 10/17/2024, Patient 25’s “wound treatment on sacrum (lower back) done as ordered.” There was no documented evidence wound treatment was provided to Patient 25’s PI on the right and left buttocks. - On 10/18/2024, Patient 25’s “wound treatment done as ordered.” There was no documented evidence wound treatment was provided to Patient 25’s PI on the right and left buttocks. - On 10/29/2024, Patient 25’s “wound treatment on sacrum done as ordered.” There was no documented evidence wound treatment was provided to Patient 25’s PI on the right and left buttocks. - CN 1 stated wound care treatment was important to ensure wound healing and prevent wound deterioration. During a concurrent interview and record review on 10/31/2024 at 11:20 a.m. with the Wound Care Nurse (WCN, Registered Nurse who specializes in the treatment of wounds), the WCN stated Patient 25’s record indicated the nurses were documenting wound treatment with the wrong wound location and following a physician’s order with no specified treatment location. The WCN stated it was not the standard practice of care. During the same interview and record review on 10/31/2024 at 11:20 a.m., the WCN confirmed that Patient 25’s wound care order on 10/16/2024, did not specify the wound location for treatment. The WCN stated the nurses should have called the physician for order clarification. During a review of the facility’s policy and procedure (P&P) titled, “Documentation, Patient Care Record,” revised 7/2020, the P&P indicated, “Patient care delivered will be continually evaluated. Response to and outcome of the care provided will be documented throughout the shift.” During a review of the facility’s policy and procedure (P&P) titled, “Physician Notification,” revised 8/2015, the P&P indicated, “The physician of record (POR) will be notified regarding patient issues in a timely manner...” 2.b. During a review of Patient 28’s “History and Physical Exam (H&P, a full, complete assessment of a patient’s medical history and current condition),” dated 10/26/2024, the H&P indicated, Patient 28 was admitted to the facility for right eyebrow laceration (a cut or tear in the skin) and hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) after an unwitnessed fall (an unplanned descent of a patient to the floor or onto a lower surface). Patient 28 had a history of high blood pressure. During a concurrent interview and record review on 10/31/2024 at 3:46 p.m. with the Intensive Care Manager (ICM), the ICM verified Patient 28’s “Vital Signs Flowsheet,” dated 10/26/2024, had the following blood pressure (BP) readings: -At 1:00 a.m., Patient 28’s BP on admission was 128/76; -At 4:55 a.m., Patient 28’s BP was 129/79; -At 6:00 a.m., Patient 28’s BP was 154/74; -At 7:54 a.m., Patient 28’s BP was 159/101; -At 8:00 a.m., Patient 28’s BP was 175/142; and, -At 9:27 a.m., Patient 28’s BP was 171/89. - The ICM stated there was no documented evidence of Patient 28’s high BP readings on 10/26/2024 from 6 a.m. through 9:27 a.m., were addressed. The ICM stated Patient 28’s high BP should have been reported to Patient 28’s physician. During a review of the facility’s policy and procedure (P&P) titled, “Physician Notification,” revised 8/2015, the P&P indicated, “The physician of record (POR) will be notified regarding patient issues in a timely manner. The POR and/or hospitalist will be notified of patient’s change in condition.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50521 Based on interview and record review, the facility failed to: 1. Ensure nursing staff develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for high fall (an unplanned change in position where a patient lands on the floor or a lower surface) risk prevention and care for one of thirty (30) sampled patients (Patient 1) in accordance with the facility’s policy and procedures regarding care plan development. This deficient practice had the potential to result in Patient 1’s treatment and care goals not being met by not identifying the patient’s needs and risks for potential fall. 2.Ensure one of 30 sampled patient’s (Patients 16), individualized nursing care plans (provides a means of communication among health care providers) to address Patient 16’s issues regarding Hypertension (high blood pressure) and Skin Impairment (damaged skin), was developed and implemented, in accordance with the facility’s policy and procedure regarding care plan development. This deficient practice had the potential to result in delayed provision of care to the patient by not identifying Patients 16’s needs and risks. Findings: 1. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/30/2024, the “H&P” indicated, Patient 1, “presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [essential nutrient to help control blood pressure and body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ...” During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1’s “Progress Notes (the part of a medical record where healthcare professionals record details to document a patient’s clinical status or achievements during treatment),” dated 5/2/2024, was reviewed. The progress note indicated on 5/2/24 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 “reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one’s sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position.” During a concurrent interview and record review on 10/30/2024 at 4:00 p.m. with the Director of Medical Surgical (DMS), Patient 1’s “Assessment” flowsheet (track patient health data over a period of time), the flowsheet indicated Patient 1 was identified on the Morse Scores (Assessment tool that predicts the likelihood that a patient will fall: falling from 0-24 indicate no risk, 25-50 indicate low risk and higher than 50 indicate high risk) at 50 which is high fall risk. During a review of Patient 1’s Computed Tomography Scan (CT scan, medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body’s internal structures), dated 5/3/2024 at 6:31 p.m., the CT scan results indicated, Patient 1 had “Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement).” During an interview and record review on 10/29/2024 at 5:00 p.m. with the Director of Medical Surgical (DMS), DMS , Patient 1’s “Rapid Response Team Assessment” report, indicated a rapid response started at 6:13 p.m. on 5/3/2024. The report indicated, Patient 1 is lethargic and AMS (altered mental status, change in mental function), CT scan was ordered, and confirmed subdural hematoma (a type of bleeding near the brain that can happen after a head injury).” Patient 1 had to be intubated (placing a tube into the patient windpipe to aid in breathing). During a concurrent interview and record review on 10/30/2024 at 10:10 a.m. with the Director of Medical Surgical (DMS), Patient1’s “Care Plan,” dated from date of admission 4/29/2024 through 5/4/2024, was reviewed. The DMS verified that there was no fall (an unplanned change in position where a patient lands on the floor or a lower surface) care plan initiated and implemented for Patient 1 throughout the hospital stayed and even after Patient 1 fell on 5/2/2024. DMS stated, “This is a deficiency here, they should have initiated the fall care plan, as that the patient fell.” During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” dated March 2023, the P&P indicated, “To create a nursing care plan for each patient within 24 hours of admission. It should be started by the patient’s primary nurse who admits the patient. To provide the highest quality of care that is individualized and goal-directed based on the initial admission assessment from nursing and all appropriate disciplines. To evaluate patient’s response to care goals and when indicated, to ensure that the plan and goals are revised. A Registered Nurse (RN) is responsible for initiating and developing an interdisciplinary plan of care within 24 hours of admission or as specified in unit specific standards. An RN and/or qualified individual from a discipline is responsible for: Identifying expected outcomes individualized to the patient. Problem identification is initiated by an RN or other qualified individuals based on direct observation of the patient and evaluation of data gathered by designated staff or family members. The RN is responsible for analyzing, synthesizing and evaluating data and identifying appropriate nursing diagnoses/patient problems. The LVN may assist with data collection. Problems identification and development of Plan of Care is: Individualized. An ongoing process throughout a patient’s hospitalization ...The Plan of Care is reviewed every shift.” During a review of the facility’s policy and procedure (P&P) titled, “Fall Assessment & Prevention Program,” dated February 2023, the P&P indicated, “Fall Risk Score assigned to Patient and Protocols implemented per risk level: Normal = 0-44 and At Risk= 45 and above, Patients who are at High Risk for falls may utilize the Bed Alert System as a less restrictive measure and alternative to restraint while continuing to monitor for unauthorized ambulation ...Monitoring Risk Prevention Protocols: follow-up of all risk reduction interventions listed in the care plan should be performed to determine the effectiveness.” 2. During a review of Patient 16’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/23/2024, the H&P indicated Patient 16 was admitted to the facility for Hypertension (HTN - high blood pressure) and Coronary Artery Disease (CAD-damage or disease in the heart’s major blood vessels). The H&P further indicated Patient 16 had a wound on the left buttock. 2.a. During a concurrent interview and record review on 10/30/2024 at 10:58 a.m. with Nurse Manager 1 (NM 1), NM 1 verified Patient 16’s care plan did not include plans for management of Patient 16’s HTN. NM 1 stated Patient 16’s care plan addressing HTN should have been initiated on admission. During an interview on 10/31/2024 at 2:30 p.m. with the Director of Behavior Health Unit (DBHU), the DBHU stated it was the Registered Nurse’s (RN) responsibility to initiate a care plan for the patient upon admission and to update the patient’s care plan every shift. The DBHU stated the patients were expected to have an individualized care plan. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” revised in 03/2023, the P&P indicated, “To create a nursing care plan for each patient, within 24 hours of admission. It should be started by the patient’s primary nurse, or the nurse who admits the patient...A Registered Nurse (RN) is responsible for initiating and developing an interdisciplinary plan of care within 24 hours of admission or as specified in unit specific standards...Problems identification and development of Plan of Care is: a. Individualized, b. an ongoing process throughout a patient’s hospitalization. The Plan of Care is developed interdisciplinary by all appropriate services based on their assessment findings.” 2.b. During a concurrent interview and record review on 10/30/2024 at 2:22 p.m. with the Nurse Manager 1 (NM 1), NM1 verified Patient 16’s “Integumentary flowsheet,” dated 10/22/2024, indicated Patient 16 had a wound on the left buttock. During a concurrent interview and record review on 10/31/2024 at 2:38 p.m. with NM 1, NM 1 verified Patient 16’s care plan on “Skin Impairment” was only developed on 10/30/2024 (8 days after Patient 16’s initial skin assessment of wound on the left buttock). NM 1 stated Patient 16’s skin impairment care plan should have been initiated on 10/22/2024, when the patient’s wound was first identified. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” revised in 03/2023, the P&P indicated, “To create a nursing care plan for each patient, within 24 hours of admission. It should be started by the patient’s primary nurse, or the nurse who admits the patient...A Registered Nurse (RN) is responsible for initiating and developing an interdisciplinary plan of care within 24 hours of admission or as specified in unit specific standards...Problems identification and development of Plan of Care is: a. Individualized, b. an ongoing process throughout a patient’s hospitalization. The Plan of Care is developed interdisciplinary by all appropriate services based on their assessment findings.