College Hospital

“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 its nursing staff protected one of 30 sampled patients (Patient 12) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policies regarding abuse (intentional maltreatment of an individual that may cause physical or psychological injury) prevention, assault (an intentional act that causes another person to reasonably fear imminent harmful or offensive contact, or an attempted physical attack) prevention and patient rights (subset of human rights. Example: the right to be free from abuse), when a Mental Health Worker (MHW 1) performed improper Nonviolent Crisis Intervention (NCI) technique (focus on de-escalation, safety, and managing challenging behaviors through verbal intervention and, as a last resort, physical, non-restrictive or restrictive, methods) on a psychiatric patient (someone receiving treatment or care for a mental health disorder or illness [Patient 12]) and dragged Patient 12 in the hallway in front of Patient 12’s room and into Patient 12’s room on 10/6/2025. This deficient practice resulted in Patient 12 being physically abused and feeling angry and agitated (feeling of irritability or severe restlessness) and had the potential to cause Patient 12 injury. (Refer to A-0145) 2. The facility failed to ensure its healthcare staff identified and reported physical abuse for one of 30 sampled patients (Patient 12), in accordance with the facility’s policy regarding abuse identification and reporting, when MHW 2 witnessed the incident (MHW 1 dragged Patient 12 back to Patient 12’s room) between Patient 12 and MHW 1 on 10/6/2025, but MHW 2 did not report to anyone. This deficient practice resulted in a delay in initiating investigation of the suspected abuse, allowing MHW 1 to finish the work shift (evening shift, from 3 p.m. to 11:30 p.m.) and potentially care for Patient 12 and other patients, putting Patient 12 and other patients at risk of further abuse and injury. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare 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 perform a Columbia Suicide Severity Rating Scale (CSSRS, used to assess an individual’s risk of suicide [intentionally ending one’s life]) assessment, every shift, for one of 30 sampled patients (Patient 8), who was placed on suicide precaution (implementing safety measures to protect individuals at risk of self-harm by removing sharp objects or cords, ensuring constant supervision, creating a safe environment, and restricting harmful items), in accordance with the facility’s policy and procedure regarding suicide assessment. This deficient practice had the potential for changes in suicidality (the risk of suicide, usually indicated by suicidal ideation or intent) to go undetected by staff, which may lead to self-harm due to unaddressed mental health conditions. (Refer to A-0395) 2. The facility failed to ensure the nursing staff performed assessment (in depth evaluation conducted by a registered nurse that evaluates a patient’s current physical, mental and emotional state) and notified the physician for one of 30 sampled patients (Patient 11), in accordance with the facility’s assessment protocol, when Patient 11’s body temperature was 102.6 degrees Fahrenheit (F, unit of measure [normal range 97 - 99 F]) during vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) check on 1/14/2026. This deficient practice had potential to result in delays in care and treatment for possible infection. (Refer to A-0395) 3. The facility failed to ensure its nursing staff maintained continuous direct visual observation and stayed within approximately one arm’s length of the patient, in accordance with the facility’s policy and procedure regarding observation and monitoring, for one of 30 sampled patients (Patient 11), who was placed on one-to-one (1:1) observation (a high-level safety intervention where a dedicated staff member is assigned to monitor a single patient at all times, typically within arm’s length or direct line-of-sight). Patient 11 was found unresponsive (unconscious, unable to be awakened, and does not react to voice, touch, or pain) while in use of Continuous Positive Airway Pressure (CPAP) machine (using a mask to deliver steady air pressure that keeps airways open during sleep) on 1/15/2026. This deficient practice had the potential to result in delay in identifying Patient 11’s change of breathing pattern or signs of respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway) while using CPAP machine, which may lead to complications such as cardiac arrest (when the heart stops beating), brain injury, and/or death. (Refer to A-0398) 4. The facility failed to check one of 30 sampled patient’s (Patient 1) allergies to medication prior to administering medications, in accordance with the facility’s policy and procedure regarding Medication Administration. This deficient practice resulted in Patient 1 receiving two medications (Atorvastatin [Lipitor] a medication used to lower “bad” cholesterol and triglycerides [fat in blood], while raising “good” cholesterol) and Fenofibrate [Tricor]a medication used to lower triglyceride levels and reduce “bad” cholesterol while raising “good” cholesterol), that were listed as allergies and had potential to cause adverse health effects for Patient 1 such as severe allergic reaction leading to skin rash and/or death. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe 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: 48212 Based on observation, interview and record review, the facility failed to: 1. Ensure its nursing staff protected one of 30 sampled patients (Patient 12) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policies regarding abuse (intentional maltreatment of an individual that may cause physical or psychological injury) prevention, assault (an intentional act that causes another person to reasonably fear imminent harmful or offensive contact, or an attempted physical attack) prevention and patient rights (subset of human rights. Example: the right to be free from abuse), when a Mental Health Worker (MHW 1) performed improper Nonviolent Crisis Intervention (NCI) technique (focus on de-escalation, safety, and managing challenging behaviors through verbal intervention and, as a last resort, physical, non-restrictive or restrictive, methods) on a psychiatric patient (someone receiving treatment or care for a mental health disorder or illness [Patient 12]) and dragged Patient 12 in the hallway in front of Patient 12’s room and into Patient 12’s room on 10/6/2025. This deficient practice resulted in Patient 12 being physically abused and feeling angry and agitated (feeling of irritability or severe restlessness) and had the potential to cause Patient 12 injury. 2. Ensure its healthcare staff identified and reported physical abuse for one of 30 sampled patients (Patient 12), in accordance with the facility’s policy regarding abuse identification and reporting, when MHW 2 witnessed the incident (MHW 1 dragged Patient 12 back to Patient 12’s room) between Patient 12 and MHW 1 on 10/6/2025, but MHW 2 did not report to anyone. This deficient practice resulted in a delay in initiating investigation of the suspected abuse, allowing MHW 1 to finish the work shift (evening shift, from 3 p.m. to 11:30 p.m.) and potentially care for Patient 12 and other patients, putting Patient 12 and other patients at risk of further abuse and injury. On 2/6/2026 at 11:41 a.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), Associate Administrator Hospital Operation and Director of Medical Staff Services (DIR 1), Chief Nursing Officer (CNO), Director of Quality Improvement and Risk Management (DQ), Director of Social Services (DIR 2), Program Director (DIR 3) of Developmental Delay and Mental Illness (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness), Nurse Manager (NM 1) for East ICU (intensive care unit, inpatient unit that provide treatment and therapy for adults who have mental, emotional and behavioral disorders) and Youth (inpatient unit that provide treatment and therapy for adolescents who have mental, emotional and behavioral disorders) and Nurse Manager (NM 2) for North and South ICU. 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 Mental Health Worker (MHW) 1 performed improper (incorrect) Nonviolent Crisis Intervention (NCI) technique (focus on de-escalation [a set of verbal, non-verbal, and behavioral techniques designed to calm an agitated patient, reduce anxiety, and prevent aggression or violence], safety, and managing challenging behaviors through verbal intervention and, as a last resort, physical, non-restrictive or restrictive, methods) on a patient (Patient 12) and dragged Patient 12 in the hallway in front of Patient 12’s room and into Patient 12’s room on 10/6/2025. This had resulted in Patient 12 being physically abused and feeling angry and agitated. The facility also failed to ensure its nursing staff identified and reported physical abuse after witnessing the physical abuse when MHW 2 witnessed the incident between MHW 1 and Patient 12 on 10/6/2025 but did not report to anyone. As a result, MHW 1 was able to remain at the facility to complete the work shift hence putting Patient 12 and other patients at risk for being abused in the unit (Unit 1). A review of the facility’s security video (no audio), date-stamped on 10/6/2025 at 10:07 p.m., with Nurse Manager (NM) 1, indicated Patient 12 and MHW 1 were seen in Unit 1 hallway exchanging verbal conversation. Patient 12 was in a patient gown with a blanket wrapped around her (Patient 12) shoulders. Situation was escalating as MHW 1 stepped closer to Patient 12 and Patient 12 displayed a spitting posture at MHW 1. MHW 1 then grabbed the front of Patient 12’s blanket with both hands and walked Patient 12 down the hallway towards Patient 12’s room. Both Patient 12’s arms were underneath the blanket. MHW 2 was at the end of the hallway as well but did not engage with MHW 1 and Patient 12. On the way to Patient 12’s room, Patient 12 dropped herself (Patient 12) on the floor in front of her (Patient 12’s) room while walking with MHW 1. Patient 12 was sitting on the floor and MHW 1 