Anaheim Community Hospital, LLC

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure NP 1 met the required specialty certification criteria before they were granted privileges. This deficient practice increased the risk of unqualified practitioners being granted privileges. Findings: Review of the hospital’s Medical Staff Bylaws approved 5/28/25, Section 5.1 showed every practitioner providing direct clinical services shall be entitled to exercise only those setting-specific privileges granted. Section 5.2.1 showed the Medical Staff will be responsible for developing criteria for granting setting-specific privileges. These criteria shall address the general competencies and assure uniform quality of patient care, treatment and services. On 7/24/26 at 1158 hours, a concurrent interview and review of credential files was conducted with the Quality Analyst and the Director of PI/Risk Management. Review of NP 1’s appointment letter dated 2/25/26, showed the NP was appointed to “Active Staff”. Review of the Nurse Practitioner Privilege Delineation signed on 8/27/25, showed NP 1 was granted core nurse practitioner privileges. Review of the delineation’s basic qualifications showed applicants were required to be certified in psychiatric and mental health nursing by the American Nurses Credentialing Center (ANCC), or be eligible for certification with completion within two years of employment. However, interview the Director of PI/Management confirmed the privilege delineation was used for both medical and psychiatric nurse practitioners and should have been maintained as separate privilege delineations. The Director stated NP 1 was a medical nurse practitioner, and the psychiatric certification requirement was not applicable to NP 1.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of the medical care provided to the patients as evidenced by: 1. NP 3 failed to provide a comprehensive update justification on why a legal hold was broken for Patient 2. 2. NPs 1 and 2 failed to provide accurate pulses or heart rates for Patient 2 on the provider notes. These failures increased the risk of substandard outcomes for these patients. Findings: Review of the hospital’s Medical Staff Rules and Regulations dated 2/25/26, showed the following: * Section 5.6.1 showed pertinent progress notes related to diagnosis and to treatment plan goals and objectives, sufficient to permit continuity of care, will be recorded at the time of observation. Wherever possible, each patient’s clinical problems should be clearly identified and correlated with specific orders, as well as results and treatments. * Section 5.6.2. showed physicians will document significant abnormal diagnostic values and their response to such in the progress note. On 7/23/26, Patient 2’s closed medical record was reviewed. Patient 2 was admitted to the hospital on 3/23/26 and discharged 3/31/26. 1. Review of Patient 2’s Inpatient-Hold dated 3/24/26 showed a 14-day 5250 hold was instated for the patient due to being gravely disabled as a result of a mental disorder. Review of the Family Session/Individual Therapy Note dated 3/31/26 at 1240 hours, showed family shared with ACW 1 the wish to take care of Patient 2 at home. The document showed ACW 1 consulted with NP 3, who stated the patient could go home if the family was willing to care for the patient. The legal hold would be broken, and Patient 2 could be discharged that day. However, review of the Psychiatric Progress Note dated 3/31/26 at 1305 hours, showed NP 3 documented Patient 2 had a primary diagnosis of delusional disorder, and a secondary disorder of failure to thrive, avoidant/restrictive food intake disorder and panic disorder. The reason for this level of care was being gravely disabled. Patient 2 met criteria for being gravely disabled related to prior hospitalization, psychiatric diagnosis, psychosocial factors, and poor insight. The 5250 hold was due to expire on 4/3/26. Additionally, review of Patient 2’s medical record failed to show a comprehensive evaluation and consideration to justify breaking the 14-day legal hold for being gravely disabled. 2. A random review of the Medical-Surgical Provider Consultation/Progress Note showed the following inaccurate heart rate data for Patient 2, as follows: - On 3/25/26 at 1154 hours, 3/30 at 1154 hours, and on 3/31/26 at 1157 hours, NP 1 documented Patient 2’s pulse as 17 beats/min. - On 3/27/26 at 1230 hours, NP 1 documented Patient 2’s pulse as 18 beats/min. - On 3/28/26 at 1757 hours, NP 2 documented Patient 2’s pulse as 18 beats/min. - On 3/29/26 at 1445 hours, NP 2 documented Patient 2’s pulse as 19 beats/min. On 7/27/26 at 1055 hours, the above concern was shared and acknowledged by the Director of PI/Risk Management.”

“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: 36703 Based on interview and record review, the hospital failed to ensure the Master Treatment Plan for one of three sampled patients (Patient 1), included for the management of an antipsychotic medication which was abruptly discontinued. This failure increased the risk of substandard outcomes for Patient 1. Findings: Review of the hospital’s P&P titled Master Treatment Plan Inpatient dated 8/27/25, showed each patient will have a written, individualized master treatment plan that formulates a plan of care which meets the patient’s objectives and needs. Treatment planning will provide appropriate communication between team members that fosters consistency and continuity of care for the patient. Ultimate responsibility for the development and implementation of the master treatment plan will rest with the physician. On 7/23/26, Patient 1’s closed medical record was reviewed. Patient 1 was admitted to the hospital on 11/3/25 and emergently taken to the ED on 5/19/26. Review of the hospital’s P&P titled Master Treatment Plan Inpatient dated 8/27/25, showed each patient will have a written, individualized treatment plan that formulates a plan of care which meets the patient’s objectives and needs. Treatment planning will provide appropriate communication between team members that fosters consistency and continuity of care for the patient. Ultimate responsibility for the development and implementation of the master treatment plan will rest with the physician. On 7/23/26, Patient 1’s closed medical record was reviewed. Patient 1 was admitted to the hospital on 11/3/25 and emergently taken to the ED on 5/19/26. Review of Patient 1’s Medication Adminstration Record showed Patient 1 was prescribed clozapine (an antipsychotic medication) 50 mg by mouth daily at 0900 hours and 450 mg by mouth daily at 2100 hours. Review of sampled MAR entries showed the medication was administered as ordered. Further review of a drug toxicology report dated 5/10/26 at 0943 hours, showed Patient 1’s serum clozapine level was 1,085 ng/mL, exceeding the reference range of 350-600 ng/mL. The MAR showed the scheduled clozapine dose on 5/10/26 were held due to a “High clozapine level,” and the medication was subsequently discontinued. Review of the MAR showed clozapine was reordered on 5/18/26 at 25 mg by mouth twice daily, with the first dose administered at 0844 hours. However, review of the Master Treatment Plan Review dated 5/15/26, failed to include the discontinuation of clozapine, interventions to address potential withdrawal or symptoms management during discontinuation, a plan for medication reinitiation, or alternative treatment strategies to manage the patient’s psychiatric symptoms while clozapine was withheld. On 7/27/26 at 1055 hours, the above concern was shared and acknowledged by the Director of PI/Risk Management.”

“VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(i) If verbal orders are used, they are to be used infrequently. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure RNs 1 and 2 followed the hospital’s P&P for medication telephone orders when they entered medication telephone orders into the EHR for one of three sampled patients (Patient 2). This failure increased the risk for medication errors and substandard outcomes for the patient. Findings: Review of the hospitals’ P&P titled Medication Administration and Records dated 11/19/25, showed verbal and telephone orders will be kept to a minimum and limited to after-hours and urgent situations where immediate attention is necessary. Verbal orders for non-urgent medications when the physician is available on the nursing unit will not be accepted. On 7/23/26, Patient 2’s closed medical record was reviewed. Patient 2 was admitted to the hospital on 3/23/26 and discharged 3/31/26. Review of the orders showed the following medication telephone orders entered for Patient 2: - Culturelle (probiotic) 1 capsule by mouth once now for one day was entered by RN 1 on 3/25/26 at 1702 hours, and prescribed by NP 1 on 3/25/26 at 1702 hours. - Effer-K (potassium supplement) 20 mEq effervescent tablet by mouth now for one day was entered by RN 2 on 3/30/26 at 1106 hours, and prescribed by NP 1 on 3/30/26 at 1106 hours. On 7/27/26 at 1055 hours, the above concern was shared and acknowledged by the Director of PI/Risk Management.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to protect and promote the rights of the patients as evidenced by: 1. The hospital failed to ensure the patient’s rights of being informed and making informed decisions regarding the patient care for one of five sampled patients (Patient 1) Cross reference to A0131. 2. The hospital failed to provide care in a safe setting for one of five sampled patients (Patient 1), when hospital staff failed to immediately report witnessing MHW 1 strike Patient 1 on the face with their closed fist three times Cross reference to A0144. 3. The hospital failed to protect one of five sampled patients (Patient 1) from abuse when MHW 1 was witnessed striking Patient 1 in the face three times with their closed fist. Cross reference to A0145. The cumulative effect of these systematic practices resulted in the hospital’s inability to provide quality health care in a safe environment.”

“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: 45560 Based on interview and record review, the hospital failed to ensure the patient’s rights of being informed and making informed decisions regarding the patient care for one of five sampled patients (Patient 1) as follows: 1. Patient 1’s Conservator was notified of a patient to staff assault that involved Patient 1 in a timely manner. 2. Patient 1’s Conservator was notified of Patient 1’s transfer to the emergency department due to injuries received during a code grey in a timely manner. 3. Patient 1’s Conservator was notified of Patient 1’s allegations accusing hospital staff of assault in a timely manner. These failures had the potential to limit the Conservators’ ability to make informed decisions about Patient 1’s care. Findings: The Electronic Code of Federal Regulations (eCFR) under the “Conditions of Participation: Patient’s rights” for hospitals. §482.13(b)(2) showed 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. Review of the hospital’s P&P titled Patient Rights reviewed 6/18/25, showed patients have the right to know their treatment options and take part in decisions about their care. Parents, guardians, family members, or others that patients choose can speak for them if they cannot make their own decisions. Review of Patient 1’s medical record was initiated on 5/6/26. The patient was admitted to the hospital on 4/10/24. Review of Superior Court of California, County of Orange, Costa Mesa Justice Complex, Minute Order dated 3/5/26, showed Patient 1 was placed under a LPS (Lanterman-Petris-Short) conservatorship (a California legal arrangement where a court-appointed conservator manages the care of an adult who is “gravely disabled” due to a mental health disorder or chronic substance abuse.). 1. Review of Patient 1’s Progress Note dated 3/21/26 at 0945 hours, showed a code grey was called on Patient 1 after Patient 1 assaulted a staff member (RN 4). Review of Patient 1’s Family Session/Individual Therapy Note dated 4/2/26, showed at 0918 hours, Patient 1’s Conservator was notified of the assault that occurred on 3/21/26 between Patient 1 and RN 4. The Conservator expressed concerns regarding lack of notification regarding the incident that occurred on 3/21. On 5/6/25 at 0945 hours, an interview was conducted with the HR Manager. The HR Manager stated on the Patient to Staff assault that occurred on 3/21/26, RN 4 suffered a broken nose after being punched in the face by Patient 1. On 5/7/26 at 1030 hours, a concurrent record review and interview was conducted with the Director of PI/Risk Management. The Director of PI/Risk Management was unable to locate documentation on Patient 1’s EMR showing Patient 1’s Conservator was notified on 3/21/26 of the assault that occurred between Patient 1 and RN 4. The Director of PI/Risk Management stated the staff should have notified Patient 1’s Conservator of Patient 1’s assault on RN 4 on the day of the incident. On 5/7/26 at 1050 hours a telephone interview was conducted with Conservator 1. Conservator 1 stated he was not notified of the assault that occurred between Patient 1 and RN 4 on 3/21/26 until 4/2/26. On 5/7/26 at 1341 hours, the Chief Nursing Officer and Director of PI/Risk Management were notified and acknowledged the above findings. 