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48186 Based on observation, interview and record review, the facility staff failed to: 1. Notify the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) (Campus 1) that one of 30 sampled patients (Patient 3) had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not), a head injury (sustained after a fall [an unexpected descent to the floor or another lower surface with or without injury to the patient]), and was refusing medical care. This deficient practice resulted in Patient 3 being discharged from the Emergency Department (ED), without being seen and cleared by an ED Physician for a possible head injury (post [after]-assault [when an individual inflicts physical contact that causes bodily harm and/or injury]) and without being evaluated for psychosis, which could have resulted in unresolved psychosis and complications from a brain bleed such as death. 2. Ensure one of 30 sampled Patients (Patient 1), who was identified as high risk for fall, received “hourly rounding (purposeful rounding by staff with the goal to protect patients and promote patient safety on the 4 P’s: Pain, Potty, Positioning, and possessions),” in accordance with the facility’s procedure regarding rounding and monitoring of patients. This deficient practice likely resulted in Patient 1’s fall (an unexpected descent to the floor or onto another surface with or without injury to the patient) on 5/2/2024 at 10:15 a.m. and sustaining a head bleed, which required transfer to a high-level care (a hospital capable of providing diagnostic or interventional care beyon the capacity of the hospital from which a patient originates) facility for surgery. 3. Ensure nursing staff assessed a patient and notified a physician in a timely manner, regarding an injury involving one of 30 sampled patients (Patient 7), after a hands-on protocol (using one or both hands to immobilize a patient) per Crisis Prevention Institute (CPI, a program that teaches people how to prevent and respond to crises) was used to restrain (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) Patient 7 to his (Patient 7) bed on 4/6/2017 (night shift). This deficient practice resulted in delay of treatment and care as physician was contacted only the next morning when Patient 7 was found with redness on left side of head and swelling in the left orbit (the bony cavity of the skull tha houses the left eye). 4. Ensure nursing staff removed a ligature (a thing used for tying) risk item, in accordance with the facility’s policy and procedure regarding contrabands (any item that is prohibited or could be dangerous to patients, staff or visitors. Example: Belts and shoelaces, etc.), for one of 30 sampled patients (Patient 9), when Patient 9 was allowed to wear a sweater with a drawstring in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders). This deficient practice resulted in putting Patient 9 and other patients’ safety at risk when the drawstring could be used as a ligature to harm self or others. 5. Ensure for three of 30 sampled patients (Patients 25, 24, and 23), Patients 25, 24, and 23’s nursing care provided by the Licensed Vocational Nurse (LVN, an entry level health care provider who is responsible for basic nursing care under the direction of a registered nurse) was supervised by the Registered Nurse (RN, a licensed professional responsible for providing patient care, education and support to the patient), in accordance with the facility’s policy and procedure regarding RN oversight, when the LVNs’ patient care documentation was not reviewed and verified by the RNs to indicate the care was completed, accurate, and provided under the RNs’ supervision. This deficient practice had the potential for Patients 25, 24, and 23 to receive incomplete and inaccurate care which may cause negative impact on the overall provision of care and may lead to patient harm and/or death. On 11/1/2024 at 1:17 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Performance Improvement and Quality Management (DPIQ), the Associate Administrator (AA), and the Chief Nursing Officer (CNO). The facility was informed facility nursing staff failed to notify the Emergency Department (ED) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) that Patient 3 had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not), head injury, and was refusing medical care. Patient 3 suffered an injury (status-post staff altercation and assault) to the face and was treated in the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) for a laceration (a deep cut or tear in skin or flesh) above the left eye. Patient 3 suffered a laceration to the head (head injury status post assault), had auditory hallucinations (when someone hears voices or noises that don’t exist in reality), and refused medical care. Patient 3 was taken into custody by the police and removed from the facility prior to receiving a medical exam and medical clearance from possible emergency head injuries (the process of evaluating someone’s health condition to determine if they are fit for a specific activity or procedure) by an ED Physician. On 11/1/2024 at 8:31 p.m., the facility submitted an Immediate Jeopardy Removal Plan (IJRP, includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) for review and approval. The IJRP included the following: Immediate Education The following education started on 11/01/2024 for emergency room staff. Education will continue every shift until all scheduled staff have been trained. The following points outline the procedures for ensuring that patients with psychosis and/or head trauma receive appropriate medical screening exam (MSE, an exam performed by a physician to determine whether a medical condition exist) and support, especially those at risk of harm or who may require additional supervision. - The hospital must provide a triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) and Medical Screening Examination to any individual who presents themselves to the emergency department for the purposes of emergency care. - If the patient is displaying signs of psychosis or has evidence of head trauma/injury they will be held in the department until they have the capacity (ability to make a decision) or they are evaluated (medical screening exam) by a physician who has the authority to order a Psychiatric Evaluation Team (PET, a team of licensed mental health clinicians) evaluation. - If the patient refuses triage, medical screening exam, and/or is refusing care, the RN must immediately notify the physician face-to-face and update him/her on the patient’s chief complaint and current status so they can discuss the risks & benefits with the patient. - This notification must be documented in the patient’s electronic medical record. - The emergency room charge RN/appointed designee shall be notified of any refusal of care to ensure the correct process is followed. On 11/1/2024 at 9:45 p.m. in the presence of the Director of Performance Improvement and Quality Management (DPIQ), the Associate Administrator (AA), and the Chief Nursing Officer (CNO), the facility was informed that the survey team was unable to accept the IJRP. The IJRP was missing information regarding the Emergency Department (ED) processes and standards of care to see, treat, and medically clear all patients presenting to the ED for treatment and care, and specifically treatment and care for patients presenting with psychosis and head injuries. On 11/1/2024 at 9:47 p.m., the facility was placed on a 23-day fast track (a process that places a hospital or other provider on a termination track if deficiencies are found that pose an immediate jeopardy to patient health and safety). On 11/6/2024, an acceptable IJRP was received from the facility. On 11/11/2024 at 12:33 p.m., the IJ was removed in the presence of the Director of Quality and the CEO after all the elements of the IJRP were verified onsite through observation, interview, and record review. Findings: 1. During a review of Patient 3’s Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not). During an interview on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ stated the following: On 8/12/2024 at approximately 2:56 a.m., the physical altercation (physical aggression that may or may not result in an injury) between Security Officer 1 (SO 1) and Patient 3 occurred in the facility’s new Emergency Department that was still under construction at the time. SO 1 was working in the new ED at the entrance. Patient 3 tried to rip off the construction barrier on the wall. Patient 3 was agitated (a state of severe restlessness or uneasiness) and got into a verbal altercation (a verbal argument) with SO 1, then Patient 3 spat on SO 1. SO 1 and Patient 3 got into a physical altercation. Patient 3 was taken by staff inside the Emergency Room. The DPIQ validated SO 1 punching Patient 3 to the head (10 times) and that the verbal interactions on facility video between SO 1 and Patient 3 appeared to be a verbal argument prior to the physical altercation. During a concurrent interview and record review on 10/30/2024 at 3:30 p.m. with the Director of Emergency Department (DED), Patient 3’s medical record, was reviewed. The DED verified the following in the medical record: The Medical Screening Exam (MSE, an exam performed by a physician to determine whether a medical condition exist) and physician note was missing from the medical record. There was no notification to the ED Physician from nursing staff about Patient 3’s physical altercation (with SO 1), head laceration (a deep cut or tear in skin or flesh), auditory hallucinations (when someone hears voices or noises that don’t exist in reality) and refusal of medical care. Patient 3 left the facility in the custody of the police without being seen by an ED Physician and without receiving medical clearance (the process of evaluating someone’s health condition to determine if they are fit for a specific activity or procedure) for psychosis or a head injury (post physical assault). During the same interview on 10/30/2024 at 3:30 p.m., the DED stated the following: Patient 3 was seen in the Emergency Department on 8/12/2024 following a physical altercation with a member of facility security staff (SO 1). There should have been a notification from nursing staff to the ED Physician that Patient 3 was having auditory hallucinations, had a head laceration following a physical altercation, and was refusing care. It was important to notify the ED Physician so that patient (Patient 3) could get the appropriate medical care. Patient 3 should not have left without being seen by a physician and being medically cleared for psychosis or a head injury (post physical assault). Nursing staff documented refusal of care, but the ED physician should have documented Patient 3’s refusal to be seen in Patient 3’s medical record. During an interview on 10/31/2024 at 3:22 p.m. with the Emergency Department (ED) Physician, Medical Doctor 4 (MD 4), MD 4 stated the following: After the triage nurse triaged a patient (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) in the ED, the ED physician sees the patient and performs a MSE. A patient who presents with a head laceration, possible danger to others (condition of a person whose behavior or significant threats support a reasonable expectation that there is a substantial risk that he will inflict physical harm upon another person in the near future) and is identified as having auditory hallucinations must be seen by a physician and must be medically cleared for psychosis or a head injury (post physical assault), by a physician prior to being discharged. During the same interview on 10/31/2024 at 3:22 p.m. with MD 4, MD 4 said a patient presenting with auditory hallucinations should be evaluated by the ED physician to determine a need for a Psychiatric Emergency Team (PET, a team of licensed mental health clinicians) evaluation. When patients are discharged in the custody of the police, the ED Physician must medically clear all patients to ensure they do not have a medical event after they leave the ED. For head trauma, the standard of care treatment