grabbed her (Patient 12’s) blanket (which was still wrapped around Patient 12’s shoulders) with both hands and dragged her (Patient 12) into the room. MHW 2 was in the background and witnessed the incident. NM 1 stated the way MHW 1 grabbed and dragged Patient 12 was considered physical abuse. As a result, Patient 12 was physically abused by MHW 1 and felt angry and agitated (feeling of irritability or severe restlessness). NM 1 further stated MHW 2 witnessed the incident but failed to report the abuse. NM 1 further stated there was a debriefing (a guided, structured conversation held shortly after a clinical, stressful, or, unexpected event) done with seven staff working that shift (night shift on 10/6/2025) to go over what could have been done to prevent the incident from happening. The debriefing was not provided for other staff in the same unit (Unit 1) and other units (Unit 2, 3, 4, 5, 6, 7, 8). The lack of education to all staff could result in staff continuing to perform improper NCI techniques on other psychiatric patients and not reporting the physical abuse hence putting other psychiatric patients at risk for injury physically and emotionally due to the physical abuse by staff. On 2/9/2026 at 1:39 p.m., the IJ was removed in the presence of the Chief Nursing Officer (CNO) and Director of Quality Improvement and Risk Management (DQ), 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 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, on 2/6/2026, the facility developed a new “De-escalation of Patient” policy to guide staff in proper de-escalating techniques with patients and removing triggering staff members, and revised the facility’s abuse policy titled, “Abuse, Prevention, Screening, Identification, Training, Protection, Investigation and Reporting,” on abuse prevention to include clear definitions and examples of physical, emotional, sexual, financial abuse, neglect, mistreatment, and intimidation. These policies will be reviewed and approved by 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) and Board of Directors (Governing Body [GB], responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) during an Ad-Hoc meeting (a spontaneous unplanned meeting called to address a specific, urgent issue that cannot wait for a scheduled recurring meeting) on 2/9/2026 with the GB kept informed of all findings and actions. Staff education began on 2/6/2026 and would continue daily until all clinical personnel including nursing, social services, activity therapy and behavioral team staff were trained. Training included two memorandums titled, “De-escalation Techniques” and “Identifying & Reporting Abuse,” emphasizing proper de-escalation steps, recognizing triggers, identifying different types of abuse and mandatory reporting requirements. Monitoring would include random video audits of Code Grey (alert in hospital involving an aggressive, combative, or violent person requiring staff to response and to de-escalate the situation) incidents and monthly staff interviews to ensure understanding of abuse definitions and reporting protocols (a set of established rules). Findings: 1. During a review of Patient 12’s “Psychiatric and Mental Status Examination (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/7/2025, the “psych eval” indicated, Patient 12 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 [Unit 1]) on 10/6/2025 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 increasing agitation (feeling of irritability or severe restlessness) and erratic behavior (actions, emotions, or patterns that are unpredictable, inconsistent, and deviate sharply from a person’s usual, logical, or socially accepted behavior) with diagnosis of schizophrenia spectrum (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) rule out paranoid schizophrenia (a chronic mental illness characterized by intense, irrational suspicion, persecution delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary] and auditory hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste]). During a review of Patient 12’s “Patient Progress Notes (nurses notes),” dated 10/7/2025 at 2:30 p.m., the “nurses notes” indicated, Patient 12 reported to Registered Nurse (RN) 1 that Patient 12 wanted to file a police report alleging one staff member (Mental Health Worker [MHW 1]) was abusing (intentional maltreatment of an individual that may cause physical or psychological injury) Patient 12 during the evening shift (PM shift, from 3 p.m. to 11:30 p.m.) on 10/6/2025. During an interview on 2/4/2026 at 2:30 p.m. with the Nurse Manager (NM) 1, NM 1 stated NM 1 reviewed the facility’s security footage and found MHW 1 engaged Patient 12 by himself (MHW 1), grabbed Patient 12 by the blanket and directed Patient 12 towards Patient 12’s room. NM 1 further stated Patient 12 was seen falling on the floor and MHW 1 continued to grab Patient 12’s blanket (which was wrapped around Patient 12’s shoulders) and pulled Patient 12 into Patient 12’s room. During a concurrent observation, interview, and review on 2/4/2026 at 2:47 p.m. with NM 1, the facility’s security