2. Review of Patient 1’s progress note dated 3/21/26 at 0945 hours, showed a code grey was called on Patient 1 after Patient 1 assaulted a staff member (RN 4). The progress note showed Patient 1 sustained injuries to their face during the code. Swelling and discoloration to bilateral periorbital area. Review of Patient 1’s orders dated 3/21/26, showed an order was entered at 1033 hours to transfer Patient 1 to the emergency room for a CT scan. On 5/7/26 at 1030 hours, a concurrent record review and interview was conducted with the Director of PI/Risk Management. The Director of PI/Risk Management was unable to locate documentation on Patient 1’s EMR showing Patient 1’s Conservator was notified on 3/21/26 of Patient 1 being transferred to the ED for a CT scan. The Director of PI/Risk Management stated the staff should have notified Patient 1’s Conservator of Patient 1’s transfer on 3/21/26. On 5/7/26 at 1050 hours, a telephone interview was conducted with Conservator 1. Conservator 1 stated he was not notified of Patient 1 being transferred to the ED for a CT scan 3/21/26 until 4/2/26. On 5/7/26 at 1341 hours, the Chief Nursing Officer and Director of PI/Risk Management were notified and acknowledged the above findings. 3. Review of Patient 1’s progress note dated 3/21/26 at 0945 hours showed, a code grey was called on Patient 1 after Patient 1 assaulted a staff member. The progress note showed Patient 1 sustained injuries to their face during the code. Swelling and discoloration to bilateral periorbital area. Review of Patient 1’s Family Session/Individual Therapy Note dated 3/30/26, showed Patient 1 referenced his black eyes and stated he was punched and then stated the hit went “deep.” Review of Patient 1’s Family Session/Individual Therapy Note dated 4/2/26, showed at 0918 hours, Patient 1’s Conservator was notified of Patient 1’s allegation that he was assaulted by hospital staff at the code grey that occurred on 3/21/26. On 5/7/26 at 1030 hours, a concurrent record review and interview was conducted with the Director of PI/Risk Management. The Director of PI/Risk Management was unable to locate documentation on Patient 1’s EMR showing Patient 1’s Conservator was notified on 3/30/26 of Patient 1 alleging assault by hospital staff. The Director of PI/Risk Management stated the staff should have notified Patient 1’s Conservator of Patient 1’s allegations of being physically abused by staff when Patient 1 brought the allegations to the attention of the hospital staff on 3/30/26. On 5/7/26 at 1050 hours, a telephone interview was conducted with Conservator 1. Conservator 1 stated he was not notified of Patient 1’s allegations of abuse by hospital staff on 3/30/26 until 4/2/26. On 5/7/26 at 1341 hours, the Chief Nursing Officer and Director of PI/Risk Management were notified and acknowledged the above findings.”

“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: 45560 Based on interview and record review, the hospital failed to provide care in a safe setting for one of five sampled patients (Patient 1), when hospital staff failed to immediately report witnessing MHW 1 strike Patient 1 on the face with their closed fist three times. This failure resulted in MHW 1 continuing to provide care to the hospital’s patient population and put the health and safety of all patients at risk of abuse from MHW 1. Findings: Review of the hospital’s P&P titled Elder or Dependent Abuse Reporting reviewed 10/8/25, showed in part, all staff at Anaheim Community Hospital are mandate reporters. All staff are trained to assess and report any suspected elder or dependent abuse to the appropriate county. Review of the hospital’s P&P titled Incident Reporting Policy and Classification System reviewed 6/18/25, showed in part, under definitions, incident is defined as an unusual event involving a patient, a visitor or employee which transpires in or on the premises of the hospital or within the course and scope of hospital operations. The event is considered unusual if it was unintended, undesirable or unexpected. Under procedure for staff, it showed the employee who is directly involved in the incident, either through witnessing the event or being told by a visitor that an event had occurred, should initiate the Incident Report after the incident occurs in the hospital’s incident reporting system. Review of Patient 1’s medical record was initiated on 5/6/26. The patient was admitted to the hospital on 4/10/24. Review of Patient 1’s H&P dated 4/11/24, showed Patient 1 was admitted to the hospital under a conservatorship and had a history of schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia [such as hallucinations or delusions] with a mood disorder [such as depression or bipolar disorder]). Review of Patient 1’s progress note dated 3/21/26 at 0945 hours, showed a code grey was called on Patient 1 after Patient 1 assaulted a staff member. The progress note showed Patient 1 sustained injuries to their face during the code. Swelling and discoloration to bilateral periorbital area. Review of Patient 1’s Family Session/Individual Therapy Note dated 3/30/26, showed Patient 1 referenced his black eyes and stated he was punched and then stated the hit went “deep.” On 5/6/26 at 1107 hours, an interview was conducted with MHW 2. MHW 2 stated on 3/21/26, during a code grey that involved Patient 1, they observed MHW 1 strike Patient 1 in the face with his closed fists three times. MHW 2 stated he notified Hospital Administration on 3/30/26, after Patient 1 alleged they were assaulted by MHW 1. MHW 2 acknowledged they did not inform hospital administration immediately of the witnessed staff to patient assault on 3/21/26. MHW 2 also acknowledged they did not report the incident on the hospital’s Incident Reporting System. On 5/7/26 at 1341 hours, an interview was conducted with the hospital’s CNO. When asked what the expectation was if a staff member observed another staff member verbally or physically abusing a patient in the hospital, the CNO stated they were expected to notify the House Supervisor ASAP. The CNO acknowledged MHW 2 did not report the witnessed assault on Patient 1 by MHW 1 at the time of the incident on 3/21/26, and it was only brought to the attention of the hospital administration nine days later on 3/30/26, after Patient 1 alleged they were assaulted during a code grey by MHW 1 on 3/21/26. On 5/7/26 at 1341 hours, the Chief Nursing Officer and Director of PI/Risk Management were notified and acknowledged the above findings.”