is to have a Computed Tomography (CT, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body’s internal structures) scan completed to rule out a brain bleed, because a brain bleed can stop someone from breathing and kill them. During the same interview on 10/31/2024 at 3:22 p.m. with MD 4, MD 4 stated if a patient refuses care, staff notifies the ED physician, and the ED physician must explain and document that the risk and benefits (risks and benefits of healthcare-relevant decisions) have been explained to the patient. Documentation of the MSE or refusal in the MD progress note should be completed within 24 hours of seeing the patient. The ED Physician has the ultimate responsibility for the patient, and the interdisciplinary team (a group of healthcare professionals with various areas of expertise who work together toward the goals of their patients), such as the Charge Nurse or Registered Nurse, should communicate changes or refusals to the ED physician. During an interview on 10/31/2024 at 4:35 p.m. with the DPIQ, the DPIQ stated the following: Once Patient 3 was taken into custody by the police, the facility was unaware of what happened to Patient 3. During a review of Patient 3’s “ED note - Nursing (ED nursing note),” dated 8/12/2024 at 2:45 a.m., the ED nursing note indicated, “patient (Patient 3) was brought in by [staff] in cuffs (a device used to secure a person’s wrists or ankles to limit their movement) into chair in emergency department (ED), patient (Patient 3) was yelling and screaming, threatening all staff and refusing care ... [staff] was able to see cut above [Patient 3’s] left eye, cleaned and dressed with 4 X 4’s dressing (a topical dressing for local management of bleeding wounds such as cuts, lacerations and abrasions) refusing triage and Medical Doctor (MD) exam, vital signs (measurements of the body’s most basic functions, such as temperature, pulse rate, respiration rate, and blood pressure) and other care, kept screaming, in police department custody.” During a review of patient 3’s “ED note - Nursing (ED nursing note),” dated 8/12/2024 at 3:21 a.m., the ED nursing note indicated the following: “Patient (Patient 3) complained of auditory hallucination ... unwitnessed altercation but patient (Patient 3) has laceration above left eye... called [local] police department immediately... police department arrived and took patient into custody.” During a review of the facility’s policy and procedure (P&P) titled, “Physician Notification,” dated 3/2023, the P&P indicated the following: “The physician of record will be notified regarding patient issues in a timely manner ... The physician of record and or hospitalist will be notified of patient’s change in condition.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Right to Refuse Care,” dated 4/2018, the P&P indicated the following: “ ...In the event that a patient refuses care or services, the physician should be notified. it is the physician’s responsibility to explain the consequences of refusal and to present alternatives if any are appropriate ...” During a review of the facility’s policy and procedures (P&P) titled, “Medical Screening Examinations,” dated 2/2020, the P&P indicated the following: “ ...Any patient who presents to [the facility] requesting emergency services is entitled to and will receive a Medical Screening Examination performed by licensed providers for the determination of whether an emergency condition exists .... Emergency Medical Condition: A medical condition manifesting itself by acute (sudden and severe in onset) symptoms of sufficient severity, (including severe pain, psychiatric disturbances and/or symptoms) such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions or serious dysfunction or serious dysfunction of any bodily organ ...” During a review of the facility’s policy and procedures (P&P) titled, “Emergency Department Standards of Practice and Care,” dated 8/2020, the P&P indicated: “ ...Important Aspects of Patient Care: ...E. Assessment and patient needs are communicated to the healthcare provider(s) who is responsible for the care and treatment of the patient: 1. Members of the multidisciplinary team ... 3. Progress/nursing notes ...” During a review of the facility’s policy and procedures (P&P) titled, “Standard of Care Procedures,” dated 10/2020, the P&P indicated: “ ...Procedure: ...M. Head injuries 1. A patient who arrives at the Emergency Department with a head injury will be evaluated for the following care: ...Notify the Emergency Department Physician ...” During a review of the facility’s policy and procedures (P&P) titled, “Triage,” dated 8/2020, the P&P indicated: “...Policy: ...B. Triage assessment and the assignment of an acuity rating do not fulfill the legal requirement of the patient receiving a medical screening examination (MSE) by the physician. C. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires medical screening of individuals seeking emergency care to determine whether an emergency medical condition exists. Stabilization of the patient, to the best of the hospital’s capabilities, is required prior to discharge or transfer ...” 2. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/30/2024, the “H&P” indicated, Patient 1, “presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [an essential nutrient that helps control blood pressure and body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ...” During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1’s “Progress Notes (the part of a medical record where healthcare professionals record details to document a patient’s clinical status or achievements during treatment),” dated 5/2/2024, was reviewed. The progress note indicated on 5/2/2024 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 “reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one’s sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position.” During a review of Patient 1’s Computed Tomography scan (CT scan, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body’s internal structures), dated 5/3/2024 at 6:31 p.m., the CT scan results indicated, Patient 1 had “Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement).” During a concurrent interview and record review on 10/30/2024 at 4:00 p.m. with the Director of Medical Surgical (DMS), Patient 1’s “Assessment” flowsheet (track patient health data over a period of time), was reviewed. The flowsheet indicated Patient 1 was identified on the Morse Scores (Assessment tool that predicts the likelihood that a patient will fall (unplanned descent to the floor or another lower surface with or without injury to the patient): falling from 0-24 indicate no risk, 25-50 indicate low risk and higher than 50 indicate high risk) at 50 which is high fall risk. DMS stated the individualized fall prevention for Patient 1 is “the bed was in low position, wheels are locked, and the patient (Patient 1) was restrained. After reviewing with DMS purpose of restraint (devices that limit a patient’s movement) in the hospital setting, DMS stated, “the patient (Patient 1) was also on hourly rounding.” During a concurrent interview and record review on 10/30/2024 at 4:15 p.m. with the Director of Medical Surgical (DMS), Patient 1’s electronic medical record titled, “Hourly Rounding (purposeful rounding by staff with the goal to protect patients and promote patient safety on the 4 P’s: Pain, Potty, Positioning, and possessions),” was reviewed. The Hourly Rounding form indicated, “Rounding every hour from 6 a.m. - 10 p.m. and rounding every two hours from 10 p.m. -6 a.m.” The form had staff’s initials hourly and every two hours for night shift (10 p.m. -6 a.m.) on 4/30/2024 and 5/1/2024, but on 5/2/2024 (date that Patient 1’s fell), the form was left blank. The form had Patient 1’s identification labeled with date of birth, medical record number, physician name and other identification numbers. DMS stated although she did not see a deficiency in practice that staff did not complete hourly rounding on 5/2/2024, on the date that Patient 1 fell, DMS stated staff should have signed the form and initiate a fall care plan. DMS further stated the purpose of hourly rounding was to “make sure that staff are going in the room and checking on patients.” During an interview on 11/1/2024 at 12:20 p.m. with Registered Nurse (RN) 5, RN 5 stated, “Hourly rounding is a standard process. Hourly rounding is completed to make sure everyone (patients) is safe and have their (patients) needs met, and to improve quality care for patients.” During an interview on 11/1/2024 at 12:20 p.m. with Registered Nurse (RN) 4, RN 4 stated, “Hourly rounding, the purpose is to monitor for safety and to see if they (patients) have change of condition. Hourly rounding is standard of care for all patients.” During an interview on 11/1/2024 at 12:20 p.m. with Registered Nurse (RN) 3, RN 3 stated, “Hourly rounding is standard of care that we do to prevents fall and make sure patients’ need are addressed.” During an interview on 11/1/2024 at 11:39 a.m. with Director of Performance Improvement/Risk Manager (DPIQ), DPIQ validate that although the facility’s Medical Surgical (provides caring, to all patients for illness, surgery or testing and observation) and telemetry (patients undergo continuous heart monitor) unit were implementing the hourly rounding process, DPIQ stated “there is no policy or procedure regarding hourly rounding process because this is something that nursing established.” DPIQ further stated, the Quality Assurance Performance department does not know who or when the “Hourly Rounding” process was established. 3. During a review of Patient 7’s Face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance), undated, the face sheet indicated, “Patient 7 was admitted to the facility on 4/4/2017 with chief complaint of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration).” During a review of Patient 7’s Progress Notes Non-Physicians (nursing progress notes), dated 4/7/2017, the nursing progress notes indicated, “in the morning patient (Patient 7) came to nurse’s station stating he (Patient 7) wants to file a report. He (Patient 7) stated, ‘staff jumped me (Patient 7) last night!’ he (Patient 7) said he (Patient 7) was hit 15 times by two staff. Red spatter found on mattress and wall. Patient (Patient 7) has redness on left side of head and swelling left orbit (bony cavity in the skull that houses the left eye).” The nursing progress notes also indicated physician was notified after Patient 7’s report on 4/7/2017. During an interview on 11/1/2024 at 5:09 p.m. with the Director (DBHU) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders), DBHU stated the following: from facility’s internal investigation, Patient 7 had aggressive behavior despite staff attempt to de-escalate (reduce the intensity of a conflict or potentially violent situation). Three Mental Health Workers (MHW 6, 7, and 8) had to use hands on (using one or both hands to immobilize a patient) per Crisis Prevention Institute (CPI, a program that teaches people how to prevent and respond to crises) protocol to restrain (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) Patient 7 on his (Patient 7’s) bed. Patient 7’s nurse was called in to talk to Patient 7. DBHU stated that Patient 7’s nurse should have performed assessment on Patient 7 after the assaultive behavior for any injury. Patient 7’s nurse should have notified the physician about the incident for any further instruction. DBHU stated Patient 7’s nurse did not document the incident, assessment or notification to Patient 7’s physician. Patient 7 was found with injury on the left side of head and swelling on the left eye next morning by the next shift nurse (morning shift nurse who took over Patient 7’s care). During a review of the facility’s policy and procedure (P&P) titled, “Assaultive Behavior,” dated 10/2021, the P&P indicated, “It is the policy of the Behavioral Health Unit to take all precautions to prevent assaultive behavior on the unit. Should potentially assaultive behavior be evidenced, or should an assault occur, specific interventions will be implemented ... if an injury occurs, the following procedures will be employed: Patient injury: Nurse evaluates extent of patient injury. Physician is notified immediately [so] proper medical and supportive care will be ordered. Vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) are recorded. Physician orders are implemented and immediate care if rendered as needed.” 