“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: 45560 Based on interview and record review, the hospital failed to protect one of five sampled patients (Patient 1) from abuse when MHW 1 was witnessed striking Patient 1 in the face three times with their closed fist. This failure resulted in Patient 1 sustaining injuries to the face and the risk of psychosocial harm to the patient. Findings: Review of the hospital’s P&P titled Elder or Dependent Abuse Reporting reviewed 10/8/25, showed in part, dependent adult is someone between 18 and 59 that has certain mental or physical disabilities that keep him or her from being able to do normal activities or protect himself or herself. The document also showed, the definition of abuse of an elder or dependent adult is physical abuse, neglect abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering. Review of Patient 1’s medical record was initiated on 5/6/26. The patient was admitted to the hospital on 4/10/24. Review of Patient 1’s H&P dated 4/11/24, showed Patient 1 was admitted to the hospital under a conservatorship and had a history of schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia [such as hallucinations or delusions] with a mood disorder [such as depression or bipolar disorder]). Review of Patient 1’s progress note dated 3/21/26 at 0945 hours, showed a code grey was called on Patient 1 after Patient 1 assaulted a staff member. The progress note showed Patient 1 sustained injuries to their face during the code. Swelling and discoloration to bilateral periorbital area. The note also showed a transfer to the ER was ordered for a CT scan of the head. Review of Patient 1’s orders dated 3/21/26, showed an order was entered at 1033 hours to transfer Patient 1 to the emergency room for a CT scan. Review of Patient 1’s Daily Nursing Flow Sheet dated 3/21/26, showed Patient 1 arrived back to the hospital at 1730 hours. Patient 1 diagnosed with facial contusion and abrasion of skin of face. Review of Patient 1’s Wound Assessment and Management note dated 3/23/26, showed a late entry was made from the code grey incident that occurred on 3/21/26. The Wound Assessment and Management note showed Patient 1 had periorbital wounds from the code grey that occurred on 3/21/26. Review of Patient 1’s Family Session/Individual Therapy Note dated 3/30/26, showed Patient 1 referenced his black eyes and stated he was punched and then stated the hit went “deep.” The document also showed, Patient 1 mentioned hitting a staff and when that incident took place, per pt 15 staff responded and “all hellfire broke loose.” The patient became tearful discussing how he had to go to the hospital after. On 5/6/26 at 1107 hours, an interview was conducted with MHW 2. MHW 2 stated on 3/21/26, during a code grey that involved Patient 1, they observed MHW 1 strike Patient 1 in the upper face and cheeks with his closed fists three times while Patient 1 was on the floor, subdued by staff in Patient 1’s room. On 5/6/26 at 0945 hours, an interview was conducted with the HR Manager. The HR Manager stated after the allegations of Patient 1 were brought to the attention of the Hospital’s Administration, it was found one staff member (MHW 2), witnessed MHW 1 strike Patient 1 in the face three times with a closed fist during the conde grey that occurred on 3/21/26. Patient 1’s assault allegations were substantiated by the hospital and MHW 1 was terminated at the conclusion of the hospital’s internal investigation on 4/14/26. On 5/7/26 at 1341 hours, the Chief Nursing Officer and Director of PI/Risk Management were notified and acknowledged the above findings.”

“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: 45560 Based on interview and record review, the hospital failed to ensure an individualized treatment plan was developed or updated to address the care needs for one of five sampled patients (Patient 1), creating the increased risk of not providing the necessary care and services to meet the care needs for the patient. Findings: Review of the hospital’s P&P titled Charting and Documentation Expectations dated 6/18/25, showed upon routine rounding peformed by an RN, any assessment, evaluation, and intervention that is performed and/or changes in the condition that, upon reassessment, warrants a change in nursing diagnosis and plan is to be charted in the electronic Medical Record. Review of Patient 1’s medical record was initiated on 5/6/26. The patient was admitted to the hospital on 4/10/24. Review of Patient 1’s Family Session/Individual Therapy Note dated 3/30/26, showed Patient 1 referenced his black eyes and stated he was punched and then stated the hit went “deep.” On 5/6/26 at 1107 hours, an interview was conducted with MHW 2. MHW 2 stated on 3/21/26, during a code grey that involved Patient 1, he observed MHW 1 strike Patient 1 in the face with his closed fists three times. MHW 2 stated he notified Hospital Administration on 3/30/26. On 5/7/26 at 1100 hours, a concurrent record review and interview was conducted with the Director of PI/Risk Management. The Director of PI/Risk Management was unable to locate an entry in Patient 1’s care plan that addressed the allegations Patient 1 made on 3/30/26, that they were assaulted by a staff member. On 5/7/26 at 1341 hours the Chief Nursing Officer and Director of PI/Risk Management were notified and acknowledged the above 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: 45560 Based on interview and record review, the hospital failed to report a patient to staff member assault that resulted in significant injury to the staff member to California Department of Public Health within 5 days as per their policy. This failure had the potential to create an unsafe environment for staff and patients at the hospital. Findings: Review of the hospital’s P&P titled Incident Reporting Policy and Classification System reviewed 6/18/25, showed in part, under definitions, incident is defined as an unusual event involving a patient, a visitor or employee which transpires in or on the premises of the hospital or within the course and scope of hospital operations. The event is considered unusual if it was unintended, undesirable, or unexpected. Pursuant to Health and Safety Code sections 1279.1 and 1279.3, adverse events shall be reported by the hospital through a secure internet website maintained by the Department pursuant to the following timelines: Adverse events that are ongoing urgent or emergent, threatening the welfare, health, or safety of patients, personnel, or visitors, shall be reported with 24 hours after the adverse event is detected. All other adverse events shall be reported to the Department no later than five (5) calendar days after the adverse event is detected. On 3/31/26, the Department of Public Health received a report from the hospital showing a staff member had been assaulted by a patient on 3/21/26 that resulted in the staff member suffering a broken nose. On 5/6/26 at 0945 hours, an interview was conducted with the HR Manager. The HR Manager stated an incident occurred on 3/21/26, where Patient 1 knocked on the door to the nurse’s station, RN 4 opened the door and was punched in the nose by Patient 1. The HR Manager stated RN 4 suffered a broken nose from the incident. On 5/7/26 at 1341 hours, the Chief Nursing Officer and Director of PI/Risk Management were notified of the above findings and acknowledged no report was sent to CDPH within 5 days of the patient to staff assault on 3/21/26, that resulted in RN 4 suffering a broken nose.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure the rights of one of five sampled patients (Patient 2) in the following areas: 1. Patient 2 and Conservator 1 were not involved in the development of the master treatment plan. 2. Conservator 1 was not notified of a medical treatment event involving Patient 1. These failures had the potential to limit the patient’s right to participate in care planning and the conservator’s ability to make informed decisions regarding the patient’s treatment. Findings: Review of the hospital’s P&P titled Master Treatment Plan/Inpatient dated 6/20/22, showed each patient admitted to the hospital will have a written, individualized master treatment plan that formulates a plan of care that meets the patient’s objectives and needs. The master treatment plan will include the patient’s involvement in the treatment plan and a guardian statement. Review of the hospital’s P&P titled Patient Rights dated 6/18/25, showed patients have the right to know their treatment options and take part in decisions about their care. Parents and guardians can speak for the patient if they cannot make their own decisions. On 4/29/26, Patient 2’s medical record review was conducted with the Director of PI/Risk Management. Patient 2 was admitted to the hospital on 11/20/25. 1. Review of Patient 2’s Temporary Letter of Conservatorship of the Person dated 1/8/26, showed Conservator 1 was appointed the temporary conservator for the patient. Review of the Master Treatment Plan Review dated 3/18/26, showed the following short-term problems identified for Patient 2: - Inability to care for self. - Alteration in reality testing. - Impaired gas exchange. - Abdominal discomfort or gastric distress. - Fall risk. - Pain. - Active infection. Further review of the document showed the RN, the social service staff, and the physician signed in attestation of the review. However, there was no signature or time stamp from Patient 2 or Conservator 1 to verify the master treatment plan was reviewed and accepted per the hospital’s P&P. 2. Review of the Progress Note dated 3/17/26 at 1342 hours, showed RN 8 observed lice on Patient 2. RN 2 documented receiving telephone orders for lice treatment, and isolation precautions. However, when asked if Conservator 1 was notified of the lice event on Patient 2, the Director of PI/Risk Management stated the conservator was not notified. On 4/30/26 at 1013 hours, the above concerns were shared and acknowledged by the Director of PI/Risk Management.”

“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: 36703 Based on interview and record review, the hospital failed to ensure one of five sampled patients (Patient 2) had documented informed consent of medications signed by Conservator 1 as per the hospital’s P&P. This failure had the potential to result in the administration of medications without authorized consent, compromising the patient’s right by placing the patient at risk for unauthorized treatment. Finding: Review of the hospital’s P&P titled Informed Consent for Psychotropic Medications dated 6/18/25, showed the patient’s legal guardian must give informed consent. On 4/29/26, Patient 2’s medical record review was conducted with the Director of PI/Risk Management. Patient 1 was admitted to the hospital on 11/20/25. Review of Patient 2’s Temporary Letter of Conservatorship of the Person dated 1/8/26, showed Conservator 1 was appointed the temporary conservator for the patient. However, review of the Consent for Psychotropic Medications showed the hospital failed to have Conservator 1 review and sign the following medications: - On 2/27/26 at 2000 hours, Patient 2 gave consent for Depakene (anti-manic) 125-2500 mg twice a day by mouth. - On 3/18/26 at 1328 hours, Patient 2 gave consent for risperidone (antipsychotic) 100-250 mg injection. Additionally, the medications Conservator 1 did give consent for, were missing the accurate date and time the authorizations were given by the conservator. For example, Conservator 1 gave verbal consent for the following medications: - Conservator 1 consented for Zyprexa (antipsychotic) 2.5 - 5 mg twice a day by mouth on 11/22/25 at 0000 hours. - Conservator 1 consented for Haldol (antipsychotic) 0.5 - 40 mg three times a day by mouth on 11/27/25 at 0700 hours. - Conservator 1 consented for Prolixin (antipsychotic) 1 - 40 mg by mouth twice a day on 12/2/25 at 2000 hours. - Conservator 1 consented for Seroquel (antipsychotic) 25-800 mg by mouth every night at 2100 hours on 1/9/26 at 1800 hours. On 4/29/26 at 1330 hours, an interview was conducted with the Director of PI/Risk Management. The Director of PI/Risk Management verified the above findings and stated the inaccurate time stamps were a known, ongoing issue that the hospital was working to resolve with the EHR provider.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the licensed nurse-to-patient ratios in the psychiatric units were maintained as required, as evidenced by: 1. Licensed nurses were assigned more patients than permitted, and the required nurse-to-patient ratios were not maintained on the following shifts: 1/3/26 AM, 1/3/26 PM, 1/10/26 PM, and 1/23/26 AM. 2. Licensed nurses were assigned six to seven patients each and were also required to cover one another’s breaks, resulting in assignments of up to 14 patients while relieving another nurse. These failures had the potential to compromise patient safety by reducing the level of supervision, delaying patient assessments and interventions, and increasing the risk of poor patient outcomes. Findings: 1. Review of the CDPH’s AFL 26-04 dated 1/27/26, showed: effective 1/1/26, SB 596 requires CDPH to treat violations of nurse-to-patient ratios on separate days as separate violations. A “day” is a 24-hour period, running from midnight to midnight. If a single nursing shift violates the ratio requirements over two calendar days, CDPH will issue two separate violations to comply with SB 596. Facilities must document their efforts to ensure compliance with nurse-to-patient staffing ratios. Facilities are not subject to an administrative penalty for violating nurse-to-patient staffing ratios if the hospital demonstrates all of the following: * Any fluctuation in required staffing levels was unpredictable and uncontrollable. * Prompt efforts were made to maintain required staffing levels. * The hospital immediately used and subsequently exhausted the hospital’s on-call list of nurses and the charge nurse. SB 596 defines on-call list as a list comprised of nurses who are scheduled to be on call for the shift and unit where an alleged violation occurred, or nurses who are assigned to a regularly scheduled float pool shift to cover any shortages across one or more specified units. A hospital contacting, or attempting to contact, licensed nurses who are not scheduled to be on call and who are not assigned to a float pool for the unit and shift where an alleged violation occurred shall not be considered as exhausting an on-call list. Hospitals are responsible for providing documentation of the specific nurses and assignments assigned for each unit upon inspection. Review of the hospital’s P&P titled Appendix C Staffing Plans for Nursing Services (undated) showed the staffing ratio/plan for psychiatric units, including 2 East (2E) and 3 South (3S), required a 1:6 nurse-to-patient ratio in accordance with Title 22, Division 5, Chapter 1, Article 3 (Section 70217). The Charge RN and Nurse Manager were identified as backup staff for multiple units, and the House Supervisor served as backup for 1 North. Backup responsibilities included covering breaks and maintaining ratio compliance when staffing shortages occurred. On 3/25/26 at 1257 hours, an interview and concurrent record review was conducted with House Supervisor 1. House Supervisor 1 stated both the House Supervisors and the Staffing Coordinator were responsible for nurse staffing. House Supervisor 1 stated the hospital did not maintain a float pool and did not schedule stand-by nurses for each shift. House Supervisor 1 stated that when a shortage occurred, the hospital contacted nurses who were not scheduled to work that shift to determine whether they could cover the shift. House Supervisor 1 stated the PM House Supervisor prepared the AM shift assignments and the AM House Supervisor prepared the PM shift assignments. House Supervisor 1 stated the Daily Patient Assignment reflected accurate assignments because 2E and 3S had planned admissions and discharges. a. Review of the Daily Patient Assignment for 1/3/26 AM Shift showed the two nurses in 2E were assigned seven patients each. Review of the Assignment sheet for 1/3/26, showed the hospital had cancelled seven nurses for the AM shift. b. Review of the Daily Patient Assignment for 1/3/26 PM Shift showed the two nurses in 2E were assigned seven patients each. House Supervisor 1 reviewed cellphone messages and was unable