4. During a review of Patient 9’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 10/24/2024, the Psych Eval indicated, Patient 9 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to being gravely disabled (inability to care self) with admitting diagnosis of paranoid schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). The Psych Eval also indicated Patient 9 had auditory (hearing) hallucinations (when someone hears voices or noises that don’t exist in reality) of evil voices commanding her (Patient 9) to kill someone. During a concurrent observation and interview on 10/30/2024 at 9:07 a.m. with the Charge Nurse (CN) 4 of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) in Patient 9’s room, Patient 9 was observed laying in bed wearing a white sweater. There was a drawstring on the hood of Patient 9’s white sweater. CN 4 stated Patient 9 should e not have any clothing with drawstring in it because it was dangerous. CN 4 stated drawstring was not allowed in the BHU because it would pose a ligature (a thing used for tying) risk on patients. During a concurrent interview and record review on 10/30/2024 at 9:39 a.m. with the Registered Nurse (RN) 7, Patient 9’s “Patient Valuables/ Belongings (belongings list, inventory of a patient’s belongings brought to the hospital),” dated 10/24/2024, was reviewed. The belongings list indicated, “clothing description with white sweater, grey graphic tee, and cheetah pants.” RN 7 stated staff would look for any drawstring or any items that could possibly harm patients on patient’s clothing upon admission. RN 7 stated if there was a drawstring on a clothing, the drawstring should be cut or placed in the contraband room. RN 7 stated, “Drawstring was a definite ‘No’ on the floor because of the ligature risk.” During an interview on 11/1/2024 at 9:35 a.m. with the Nurse Manager (NM) 1 of Behavioral Health Unit, NM 1 stated nursing staff should perform initial check upon patients’ admission to BHU for any contraband. NM 1 stated drawstring on clothing was considered as contraband and it was a ligature risk because patients could use the drawstring to harm self or others. During a review of the facility’s policy and procedure (P&P) titled, “Identification and Securing of Contraband,” dated 5/2021, the P&P indicated, “To preserve the safety of patients, employees and visitors of the hospital by identifying and preventing prohibited items (contraband) from entering the hospital facilities ... What to do with contraband: immediately dispose, place in personal vehicle of patient/visitor or place in [facility] locker. Identified contraband will not be allowed to be brought into the facility ... hanging risk (ropes, electrical wires ...string/rope/cord longer than eight inches).” 5.a. During a review of Patient 25’s “History and Physical Exam (H&P, a full and complete assessment of a patient’s medical history and current condition),” dated 10/17/2024, the H&P indicated, Patient 25 was medically cleared (means someone was examined by a physician and deemed healthy enough for a particular task) and was admitted to the Behavioral Health Unit (BHU, unit that provides services for patients with mental health and substance abuse issues) on a 5150 hold (California law that allows a person to be involuntary detained for up to 72 hours for psychiatric evaluation and treatment) for grave disability (unable to provide for their basic needs like food, clothing, shelter due to a mental health disorder). Patient 25 also had a history of paraplegia (loss of movement and/or sensation, to some degree, of the legs). During an interview on 10/29/2024 at 2:30 p.m. with the BHU Charge Nurse 3 (CN 3), the CN 3 stated the LVNs does not admit patients on the unit because the LVNs could not perform nursing assessment on the patient. CN 3 stated the LVNs collects data and perform wound treatments which would be verified by the charge nurse or a designated RN at the end of their shift. During a concurrent interview and record review on 10/31/2024 at 11:48 a.m. with the Director of Behavioral Health Unit (DBHU), Patient 25’s “Form Browser (a section in the patient’s electronic health record that contained documented clinical information),” dated 10/29/2024, was reviewed and indicated the following: -At 2:00 a.m., Patient 25’s acuity (method to determine severity of illness or condition by combining assessment with other factors) was completed by LVN 3; - At 10:00 a.m., Patient 25’s Suicide Risk Assessment Tool (an assessment tool/process of estimating the likelihood for a person to attempt or die by suicide) was completed by LVN 4; and, - At 2:00 p.m., Patient 25’s acuity was completed by LVN 4. There was no documented evidence Patient 25’s “Form Browser,” on 10/29/2024, documented by LVN 3 and LVN 4, was reviewed and verified by the RN. The DBHU stated the RN verification should be done every shift when an LVN’s patient assignment was under the supervision of an RN. The DBHU further stated, the RN’s responsibility was to ensure the patient’s assessment was accurate and care was provided. During a concurrent interview and record review on 11/01/2024 at 12:37 p.m. with the Nursing Education Manager (NEM), the onboarding education material, from the Nursing Education Department titled, “LVN/RN Verification,” undated, was reviewed. The “LVN/RN Verification” indicated the following: “RN/LVN Verification Process” “RN covering LVN must log into Cerner (facility’s electronic health record system) and “build a relationship” (assign to) with the LVN’s patient.” “RN to review the MAR for completion of medication administration.” “RN to review the notes from LVN assigned to this patient.” Step 1) click on Adhoc (tool that allows access and complete standardized documentation) Step 2) click on ALL ITEMS Step 3) Find folder RN/LVN and click on LVN/RN verification Step 4) Open the LVN/RN Verification “Reviewed Care by which given by: (LVN assigned to patient)” “Care reviewed from and to: (Date of shift-beginning to end of shift).” “Care reviewed (check off boxes): I supervised the LVN in provision of care within practice scope; I have reviewed all pertinent clinical documentation and concur.” The NEM stated the RNs were required to complete the RN/LVN verification at the end of each shift when the LVN was under their supervision. During a review of the facility’s policy and procedure (P&P) titled, “Documentation, Patient Care Record,” revised in 7/2020, the P&P indicated, “An LVN/LPT may assess and gather information for the RN. The RN is responsible for reviewing, completing, and verifying the information. Each patient shall be reassessed each shift, and as indicated when condition changes, by a Registered Nurse and documents assessment findings.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Department Scope of Service,” revised in 2/2023, the P&P indicated, “Licensed Vocational Nurse (LVN) is a licensed nurse who assists the RNs in the care of the patient within the LVN scope of practice. They work under the supervision of the RN.” 5.b. During a review of Patient 24’s “History and Physical Exam (H&P, a full and complete assessment of a patient’s medical history and current condition),” dated 10/02/2024, the H&P indicated Patient 24 was medically cleared and was admitted to the Behavioral Health Unit (BHU, unit that provides services for patients with mental health and substance abuse issues) on a 5270 hold (legal extension of a mental health hold that can last up to 30 days) for grave disability (unable to provide for their basic needs like food, clothing, shelter due to a mental health disorder). Patient 24 had a history of brain tumor resection (cutting out tissue), status post (after) debridement (removal of dead/infected tissue) of posterior (back) scalp, and left wrist fracture (broken bone). During a concurrent interview and record review on 10/30/2024 at 2:14 p.m. with Charge Nurse 1 (CN 1), Patient 24’s “Form Browser (a section in the patient’s electronic health record that contained documented clinical information),” dated 10/29/2024, was reviewed and indicated the following: - At 10:00 a.m., Patient 24’s Suicide Risk Assessment Tool (an assessment tool/process of estimating the likelihood for a person to attempt or die by suicide) was completed by LVN 4; and, - At 2:00 p.m., Patient 24’s Acuity (method to determine severity of illness or condition by combining assessment with other factors) was completed by LVN 4. There was no documented evidence Patient 24’s “Form Browser,” on 10/29/2024, documented by LVN 4, was reviewed and verified by the RN. CN 1 stated, LVN 4 was under the RN’s supervision and the RN was responsible to ensure that the patient’s assessment was accurate, and care was provided. During a concurrent interview and record review on 11/01/2024 at 12:37 p.m. with the Nursing Education Manager (NEM), the onboarding education material, from the Nursing Education Department titled, “LVN/RN Verification,” undated, was reviewed. The “LVN/RN Verification” indicated the following: “RN/LVN Verification Process” “RN covering LVN must log into Cerner (facility’s electronic health record system) and “build a relationship” (assign to) with the LVN’s patient.” “RN to review the MAR for completion of medication administration.” “RN to review the notes from LVN assigned to this patient.” Step 1) click on Adhoc (tool that allows access and complete standardized documentation) Step 2) click on ALL ITEMS Step 3) Find folder RN/LVN and click on LVN/RN verification Step 4) Open the LVN/RN Verification “Reviewed Care by which given by: (LVN assigned to patient)” “Care reviewed from and to: (Date of shift-beginning to end of shift).” “Care reviewed (check off boxes): I supervised the LVN in provision of care within practice scope; I have reviewed all pertinent clinical documentation and concur.” The NEM stated the RNs were required to complete the RN/LVN verification at the end of each shift when the LVN was under their supervision. During a review of the facility’s policy and procedure (P&P) titled, “Documentation, Patient Care Record,” revised in 7/2020, the P&P indicated, “An LVN/LPT may assess and gather information for the RN. The RN is responsible for reviewing, completing, and verifying the information. Each patient shall be reassessed each shift, and as indicated when condition changes, by a Registered Nurse and documents assessment findings.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Department Scope of Service,” revised in 2/2023, the P&P indicated, “Licensed Vocational Nurse (LVN) is a licensed nurse who assists the RNs in the care of the patient within the LVN scope of practice. They work under the supervision of the RN.” 5.c. During a review of Patient 23’s “History and Physical Exam (H&P, a full and complete assessment of a patient’s medical history and current condition),” dated 10/11/2024, the H&P indicated Patient 23 was medically cleared and was admitted to Behavioral Health Unit (BHU, unit that provides services for patients with mental health and substance abuse issues) on a 5270 hold (legal extension of a mental health hold that can last up to 30 days) for grave disability (unable to provide for their basic needs like food, clothing, shelter due to a mental health disorder). Patient 23 also had a history of high blood pressure and pulmonary embolism (a blockage in a lung artery that occurs when a blood clot breaks loose and travels to the bloodstream to the lungs). During a concurrent interview and record review on 10/30/2024 at 2:14 p.m. with Charge Nurse 1 (CN 1), Patient 23’s “Form Browser (a section in the patient’s electronic health record that contained documented clinical information),” dated 10/28/2024 through 10/29/2024, was reviewed and indicated the following: - On 10/28/2024 at 10:00 a.m., Patient 23’s Suicide Risk Assessment Tool (an assessment tool/process of estimating the likelihood for a person to attempt or die by suicide) was completed by LVN 7; - On 10/28/2024 at 2:00 p.m., Patient 23’s acuity (method to determine severity of illness or condition by combining assessment with other factors) was completed by LVN 7; -On 10/29/2024 at 2:00 a.m., Patient 23’s acuity was completed by LVN 3; - On 10/29/2024 at 9:00 a.m., Patient 23’s Suicide Risk Assessment Tool was completed by LVN 4; and, - On 10/29/2024 at 2:00 p.m., Patient 23’s acuity was completed by LVN 4. There was no documented evidence Patient 23’s “Form Browser,” on 10/28/2024 through 10/29/2024, documented by LVN 7, LVN 3, and LVN 4, was reviewed and verified by the RN. CN 1 stated, the LVNs were under the RN’s supervision and the RN was responsible to ensure that the patient’s assessment was accurate, and care was provided. During a concurrent interview and record review on 11/01/2024 at 12:37 p.m. with the Nursing Education Manager (NEM), the onboarding education material, from the Nursing Education Department, titled “LVN/RN Verification,” undated, was reviewed. The “LVN/RN Verification” indicated the following: “RN/LVN Verification Process” “RN covering LVN must log into Cerner (facility’s electronic health record system) and “build a relationship” (assign to) with the LVN’s patient.” “RN to review the MAR for completion of medication administration.” “RN to review the notes from LVN assigned to this patient.” Step 1) click on Adhoc (tool that allows access and complete standardized documentation) Step 2) click on ALL ITEMS Step 3) Find folder RN/LVN and click on LVN/RN verification Step 4) Open the LVN/RN Verification “Reviewed Care by which given by: (LVN assigned to patient)” “Care reviewed from and to: (Date of shift-beginning to end of shift).” “Care reviewed (check off boxes): I supervised the LVN in provision of care within practice scope; I have reviewed all pertinent clinical documentation and concur.” The NEM stated the RNs were required to complete the RN/LVN verification at the end of each shift when the LVN was under their supervision. During a review of the facility’s policy and procedure (P&P) titled, “Documentation, Patient Care Record,” revised in 7/2020, the P&P indicated, “An LVN/LPT may assess and gather information for the RN. The RN is responsible for reviewing, completing, and verifying the information. Each patient shall be reassessed each shift, and as indicated when condition changes, by a Registered Nurse and documents assessment findings.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Department Scope of Service,” revised in 2/2023, the P&P indicated, “Licensed Vocational Nurse (LVN) is a licensed nurse who assists the RNs in the care of the patient within the LVN scope of practice. They work under the supervision of the RN.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to: 1. Ensure one of 30 sampled Patient’s (Patient 1) PRN (as needed) medication, Hydralazine (prescribed medication used to treat high blood pressure)) was administered as ordered by the physician and in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice had the potential to result in worsening of Patient 1’s condition with further increase in blood pressure that may result in complications such as seizure (abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness [describes a person’s awareness and understanding of what is happening in their surroundings]), stroke (a clot in the brain), and/or death. 2. Ensure nursing staff performed safe medication administration for one of 30 sampled patients (Patient 10), in accordance to the facility’s policy and procedure regarding medication administration, when a Licensed Vocational Nurse (LVN) 1 allowed Patient 10 walk away with two medication ointment in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders). This deficient practice had the potential to result in Patient 10 not receiving prescribed medication correctly. This deficient practice may also cause additional complications such as Patient 10 swallowing it or giving the medication to other patients in BHU who might end up using the medications inappropriately. 3. Ensure one of 30 sampled patient’s (Patient 14) Valproic acid (also known as Depakene, medication used to treat seizure disorders (abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness [describes a person’s awareness and understanding of what is happening in their surroundings], mental/mood conditions, and to prevent migraine headaches), was administered in accordance with the physician’s order. This deficient practice had the potential for Patient 14’s behavioral condition such as agitation (a feeling of irritability and severe restlessness) to remain unresolved and may also lead to prolonged hospitalization. Findings: 1. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/30/2024, the “H&P” indicated, Patient 1, “presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [essential nutrient that regulates blood pressure and body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stool) ...” During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1’s “Progress Notes (the part of a medical record where healthcare professionals record details to document a patient’s clinical status or achievements during treatment),” dated 5/2/2024, was reviewed. The progress note indicated on 5/2/24 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 “reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one’s sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position.” During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1’s “Progress Notes,” dated 5/3/2024 at 8:00 a.m., was reviewed. The progress notes indicate Patient 1 was “drowsy and lethargic (a symptom that involves an unusual decrease in consciousness); eyes are not open to pain, but pt. (Patient 1) is grunting (to make a short low sound instead of speaking) and moving hands to sternal rub (a technique to test an unconscious person’s responsiveness).” The DMS verified that there was no progress note by physician that Patient 1 was assessed for a change in condition (drowsy and lethargic, eyes do not open to pain) until 5/3/2024 at 10:59 p.m., when a progress note by MD 1, date of service/time was 5/3/2024 at 10:59 p.m. indicated, “24 hour event: rapid response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stop], or death) was called on the patient (Patient 1) at approximately 6 p.m. neurologically (the branch of medicine that deals with problems affecting the brain) twitching in all extremities was noted and neurology was called.” During a concurrent interview and record review on 10/29/2024 at 4:45 p.m. with the DMS, Patient 1’s “flow sheet (track patient health data over a period of time),” for vitals dated from 5/3/2024 at 8:00 a.m., at 12:00 p.m., and at 7:15 p.m., was reviewed. Patient 1’s vital signs were as follows: On 5/3/2024 at 8:00 a.m., Patient’s 1 blood pressure (BP, measures the blood pushing against the blood vessel walls when the heart beats) was elevated, 179/92. The blood pressure was not addressed. DMS confirmed that PRN (as needed) Hydralazine (prescribed medication used to treat high blood pressure) that was prescribed to be administered if the systolic BP (the first number in measurement of the pressure the blood pressure) was over 160s, was not given. The DMS verified that the BP was not reassessed until (4 hours later) at 12:00 p.m., when the systolic BP continued to be elevated at 160. The DMS confirmed that the elevated BP was not addressed again at 12:00 p.m. On 5/3/2024 at 7:15 p.m., Patient 1’s BP increased to 205/100. During a review of the facility’s policy and procedure titled, “Medication Administration,” dated July 2023 indicated, “Medications not eligible for scheduled dosing times are medications that require exact or precise timing of administration, based on diagnosis type, treatment requirements, or therapeutic goals: Medications prescribed on an as needed basis ...Medications are administered only with legitimate and appropriate orders ... Before administering a medication, the authorized individual administering the medication will complete the following: Verify that the medication selected for administration is correct based on the medication order and product label ... For as needed (prn) medications, the nurse will assess the patient condition and document the need for the medication prior to administration. The patient will be monitored for patient response appropriately, and reassessment will occur per hospital policy.” 2. During a review of Patient 10’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/24/2024, the Psych Eval indicated, Patient 10 was admitted to the facility with 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to being gravely disabled (inability to care self). During an observation on 10/30/2024 at 9:03 a.m. at the facility’s (Campus 2) behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) medication room, a Licensed Vocational Nurse (LVN) 1 gave two (2) paper medicine cups to Patient 10. Patient 10 walked away with two paper medicine cups in hand. During an interview on 10/30/2024 at 9:04 a.m. with LVN 1, LVN 1 stated the following: he (LVN 2) gave two (2) ointment to Patient 10. The two medication ointments were Vitamin A & D topical (medication applied to the skin) ointment (medication to relieve dry skin) and Preparation H Rectal Ointment (medication to relieve swelling and pain caused by hemorrhoids [swollen veins in the anus or rectum). He (LVN 1) trusted Patient 10 to do it herself (Patient 10). LVN 1 stated he (LVN 1) would not know if Patient 10 would apply the ointment correctly because he (LVN 1) did not watch Patient 10 applying them. LVN 2 stated Patient 10 could have applied at a wrong site, swallow the ointment or give to other patients. During a review of Patient 10’s physician orders, undated, the physician orders indicated Patient 10’s active medications including but not limited to the following: “Preparation H Rectal Ointment, 1 application rectally daily as needed for pain with start date of 10/25/2024 and Vitamin A & D topical ointment, 1 application topical twice a day as needed for dry skin with start date of 10/25/2024.” During a concurrent interview and record review on 10/30/2024 at 9:45 a.m. with the Registered Nurse (RN) 8, Patient 10’s “Medication Administration Record (MAR, record of medications given to a patient),” dated 10/30/2024, was reviewed. The MAR indicated, Patient 10 received Preparation H Rectal Ointment at 9 a.m. and Vitamin A & D topical ointment at 9:03 a.m. RN 8 stated the nursing staff should take Patient 10 aside and observe Patient 10 apply the ointment to the correct area if she (Patient 10) would like to apply herself (Patient 10). During an interview on 11/1/2024 at 9:30 a.m. with the Nurse Manager (NM) 1 of BHU, NM 1 stated nursing staff should not let patients walk out with medicine cups because there were medications inside. NM 1 stated the nursing staff should apply ointment for patients or observe patients applying. NM 1 stated there was risk for patients eating the ointment or giving to someone who did not need it. During a concurrent interview and record review on 11/1/2024 at 10:14 a.m. with the Director of Pharmacy (PHARM), the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 7/2023, was reviewed. The P&P indicated, “To ensure medications are administered by authorized individuals in a safe and timely manner to meet the needs of the patient ... the authorized personnel will observe the patient take the medication and will stay with the patient until he/she has swallowed the medication.” PHARM stated the P&P should be more extensive to include different routes including topical application but nursing staff should observe ointment was applied per physician order. PHARM stated it was not a complete medication administration if nursing staff did not observe the ointment being applied as ordered by physician. 