to provide evidence of efforts to maintain required staffing levels for the shift. On 3/25/26 at 1411 hours, an interview and concurrent record review was conducted with the Staffing Coordinator. The Staffing Coordinator was unable to provide documentation of efforts made to maintain required staffing levels for the 1/3/26 PM Shift. c. Review of the Daily Patient Assignment for 1/10/26 PM Shift showed all five licensed nurses in 3S were not within the required nurse-to-patient ratio and were assigned seven to eight patients each. Review of the Assignment sheet for 1/10/26, showed the hospital had cancelled three nurses for the PM shift. House Supervisor 1 stated the nurses were cancelled due to overstaffing, but one nurse did not report for the scheduled shift. Review of cellphone messages showed a group text message sent on 1/10/26 at 1416 hours requesting volunteers to be cancelled for the PM shift. d. Review of the Daily Patient Assignment dated 1/23/26 AM Shift showed four of the five licensed nurses in 3S were not within the required nurse-to-patient ratio and were assigned seven patients each. Review of the Assignment sheet dated 1/23/26, showed there were no scheduled stand-by nurses for that shift. 2. On 3/25/26 at 1257 hours, an interview and concurrent record review was conducted with House Supervisor 1. Record review of the Daily Patient Assignments for 1/3/26 AM, 1/3/26 PM, 1/10/26 PM, and 1/23/26 AM showed nurses were assigned six to seven patients each and were also assigned to cover one another’s breaks, resulting in assignments of up to 14 patients while relieving another nurse. For example: - On 1/3/26 (AM and PM), the two nurses in 2E were each assigned seven patients and covered one another’s breaks. - On 1/10/26 PM, all five nurses in 3S were assigned seven to eight patients each and covered one another’s breaks, resulting in assignments of up to 14 patients. - On 1/23/26 AM, four of five nurses in 3S were assigned seven patients each and covered one another’s breaks, resulting in assignments of up to 14 patients. House Supervisor 1 verified that nurses cover each other’s lunch breaks within the same unit. On 3/26/26 at 0855 hours, an interview and concurrent record review with RN 9 showed the Daily Patient Assignment for 3/26/26 AM shift showing nurses in 4W were assigned six patients each and covered one another’s breaks, resulting in assignments of up to 12 patients while relieving another nurse. On 3/26/26 at 1241 hours, an interview was conducted with the CNO. The CNO stated Charge Nurses and House Supervisors were expected to cover nurses’ lunch breaks and stated she was not aware nurses were covering one another’s breaks. The CNO stated nurses should not be covering each other’s lunch breaks. The CNO verified the hospital did not schedule stand-by nurses and did not maintain a float pool to address staffing shortages. These findings showed the hospital failed to maintain required nurse-to-patient ratios on multiple shifts and did not demonstrate that the violations met the criteria for exemption from administrative penalties under SB 596. Specifically, staffing shortages were not unpredictable or uncontrollable, as nurses were cancelled for scheduled shifts. The hospital did not provide documentation of prompt efforts to maintain required staffing levels. Additionally, the hospital did not maintain or exhaust an on-call list as defined by SB 596, as it did not utilize scheduled on-call staff or a float pool and instead contacted nurses who were not scheduled to work.”

“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: 39199 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&Ps as evidenced by: 1. RN 7 failed to wear identification while on hospital property. 2. RN 7 failed to perform hand hygiene in accordance with the hospital’s P&P. These failures posed a risk to patient safety by preventing reliable staff identification, compromising patient security, and increasing the likelihood of transmitting infectious organisms. Findings: 1. Review of the hospital’s P&P titled Identification Badges dated 8/27/25, showed all staff, visitors, and partial program patients are required to wear identification while on hospital property. Staff are required to wear identification badges while in the facility. On 3/26/26 at 0834 hours, during a medication administration, RN 7 was observed in the 4W nurses’ station, 4W hallway and in Patient 2’s room without wearing an identification badge. RN 7 verified the findings and stated they had forgotten their identification badge at home. On 3/26/26 at 0900 hours, the PI RN verified all staff were required to always wear identification badges while in the facility. 2. Review of the hospital’s P&P titled Hand Hygiene dated 11/19/25, showed the purpose of the P&P is to reduce the carriage of potentially pathogenic microorganisms on the hands of health care personnel and to prevent the transmission of potentially pathogenic microorganisms to patients and employees. Hospital personnel will decontaminate their hands to prevent the spread of infections under the following conditions and circumstances: - Before, between, and after contact with individual patients, - After removing gloves, - Before touching medications. On 3/26/26 at 0834 hours, RN 7 was observed administering medications to Patient 2, with the PI RN present. After removing medications from the automated medication dispensing cabinet in the nurses’ station, RN 7 donned gloves without performing hand hygiene, grabbed the vital sign machine, transported the machine through the hallway and into Patient 2’s room, and obtained the patient’s vital signs without removing the gloves or performing hand hygiene. RN 7 then removed the gloves without performing hand hygiene and returned the vital sign machine to the nurses’ station. RN 7 again donned gloves without performing hand hygiene, scanned each medication, and returned to Patient 2’s room wearing the same pair of gloves. RN 7 removed the medications from their packaging and handed them to Patient 2 while wearing the same gloves and without performing hand hygiene. After administering the medications, RN 7 removed the gloves without performing hand hygiene. On 3/26/26 at 0900 hours, the PI RN verified RN 7 failed to perform hand hygiene before and after patient contact, after glove removal, and before handling the patient’s medications, as required by policy.”