3. During review of Patient 14’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 8/13/2024, Patient 14 presented to the Facility Campus 3 (Campus 3) with increased bizarre and disorganized behavior, agitation (a feeling of irritability and severe restlessness) with thoughts of suicide (thoughts of ending one’s own life). During a concurrent interview and record review on 11/01/2024 at 9:33 a.m. with Charge Nurse 2 (CN 2), CN 2 verified Patient 14’s, “Order Information,” dated 10/06/2024 indicated a physician’s order for Patient 14 to receive valproic acid (Depakene, medication used to treat seizure disorders [abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness which describes a person’s awareness and understanding of what is happening in their surroundings], mental/mood conditions, and to prevent migraine headaches) 250 milligram/5 milliliter (mg/ml, a unit of measurement) by mouth 1000 mg twice a day after meals. During the same interview and record review on 11/01/2024 at 9:33 a.m., CN 2 verified Patient 14’s “Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient),” indicated Patient 14’s Depakene scheduled dose on 10/28/2024 at 6:00 p.m. was omitted. CN 2 stated Patient 14’s record did not have clinical documentation as to why Patient 14’s Depakene was omitted. CN 2 further stated, Patient 14’s Depakene was for mood stabilization and if omitted could cause Patient 14 to become agitated and frustrated. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” reviewed in 07/2023, the P&P indicated, “Time critical scheduled medication include: ...Psychotropic medications (drugs that affect the mind, behavior, and emotions) require timely administration to ensure patients and staff safety ...When medications eligible for a scheduled dosing time are not administered within the defined time period, the nurse will: i. Document the reason the dose was missed or delayed...Notify the prescribing/attending physician if the delay poses an immediate patient care issue and for time-critical medication...Medication errors that are the result or missed or late dose administration must be reported in accordance with hospital policy.” During a review of the facility’s policy and procedure (P&P) titled, “Medication: Error Reporting,” reviewed in 02/2023, the P&P indicated, “Medication error shall be reported and reviewed in accordance with this policy ...Examples of medication errors included but are not limited to: ...omission of a dose ...Reports to practitioner who ordered the drug. Medication errors shall be reported in a timely manner to the practitioner who ordered the drug...E. Recording errors in patient’s record. The drug administered in error or omitted in error and the action taken shall be properly recorded in the patient’s medical record...The facility shall review all medication error reports.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46238 Based on interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to develop and implement a treatment care plan (provides a framework for evaluating and providing patient care needs related to the treatment process including discharge planning) for one of 30 sampled patients (Patient 2) to ensure that Patient 2 was safely discharged from the facility in accordance with the facility’s policy and procedure regarding treatment care plan and discharge planning (the process of identifying and preparing for a patient’s anticipated health care needs after they leave the hospital). Patient 2 (who was a conserved [when another person has authority over another person based on a court decision made by a judge] patient) was discharged on 11/4/2023 without the facility notifying Patient 2’s Public Guardian (court appointed representative for Patient 2). Patient 2’s whereabouts remained unknown post discharge. This deficient practice resulted in Patient 2’s discharge planning goals not being met by not identifying the patient’s needs and risks post discharge. This deficient practice also had the potential to put Patient 2 at risk for injury and/or death since Patient 2 was diagnosed as danger to self (if a person is unable to care for himself or puts himself in a position of danger or is likely to suffer harm), thus requiring a Public Guardian. (Refer to A-0396). 2. The facility failed to ensure two of 30 sampled patients (Patient 1 and Patient 7) received medication treatment (Antibiotic topical ointment [used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns] and Prazosin [medication to treat high blood pressure]) as ordered by the physician in accordance with the facility’s policy and procedure regarding medication administration. Patient 1 did not receive the antibiotic topical ointment for seven days and Patient 7 did not receive Prazosin for 10 days. This deficient practice had the potential for Patient 1’s lacerations (cut in the skin) to develop infection and remain untreated as well as for Patient 7’s hypertension (high blood pressure) to get worse which may prolong both patients’ (Patient 1 and Patient 7) hospitalization. (Refer to A-0398) 3. The facility failed to ensure an incident of alleged abuse (intentional maltreatment of an individual that may cause physical or psychological injury) involving one of 30 sampled patients (Patient 1) was reported to the Department within the required timeframe (within 24 hours) in accordance with the facility’s policy and procedure regarding mandated reporting for abuse. This deficient practice had the potential to leave Patient 1 in an unsafe environment due to delay of investigation which may result in patient harm and/or death. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment. These deficient practices also placed the patients’ health and safety at risk by not reporting an alleged abuse incident in a timely manner (within 24 hours) and by not ensuring the safe discharge of a conserved patient. On 11/30/2023 at 5:35 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Facility Executive Director Quality Risk and PI (Performance Improvement and the Manager for PI/Quality Management. Patient 2 was admitted on a 5150 hold (involuntary detention of a patient for 72 hours for a psychiatric [mental, emotional and behavioral conditions] evaluation and treatment) for being a danger to self (DTS), on 10/29/2023 at 6:30 p.m. in the Behavioral Health Unit (area of the hospital designed to stabilize a patient with a mental health emergency). The facility’s Social Worker (SW 1) was contacted by Patient 2’s Public Guardian, who was the court’s appointed representative for Patient 2, on 10/30/2023 at 3:40 p.m. regarding Patient 2’s status. The facility failed to safely discharge Patient 2, who was conserved (when another person has authority over another person based on a court decision made by a judge) by a Public Guardian by: 1. Not updating the patient ’ s (Patient 2) information legal status on patient medical records that Patient 2 was conserved. 2. SW 1 received the notification, on 10/30/203, that Patient 2 was conserved and did not report to the interdisciplinary team (nurses, discharge planner, physician, and case manager). 3. Patient 2’s interdisciplinary (IDT- comprise of the attending psychiatrist, nursing, discharge planners, etc.) note, dated 10/31/2023 indicated, Patient 2 was going to be discharged home independently, no conservatorship status (when a judge appoints another person to act or make a decision for the person who needs help) was recorded in the note. 4. According to facility policy and procedure for Social Services, the social worker will be paired with a discharge planner. Both are required to review the notes from their counterpart daily. The discharge planner did not review the social worker’s note regarding Patient 2 being conserved on 10/20/2023. This deficient practice has resulted in Patient 2 being discharged without notification to the Public Guardian and Patient 2’s whereabouts remained unknown. On 12/1/2023 at 4:23 p.m., the IJ was removed in the presence of the Facility Executive Director Quality Risk and PI (Performance Improvement and the Manager for PI/Quality Management after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ removal plan indicated updates/revision of the facility’s policy and procedures regarding “Discharge Planning/Guidelines,” “Social Services Policy,” and “Multidisciplinary treatment Plan (treatment plan involving different disciplines such as nursing, social work, attending psychiatrist, etc.).” The revised policies included the following updates: 1. Social Work will coordinate with discharge planning on conservator status (when a judge appoints another person to act or make a decision for the person who needs help) 2. Discharge planner will review the social work discharge assessment for concurrence within 24 hours of completion 3. Social work will coordinate with discharge planning on conservator status. 4. Mandatory attendance of nursing, social work, discharge planning, recreational therapy, the attending psychiatrist and the patient (if possible) at both the initial and weekly treatment team meetings to ensure all care team members communicate and develop a plan of care and safe discharge plan. The IJ removal plan also included education and competency assessment validation for social workers and discharge planners which began 12/1/2023 until 12/6/2023.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to develop and implement a treatment care plan (provides a framework for evaluating and providing patient care needs related to the treatment process including discharge planning) for one of 30 sampled patients (Patient 2) to ensure that Patient 2 was safely discharged from the facility in accordance with the facility’s policy and procedure regarding treatment care plan and discharge planning (the process of identifying and preparing for a patient’s anticipated health care needs after they leave the hospital). Patient 2 (who was a conserved [when another person has authority over another person based on a court decision made by a judge] patient) was discharged on 11/4/2023 without the facility notifying Patient 2’s Public Guardian (court appointed representative for Patient 2). Patient 2’s whereabouts remained unknown post discharge. This deficient practice resulted in Patient 2’s discharge planning goals not being met by not identifying the patient’s needs and risks post discharge. This deficient practice also had the potential to put Patient 2 at risk for injury and/or death since Patient 2 was diagnosed as danger to self (if a person is unable to care for himself or puts himself in a position of danger or is likely to suffer harm), thus requiring a Public Guardian. On 11/30/2023 at 5:35 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Facility Executive Director Quality Risk and PI (Performance Improvement and the Manager for PI/Quality Management. Patient 2 was admitted on a 5150 hold (involuntary detention of a patient for 72 hours for a psychiatric [mental, emotional and behavioral conditions] evaluation and treatment) for being a danger to self (DTS), on 10/29/2023 at 6:30 p.m. in the Behavioral Health Unit (area of the hospital designed to stabilize a patient with a mental health emergency). The facility’s Social Worker (SW 1) was contacted by Patient 2’s Public Guardian, who was the court’s appointed representative for Patient 2, on 10/30/2023 at 3:40 p.m. regarding Patient 2’s status. The facility failed to safely discharge Patient 2, who was conserved (when another person has authority over another person based on a court decision made by a judge) by a Public Guardian by: 1. Not updating the patient’s (Patient 2) information legal status on patient medical records that Patient 2 was conserved. 2. SW 1 received the notification, on 10/30/203, that Patient 2 was conserved and did not report to the interdisciplinary team (nurses, discharge planner, physician, and case manager). 