“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: 39199 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the provider’s medication administration orders for one of three sampled patients (Patient 2). This failure posed a risk of adverse health outcomes to the patient. Findings: Review of the Metformin drug sheet from the National Library of Medicine (undated) showed metformin does not produce hypoglycemia in patients with type 2 diabetes or normal subjects. On 3/26/26 at 0834 hours, RN 7 was observed administering medications to Patient 2. RN 7 pulled the following medications from the automated medication dispensing cabinet: - Metformin (first-line medication for managing Type 2 diabetes by reducing liver glucose production and enhancing insulin sensitivity) 500 mg, one tablet, - Amlodipine (medication used to treat high blood pressure and chest pain) 5 mg, one tablet, - Risperdal (atypical antipsychotic medication) 1 mg, three tablets, - Cogentin (medication used to treat Parkinson’s disease symptoms and movement disorders) 0.5 mg 1 tablet, and - Depakote DR (medication primarily used to treat seizure disorders, manic episodes associated with bipolar disorder, and to prevent migraine headaches) 500 mg, one tablet. RN 7 was observed administering all medications except the metformin to Patient 2. RN 7 stated the metformin was held because Patient 2 had refused a blood glucose check that morning. On 3/26/26 at 0929 hours, an interview and concurrent record review of Patient 2’s medical record was conducted with the PI RN. The PI RN stated a provider order was required to hold a scheduled medication. The PI RN stated there was no provider order or documented parameters authorizing the metformin to be held. On 3/26/26 at 0937 hours, an interview was conducted with Pharmacist 1, who stated metformin was a scheduled medication and should only be held if there was a provider order or documented parameters to do so.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the medical staff memberships were properly processed and approved as evidenced by: 1. The medical staff failed to ensure the Governing Body approved the reappointments of MD 1, MD 2, and NP 1. Required approvals from the Credentialing Committee and Board of Trustees were either missing or future-dated without proper review. 2. The hospital did not follow the reappointment process required by the Medical Staff Bylaws. The reappointment applications and updated health status for MD 1 and MD 2 were missing. 3. The hospital failed to complete and approve a new privilege form when NP 2 changed supervising physicians. These failures created the increased risk that unqualified medical staff could provide medical services to the patients. Findings: 1. During a review of Hospital’s Medical Staff Bylaws under Article 4: “Procedures for Appointment & Reappointment,” effective date 2/22/23, showed the following: 4.5.2. The Governing Body’s Action. The Governing Body shall review any favorable approval and/or recommendation from the Medical Executive Committee and take action by adopting, rejecting, modifying or sending the recommendation back for further consideration. The Governing Body shall make its final determination if needed giving great weight to the actions, approvals and recommendations of the Medical Executive Committee. During a concurrent interview and record review on 8/26/25 at 1040 hours, with the Quality Analyst and Director of PI/Risk Management, the credential files for MD 1 and MD 2 were reviewed. a. During a concurrent interview and record review on 8/26/25 at 1040 hours, with the Quality Analyst, the credential file documentation for MD 1 was reviewed. The Quality Analyst stated MD 1 was reappointed to the hospital from 6/23/22 to 6/23/25. The Psychiatrist Privilege Request form dated 5/7/25, showed MD 1 requested privileges to practice in the hospital. The form was signed by the Medical Director and Medical Executive Committee on 8/27/25. Further record review failed to show signatures from the Credential’s Committee and Board of Trustees on the form. However, the form was dated 8/27/25. The Quality Analyst stated the Governing Body meeting was scheduled on 8/27/25 and that the form was future-dated for the Credential’s Committee and Board of Trustees. b. During a review of MD 2’s credential files, it showed MD 2 was reappointed to the hospital from 6/23/22 to 6/23/25. Review of the Psychiatrist Privilege Request Form dated 6/23/25, showed MD 1 requested privilege to practice in the hospital. Further record review showed the areas to sign for Medical Director, Credential’s Committee, Medical Executive Committee, and Board of Trustee were left blank. The options of approved, denied, or deferred were also left blank. c. During a review “Hospital’s Medical Staff Bylaws” under Article 6: Allied Health Professionals. 6.2. Categories effective 2/22/23, showed the Governing Body shall determine, based upon comments of the Medical Executive Committee and such other information as it has before it, those categories of AHPs that shall be eligible to exercise privileges in the hospital. During a concurrent interview and record review on 8/26/25 at 1245 hours, with the Quality Analyst, NP 1’s credential files were reviewed. NP 1’s credential file showed NP 1 was appointed to practice at the hospital from 6/23/22 to 6/23/25. Review of the Nurse Practitioner Privilege delineation dated 8/27/25, showed the Medical Director and Medical Executive Committee signed on the form. Further record review failed to show Credential’s Committee and Board of Trustee signed on the form. However, the 8/27/25 was dated. The Quality Analyst stated the Governing Body meeting was scheduled for 8/27/25 and the Quality Analyst future-dated for Credential’s Committee and Board of Trustee. 2. Review of Hospital’s Medical Staff Bylaws under Article 4: “Procedures for Appointment & Reappointment,” effective 2/22/23, showed the following: 4.4 Application for Initial Appointment and Reappointment. 4.4.1. Application Form. Practitioners applying for appointment and reappointment shall complete a written application form that seeks information regarding the applicant and documents the applicant’s agreement to abide by the Medical Staff bylaws and Rules (including the standards and procedures for evaluating applicants contained therein) and to release all persons and entities from any liability that might arise from their investigation and/or acting on the application. 4.4.3. Basis for Reappointment. Recommendation for reappointment to the Medical Staff and for renewal of privileges shall be based upon a reappraisal of the member’s health status, current proficiency in the hospital’s general competencies in light of his/her performance at this hospital and in other settings. During a concurrent interview and record review on 8/26/25 at 1040 hours, with the Director PI/Risk Management, MD 1 and MD 2’s credential file were reviewed. MD 1 and MD 2’s credential files failed to show the reappointment application and health status. The Director PI/Risk Management stated there was no application or updated health status required for reappointment because those were done during initial appointment. 3. During a concurrent interview and record review on 8/26/25 at 1315 hours, with the Quality Analyst, NP 2’s credential file was reviewed. During a review of the Nurse Practitioner Privilege Delineation for NP 2 dated 8/28/25, showed MD 3 agreed to be a supervising physician for NP 2. During a review of the Letter in NP 2’s credential files dated 8/21/23, the Letter showed NP 2 had requested a change on their privilege form. Effective, August 21, 2023, the practitioner’s supervising physician was MD 1. The official privilege form would go through the next Credential, MEC and Governing Board meeting. Further credential record review failed to show the new Nurse Practitioner Privilege Delineation for NP 2 signed by MD 1 as supervising physician. During an interview on 8/26/25 at 1415 hours, with the Director PI/Risk Management, the Director PI/Risk Management verified the above findings.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the Medical Staff Bylaws were aligned with the hospital’s P&P regarding the appointment/reappointment duration. This failure created the risk of poor health outcomes for the patients in the hospital. Findings: During a review of the hospital’s “Medical Staff Governance and Credentialing Committee Minutes,” dated 2/17/25, the “Medical Staff Governance and Credentialing Committee Minutes” showed to accept the change from two to three years between credentialing cycles. During a review of the hospital’s P&P titled “Appointment, Advancement and Reappointment to the Medical and Allied Staff,” revised on 2/17/25, the P&P showed “... a practitioner’s reappointment is scheduled for three years from the date of their initial staff appointment ...” During a review of the “Medical Staff Bylaw,” under Article 4: Procedures for Appointment & Reappointment revised on 5/12/25, the Procedures for Appointment & Reappointment showed “reappointment and privileges to be once every two years.” During an interview and concurrent record review on 8/26/25 at 1120 hours, the Director PI/Risk Management verified the above findings. During an interview on 8/26/25 at 1120 hours, with the Director of PI/Risk Management, the Director of PI/Risk Management stated the above findings were accurate.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 39199 Based on observation, interview, and record review, the hospital failed to ensure an adequate number of mental health workers and the licensed nurse-to-patient ratio in the psychiatric units were maintained as required. This failure had the potential for poor patient outcomes. Findings: Review of the hospital’s P&P titled Appendix C Staffing Plans for Nursing Services (undated) showed the staffing ratio/plan in the psychiatric units shall be 1:6 nurse-to-patient ratio for 2 East and 3 South, and 1:4-5 nurse-to-patient ratio for the 5 North Unit. For low acuity, 2 East will have 1 MHW, 3 South will have 2 MHWs, and 5 North will have 1 MHW. The nurse-to-patient ratio is referenced by Title 22 Division 5 Chapter 1 Article 3 (70217). The Charge RN and Nurse Manager serves as backup for 2 East, 3 South, 4 West, 5 North, OR/Procedural Unit. The House Supervisor serves as backup for 1 North. Backup includes breaking and or being charge/lead to ensure ratio consistency when staff call-ins cannot be covered by the staffing coordinator. The Staffing Coordinator will contact additional staff that is needed to meet ratio when staffing it out of ratio for any unit. Review of the hospital’s P&P titled Meal Breaks and Rest Periods dated 6/23/22, showed in order to provide meal periods to employees, supervisors are required to relieve their employees of all duty, relinquish control over their activities and permit them a reasonable opportunity to take an uninterrupted 30-minute break. Supervisors must not impede or discourage employees from taking meal periods. Supervisors must also schedule meal periods and adequate relief coverage where necessary to provide meal periods consistent with this policy. Moreover, non-exempt employees may not be required to be “on-call” during meal periods. On 2/5/25 at 0915 hours, a tour of the hospital was conducted with the CNO. On 2/5/25 at 0932 hours, an interview, observation, and concurrent record review of the Daily Patient Assignment dated 2/5/25, was conducted with RN 2 in the 2 East Unit. Two nurses were observed working in the unit. RN 2 stated there were 14 patients in the unit and two nurses assigned in the unit, with each nurse assigned seven patients. RN 2 stated there was currently no MWH in the 2 East Unit as the assigned MWH was floated to the 5 North Unit. RN 2 stated there was supposed to be at least one MHW staffed in the unit, and she had to take over the MHW’s tasks and responsibilities in addition to her own. RN 2 stated the nurse-to-patient ratio was supposed to be 1:6 and verified she was out of ratio. On 2/5/25 at 0938 hours, an interview was conducted with RN 3 in the 2 East Unit. RN 3 stated he was not sure what the nurse-to-patient ratio was supposed to be, but stated he was assigned seven patients. The CNO who was in the vicinity, verified the nurses in the 2 East Unit were not within the required nurse-to-patient ratio. On 2/5/25 at 1012 hours, an interview was conducted with MHW 1 who was assigned to the 3 South Unit. MHW 1 stated she was the only MHW assigned to the 3 South Unit. On 2/5/25 at 1046 hours, an interview was conducted with LVN 1 who was assigned to the 3 South Unit. LVN 1 stated she was assigned seven patients today and verified she was out-of-ratio. On 2/5/25 at 1054 hours, an interview and concurrent record review of the Daily Patient Assignment dated 2/5/25, was conducted with RN 6. The Daily Patient Assignment showed the nurses in the 3 South Unit were assigned six to seven patients each and were also assigned to cover each other’s breaks, giving them up to 14 patients while they relieved another nurse. RN 6 verified the findings and stated it was because they did not have a Charge Nurse or Resource Nurse today to cover the nurses’ breaks. On 2/5/25 at 1313 hours, an interview and concurrent record review was conducted with House Supervisor 1, the Director of PI and RM, and the CNO. The CNO stated the nurses were out of ratio today because there were several sick calls including the Charge Nurse who would normally relieve the nurses for their breaks. The Director of PI and RM verified the 2 East Unit required one MHW and the 3 South Unit should have two MHWs and one more nurse. Review of random Daily Patient Assignments showed the following: - On 12/1/24, the morning and night shift nurses in the 2 East Unit were out of ratio. - On 12/2/24, on the morning shift, one nurse in the 2 East Unit was not within ratio, one MHW was being shared between the 2 East Unit and 5 North Unit, and there was no MHW in the 3 South Unit until 1530 hours. - On 2/1/25, on the night shift, four nurses in the 3 South Unit were out of ratio. - On 2/2/25, on the night shift, the nurse in the 5 North Unit was out of ratio, and four nurses in the 3 South Unit were out of ratio. On 2/5/25, during the interview and concurrent record review, the Director of PI and RM verified the findings.”