3. Patient 2’s interdisciplinary (IDT) note, dated 10/31/2023 indicated, Patient 2 was going to be discharged home independently, no conservatorship status (when a judge appoints another person to act or make a decision for the person who needs help) was recorded in the note. 4. According to facility policy and procedure for Social Services, the social worker will be paired with a discharge planner. Both are required to review the notes from their counterpart daily. The discharge planner did not review the social worker’s note regarding Patient 2 being conserved on 10/20/2023. This deficient practice has resulted in Patient 2 being discharged without notification to the Public Guardian and Patient 2’s whereabouts remained unknown. On 12/1/2023 at 4:23 p.m., the IJ was removed in the presence of the Facility Executive Director Quality Risk and PI (Performance Improvement and the Manager for PI/Quality Management after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ removal plan indicated updates/revision of the facility ’ s policy and procedures regarding “Discharge Planning/Guidelines,” “Social Services Policy,” and “Multidisciplinary treatment Plan (treatment plan involving different disciplines such as nursing, social work, attending psychiatrist, etc.).” The revised policies included the following updates: 1. Social Work will coordinate with discharge planning on conservator status (when a judge appoints another person to act or make a decision for the person who needs help) 2. Discharge planner will review the social work discharge assessment for concurrence within 24 hours of completion 3. Social work will coordinate with discharge planning on conservator status. 4. Mandatory attendance of nursing, social work, discharge planning, recreational therapy, the attending psychiatrist and the patient (if possible) at both the initial and weekly treatment team meetings to ensure all care team members communicate and develop a plan of care and safe discharge plan. The IJ removal plan also included education and competency assessment validation for social workers and discharge planners which began 12/1/2023 until 12/6/2023. Findings: During a review of Patient 2’s “History and Physical (H&P- a formal and complete assessment of the patient and the problem),” dated 10/30/2023, the “H&P” indicated, Patient 2 was admitted to the facility on a 5150 hold (a 72-hour psychiatric [mental, emotional and behavioral conditions] hospitalization, an involuntarily detention of an adult who is experiencing a mental health crisis when evaluated to be a danger to others [if a person is likely to perform an act intentionally or unintentionally to others and such act maybe either violent or nonviolent], or to himself or herself, or gravely disabled [a condition in which a person, as a result of mental disorder, is unable to provide for his or her basic personal needs for food, clothing, and shelter) for danger to self (if a person is unable to care for himself or puts himself in a position of danger or is likely to suffer harm). During a review of Patient 2’s medical record, titled “Social Services Progress Note,” dated 10/30/2023, the Social Services Progress note indicated, Social Worker (SW 1) was contacted by Patient 2’s Public Guardian (PG, court appointed representative for Patient 2) to find out about Patient 2’s well-being. The note further indicated, SW 1 documented PG’s contact information and was aware of conserved status (when another person has authority over another person based on a court decision made by a judge) of Patient 2. However, the SW 1 did not communicate Patient 2’s conservatorship status to the Discharge planner in order to have the master treatment care plan updated with the patient’s legal status. Likewise, the Discharge Planner, who participates in the interdisciplinary team meeting, to discuss the treatment care plan (provides a framework for evaluating and providing patient care needs related to the treatment process), did not review the Social worker ’ s notes regarding Patient 2’s conservatorship status. This information was verified by the Director of Behavioral Health Unit (DBHU 2). During a review of Patient 2’s Interdisciplinary (care team comprised of the attending psychiatrist, nursing, discharge planner, etc.) treatment care plan, dated 10/31/2023, the treatment care plan indicated, the treatment team participating in Patient 2’s discussion of treatment and discharge planning needs, did not include a social worker present during the meeting. The documentation further indicated, nursing created the treatment care plan and signed off on the information discussed during the meeting. The treatment care plan also indicated, nursing did not review the SW 1’s note, dated 10/30/2023, where the SW 1 documented that Patient 2 was conserved. Therefore, the information regarding Patient 2’s conserved status was not included in the treatment care plan which was prepared by nursing. During further review of Patient 2’s medical record, dated 10/30/2023 to 11/4/2023, Patient 2’s medical record did not contain any reference to Patient 2’s conserved status, no further follow up or documentation of any communication with Patient 2’s Public Guardian was done or documented, and there was no documentation of inclusion of Patient 2’s Public Guardian in discharge planning (the process of identifying and preparing for a patient’s anticipated health care needs after they leave the hospital), and there is no mention of the patient’s conservatorship in the treatment care plan to ensure that everyone is aware about the patient’s conservatorship status in preparation for a safe discharge specific to Patient 2’s needs and risks. This lack of documentation or updates in Patient 2’s treatment care plan was verified by the facility’s Director of Behavioral Health Unit (DBHU 2). During a review of Patient 2’s Discharge Summary (a summary of the patient’s health journey during their hospital stay including their initial condition, progress, treatment responses, and health status at discharge), dated 11/04/2023, the Discharge Summary indicated Patient 2 was discharged to own resources/self-care on 11/04/2023. During an interview with Patient 2’s Public Guardian (PG), on 11/27/2023 at 9:33 a.m., the PG stated, the whereabouts of Patient 2 remained unknown until 11/27/2023 (during the time of the interview). During a concurrent interview and record review on 11/29/2023 at 9:53 a.m. with the director of Behavioral Health Unit (DBHU 2) and the Discharge Planner (DP 1) Patient 2’s medical record (MR), dated 10/30/2023 to 11/4/2023, was reviewed. The MR indicated, on 10/30/2023, Patient 2 was admitted on a 5150 hold for being a danger to self (DTS). The MR further indicated, on 10/30/2023, the Social Worker (SW 1), documented being contacted by Patient 2’s Public Guardian (PG) to check how Patient 2 was doing. No further follow up by SW 1 in regard to Patient 2’s conservatorship status was documented or found in Patient 2’s medical chart. No copy of Patient 2’s conservatorship documents was uploaded in Patient 2’s chart. This finding was verified by the DBHU2 and the DP 1. Patient 2’s interdisciplinary (IDT) note (a note containing documentation of all members of the treatment team [interdisciplinary team consisting of a charge nurse, primary nurse, social worker, discharge planner and a physician]), dated 10/31/2023 indicated, Patient 2 was going to be discharged home independently, no conservatorship status was recorded in the note. The MR further indicated, on 11/3/2023, SW 1 documented, Patient 2 continued to remain on a 14-day hold (involuntary detention of a patient for psychiatric treatment as mandated by a court). DBHU 2, stated, a patient who is conserved by a Public Guardian should not be placed on an extended hold due to patient’s conserved status requiring the legally appointed Public Guardian to make psychiatric medical decisions on patient’s behalf regarding patient treatment, discharge, and placement. The DP 1 stated, Patient 2’s discharge plan had to be coordinated with Patient 2’s PG because conserved patients cannot be safely discharged to self when conserved by a Public Guardian because such patients are unable to properly care for themselves and or make safe decisions about personal safety and well-being. During an interview, on 11/29/2023 at 10:09 a.m. with social worker (SW 2), SW 2 stated, when the facility became aware of Patient 2’s unsafe discharge, the investigation showed, the SW 1 received the required conservatorship documents for Patient 2. However, SW 1 failed to upload the received legal documentation. In addition, SW 1 continued to document as if Patient 2 was on a 14-day psychiatric hold and had no legal conservator. Likewise, SW 1 failed to communicate with the care team (comprised of the attending psychiatrist, nursing, discharge planner, etc. who are involved in the care of the patient) the legal conservatorship status of Patient 2. SW 2 further stated SW 1 was terminated due to negligence because it was solely the social worker’s responsibility to obtain the conservatorship documents and communicate with the rest of the care team. During an interview on 11/29/2023 at 10:40 a.m., with discharge planner (DP 1), the DP 1 stated, updating legal status of a patient, especially the conservatorship information, is a responsibility of a social worker and the expectation is for the social worker to do the job. The DP 1 further stated, the discharge planners do not regularly read social worker’s notes. During an interview, on 11/30/2023 at 10:16 a.m. with the Director of Case Management (DCM), the DCM stated, the social worker’s job responsibility includes obtaining the conservatorship documents and communicating information with the rest of the care team. The DCM further stated, the expectation of the care team is to communicate effectively, especially the status of conserved patients as they have different discharge pathway (process of discharging a patient) and cannot be discharged without a safe plan discussed with a conservator or with a Public Guardian. DCM further stated, every patient has a social worker and a discharge planner on their case, they work in the same department and share similar responsibilities; and the expectation is for them to communicate effectively and read each other’s notes. The DCM further stated, the expectation of reading patient’s chart applies to all care team members, and all must read each other’s notes because this is what they are trained to do. During a review of the facility’s policy and procedures (P&P) titled, “Admission Assessment,” dated 10/2021, the P&P indicated, “All patients admitted to the Behavioral Health Unit (area of the hospital designed to stabilize a patient with a mental health emergency) must have legal status assessment completed to determine a legal history and a preliminary discussion to determine how much the patient ’ s legal situation will influence their progress in treatment and the urgency of the legal situation, discharge planning needs and assessment.” During a review of the facility’s policy and procedure (P&P) titled “Social Services,” dated 10/2021, the P&P indicated, “It is the policy of the Behavioral Health Unit to collaborate with the Social Service Department to provide a continuum of patient care in relation to the psychosocial, legal and discharge planning needs of patients in the Unit. Social Service staff performs a comprehensive assessment of the patient that addresses the patient’s social, emotional, functional and legal status. Based on this assessment, treatment and discharge planning needs are identified. Social Service Staff are also a liaison to ensure that the patient’s legal needs are handled in a timely manner. Social Service Staff are a part of the interdisciplinary team (comprise of the attending psychiatrist, nursing, social services, discharge planners, etc.) and provide pertinent information to nursing and physician staff regarding the patient.” During a review of the facility’s policy and procedure (P&P) titled “Conservatorship,” dated 10/2021, the P&P indicated,” If the Conservatee (a person deemed incompetent by a court) is under Public Guardianship, Behavioral Health Unit (BHU) staff will call the office of the Public Guardian immediately after admission to verify Conservatorship (when a judge appoints another person to act or make a decision for the person who needs help) and obtain treatment consent. The nurse must document in the Conservatee’s chart the person with whom the staff member spoke, Conservatorship court number, and expiration date.” During a review of the facility’s policy and procedures (P&P) titled, “Multidisciplinary (comprise of the attending psychiatrist, nuraing, social services, discharge planners, etc.) Treatment Plan,” dated 10/2021, the P&P indicated, “Each patient admitted to the BHU shall have an individualized written treatment plan which is based on interdisciplinary clinical assessments, beginning at the time of admission and continuing through discharge. Each discipline (medical, nursing, social and behavioral services, case management, and adjunct therapy [therapy given in addition to the main treatment to maximize its effectiveness) must assess the patient, address problems on the master problem list by writing interventions to be utilized by the specific discipline and should include specific discharge criteria necessary for the patient to achieve and maintain stability as deemed appropriate for the patient’s capabilities.” During a review of the facility’s policy and procedures (P&P) titled, “Multidisciplinary Treatment Plan,” dated 10/2021, the P&P indicated, “The treatment planning takes place prior to the first treatment team meeting for the patient and is reviewed at the first treatment meeting and in regular reviews.” During a review of the facility’s policy and procedure (P&P) titled “Discharge Planning,” dated 10/2021, the P&P indicated, “Discharge planning is an organized, coordinated with the disciplinary treatment team process in order to meet the unique and individualized needs of the patient...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure: 1. Two of 30 sampled patients (Patient 1 and Patient 7) received medication treatment (Antibiotic topical ointment [used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns] and Prazosin [medication to treat high blood pressure]) was administered as ordered by the physician in accordance with the facility’s policy and procedure regarding medication administration. Patient 1 did not receive the antibiotic topical ointment for seven days and Patient 7 did not receive Prazosin for 10 days. This deficient practice had the potential for Patient 1’s lacerations (cut in the skin) to develop infection and remain untreated as well as for Patient 7’s hypertension (high blood pressure) to get worse which may prolong both patients’ (Patient 1 and Patient 7) hospitalization. 2. An incident of alleged abuse (intentional maltreatment of an individual that may cause physical or psychological injury) involving one of 30 sampled patients (Patient 1) was reported to the Department within the required timeframe (within 24 hours) in accordance with the facility’s policy and procedure regarding mandated reporting for abuse. This deficient practice had the potential to leave Patient 1 in an unsafe environment due to delay of investigation which may result in patient harm and/or death. Findings: 1a. During a review of Patient 1’s “History and Physical (H&P- a formal and complete assessment of the patient and the problem)” dated 7/12/2022, the H&P indicated Patient 1 was admitted to the facility for depression (a mental disorder which involves loss of pleasure or interest in activities for long periods of time), psychosis (a mental disorder in which people have trouble distinguishing between what is real and what is not), and danger to self (if a person is unable to care for himself or puts himself in a position of danger or is likely to suffer harm). The “H&P” also indicated that Patient 1 had multiple wounds and cellulitis (infection of skin). During a review of Patient 1’s physician order dated 7/12/2022, the order indicated Triple Antibiotics topical ointment (used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) to be applied to bilateral (both) forearms and left thigh superficial lacerations (cut in the skin) twice a day for 7 days starting 7/12/2022. During a concurrent interview and record review on 11/28/2023 at 11:19 a.m. with Performance Improvement RN (RN 8), Patient 1’s “Medication Administration Record (MAR)” from 7/12/2022 to 7/18/2022 was reviewed. The MAR indicated, the Triple Antibiotic topical ointment was recorded as “not done due to equipment/supplies unavailable” on 7/12/2022 p.m. shift, 7/13/2022 a.m. shift and p.m. shift, 7/14/2022 p.m. shift, 7/15/2022 a.m. shift and p.m. shift, 7/16/2022 a.m. shift and p.m. shift, 7/17/2022 a.m. shift and p.m. shift, 7/18/2022 a.m. shift and p.m. shift. RN 8 stated the medication was not given for 7 days because it was not available per MAR. Likewise, the RNs assigned to Patient 1 did not call the pharmacy to follow-up on the missing medication (antibiotic topical ointment). The RNs just documented that the medication (antibiotic topical ointment) was unavailable. During an interview on 11/28/2023 at 3:38 p.m. with Director of Behavioral Health (DBHU2), DBHU2 stated if medication is not available, nurse should call Pharmacy to deliver the medication. DBHU2 stated, “it ’ s doctor order and we need to follow up.” DBHU2 further stated the patient could decompensate (deteriorate or worsen) and wound could potentially get worse and get infected if treatment was not done. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 11/2021, the P&P indicated, “Pharmacy will deliver the new medications to the nursing unit. Nursing has the option of picking medications up from Pharmacy.” 1b. During a review of Patient 7’s “History and Physical (H&P- a formal and complete assessment of the patient and the problem)” dated 6/8/2023, the “H&P” indicated Patient 7 was admitted to the facility for acute respiratory distress (a serious lung condition that is caused by low blood oxygen), accelerated hypertension (high blood pressure), and depression (a mental health disorder characterized by loss of interest in activities which causes significant impairment in daily life). During a concurrent interview and record review on 11/29/2023 at 12:07 p.m. with Licensed Vocational Nurse (LVN 2), Patient 7’s “Medication Administration Record (MAR)” from 11/18/2023 to 11/27/2023 was reviewed. The MAR indicated, the Prazosin (medication to treat high blood pressure) 1 milligram (mg- a unit of measurement) at bedtime to be given by mouth for 30 days starting 10/23/2023 was recorded as “not done due to patient refused” on 11/18/2023, 11/19/2023, 11/20/2023, 11/21/2023, 11/22/2023, 11/23/2023, 11/24/2023, 11/25/2023, 11/26/2023 and 11/27/2023. LVN 2 stated the medication was not given for 10 days because of patient refusal per MAR. LVN 2 said nurse should notify physician if the patient refused to take the medication and document in the nurses notes. LVN 2 further stated that there was no documentation indicating communication with physician about patient’s (Patient 7) refusal of Prazosin. During a review of Patient 7’s Vital signs (temperature, blood pressure, heart rate, respiratory rate) record on 11/29/2023 at 12:07 p.m., the Vital signs record indicated that from 11/18/2023 to 11/27/2023, when Patient 7 was refusing to take his (Patient 7) Prazosin medication for blood pressure maintenance, Patient 7’s systolic blood pressure (measures the pressure in the arteries when the heart beats) range was from 150 to 184 millimeters of mercury (mmHg- a unit of measurement; any systolic blood pressure above 130 mmHg is considered hypertensive [high blood pressure]). During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 11/2021, the P&P indicated, “when medications eligible for a scheduled dosing time are not administered within the defined time period, the nurse will notify the prescribing/ attending physician ... the physician is to be notified of all refused medications.” 2. During a review of Patient 1’s “History and Physical (H&P - a formal and complete assessment of the patient and the problem)” dated 7/12/2022, the H&P indicated Patient 1 was admitted to the facility for depression (a mental disorder involves loss of pleasure or interest in activities for long periods of time), psychosis (a mental disorder that people have trouble distinguish between what is real and what is not), and danger to self. During a review of Patient 1’s “Progress Notes Non-Physician (nurses notes),” dated 7/15/2022 at 4:02 p.m., the nurses notes indicated “bruises noted under both eyes with bright redness to left eye. When asked what happened he states, ‘I got beat up by staff.’ Charge nurse notified.” During a review of Patient 1’s nurses notes dated 7/16/2022 at 10:38 p.m., the nurses notes indicated the Police Department arrived at the facility for investigation and the physician was aware of bruises on Patient 1’s both eyes and ordered computed tomography scan of head without contrast (CT scan, an imaging test to help diagnose internal injuries and disease providing cross-sectional images of bones, blood vessels and soft tissues inside the body). During a review of Patient 1’s “CT Brain without contrast report (CT report),” dated 7/18/2022 with addendum added on 8/19/2022, the CT report indicated, “Right orbital floor fracture (there is a break in one of the bones surrounding the eyeball) with displacement of 4 millimeters (mm- a unit of measurement) is identified of questionable age.” During a review of the facility’s “Report of Adverse Event/Unusual Occurrence” report, dated 7/25/2022, the report indicated the date event of discovery of incident was 7/20/2022. However, the facility submitted the report to CDPH only on 7/26/2022 (6 days from the recorded date of discovery [7/20/2023] and 11 days from the day that Patient 1 reported the alleged assault to the nursing staff (7/15/2023]). During an interview on 11/28/2023 at 1:16 p.m. with Director of Quality (DQ), DQ stated alleged assault (when someone inflicts physical contact that causes bodily harm and/or injury to another individual) qualified for adverse event (event in which care resulted in an undesirable outcome) and it should be reported to the Department within 5 days. During an interview on 11/29/2023 at 3:05 p.m. with Director of Quality (DQ), DQ stated nurse reported Patient 1 ’ s alleged assault on 7/15/2022 in the afternoon but Quality department did not investigate until 7/20/2022. DQ said, “it was a delay on our end.” During an interview on 12/2/2023 at 12:02 p.m. with the Quality Manager (QM), QM stated everyone was a reporter when it came to abuse (intentional maltreatment of an individual that may cause physical or psychological injury). Staff should notify Adult Protective Service (APS- a government agency that assists adults when they are unable to meet their own needs, or are victims of abuse, neglect [failure to meet basic needs] or exploitation [deliberate maltreatment or manipulation]) as soon as possible and follow the step to notify charge nurse, department director and quality department. QM further stated the alleged abuser would be removed from the schedule during investigation. During a review of the facility’s policy and procedure (P&P) titled, “Abuse and Neglect,” dated 10/2021, the P&P indicated, “[Name of facility] staff will notify the Department of all physical abuse or serious injury involving a psychiatric (mental, emotional and behavioral conditions) patient by appropriately transmitted document within 24 hours of occurrence.” During a review of the facility’s policy and procedure (P&P) titled, “Mandated Adverse Event Reporting to the California Department of Public Health (agency responsible for investigation cases of reported abuse in healthcare facilities),” dated 6/2019, the P&P indicated, “It shall be the policy of the organization to report an adverse event (previously known as sentinel event), as defined by California Health and Safety Code §1279.1 (regulation that governs mandatory reporting)... to the California Department of Public Health (CDPH) no later than five days after the event has been detected ... An adverse event, as defined under the Code includes any of the following ... criminal events, including the following: the death of significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds.” The P&P further indicated, “it will be the responsibility of the Quality Management Department to develop and submit the report to CDPH, as well as serve as liaison with CDPH during the subsequent investigation process.””