footage (no audio), date-stamped on 10/6/2025, was reviewed. The following was observed in the facility’s security footage: -at 10:07 p.m.: Patient 12 was seen in unit (Unit 1) hallway exchanging verbal conversation with MHW 1. Patient 12 was in a patient gown with a blanket wrapped around Patient 12’s shoulders; -at 10:08 p.m.: MHW 1 stepped closer to Patient 12; -at 10:09:40 p.m.: Patient 12 displayed a spitting posture at MHW 1. MHW 1 then grabbed the front of Patient 12’s blanket with both hands and walked Patient 12 down the hallway towards Patient 12’s room. Both Patient 12’s arms were underneath the blanket. MHW 2 was at the end of hallway as well but did not engage with MHW 1 and Patient 12; -at 10:09:50 p.m.: Patient 12 dropped herself (Patient 12) on the floor in front of her (Patient 12’s) room while walking with MHW 1. Patient 12 was observed sitting on the floor and MHW 1 grabbed her (Patient 12’s) blanket (still wrapped around Patient 12’s shoulders) with both hands and dragged her (Patient 12) into the room. MHW 2 was in the background and witnessed the incident; -at 10:10 p.m.: MHW 2 walked into Patient 12’s room. -NM 1 stated that what MHW 1 did was inappropriate. NM 1 stated the way MHW 1 grabbed and dragged Patient 12 was considered a physical abuse. During an interview on 2/4/2026 at 3:27 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) also reviewed the security footage (date-stamped on 10/6/2025) of the incident between MHW 1 and Patient 12. CNO stated, “not good. This cannot be happening (referring to MHW 1’s behavior).” During an interview on 2/5/2026 at 10:06 a.m. with NM 1, NM 1 stated MHW 1 was placed on investigatory suspension (temporary leave used by employers to remove employee from the workplace while investigating alleged misconduct) on 10/7/2025 in the afternoon and was terminated on 10/9/2025 due to improper Nonviolent Crisis Intervention (NCI) technique (focus on de-escalation, safety, and managing challenging behaviors through verbal intervention and, as a last resort, physical, non-restrictive or restrictive, methods) and potential abuse. During an interview on 2/5/2026 at 10:16 a.m. with NM 1, NM 1 stated NCI technique should not be done by one person at any time because it would be difficult to control the patient’s body by oneself, and patient could end up getting hurt. During an interview on 2/5/2026 at 3:28 p.m. with MHW 2, MHW 2 stated when he (MHW 2) entered the room (Patient 12’s room) after MHW 1 and Patient 12, Patient 12 was in bed screaming and yelling. MHW 2 stated Patient 12 was angry and agitated. During an interview on 2/6/2026 at 1:10 p.m. with RN 1, RN 1 stated Patient 12 reported to RN 1 on 10/7/2025 alleging Patient 12 was dragged down the hallway by MHW 1 because she (Patient 12) was asking for a towel. During an interview on 2/6/2026 at 1:24 p.m. with RN 1, RN 1stated she (RN 1) reviewed the security footage (date-stamped on 10/6/2025) of the incident between MHW 1 and Patient 12. RN 1 stated it was not okay for MHW 1 to drag Patient 12 after Patient 12 was sitting on the floor because it compromised Patient 12’s dignity and MHW 1 did not provide safe care. RN 1 stated the incident (involving Patient 12 and MHW 1) would be considered as patient abuse. During a review of the facility’s policy and procedure (P&P) titled, “Abuse Prevention, Screening, Identification, Training, Protection, Investigation and Reporting,” dated 10/2023, the P&P indicated, “All patients have the right to be free from all forms of abuse and/or harassment... abuse: is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish.” During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Rights/ Philosophy,” dated 10/2023, the P&P indicated, “[the facility] shall support and protect the fundamental human, civil, constitutional, and statutory rights of the individual patient and recognize and respect the personal dignity of the patient at all times ... the basic patients’ rights for voluntary and involuntary patients are as follows ... the rights to individualized treatment consisting of adequate and humane services, treatment ...” During a review of the facility’s policy and procedure (P&P) titled, “Assault Precaution and Occurrence,” dated 6/2025, the P&P indicated, “Staff are to be aware of potentially escalating behaviors and redirect patient from trigger(s) ...Staff utilize NCI techniques in an effort to prevent acting out ... staff will obtain a back-up person or persons before approaching patient to discourage potentially aggressive behavior ...” 2. During a review of Patient 12’s “Psychiatric and Mental Status Examination (psych eval),” dated 10/7/2025, the “psych eval” indicated, Patient 12 was admitted to the facility’s behavioral health unit (BHU [Unit 1]) on 10/6/2025 on a 5150-hold due to increasing agitation and erratic behavior with diagnosis of schizophrenia spectrum rule out paranoid schizophrenia. During a review of Patient 12’s “Patient Progress Notes (nurses notes),” dated 10/7/2025 at 2:30 p.m., the “nurses notes” indicated, Patient 12 reported to Registered Nurse (RN) 1 that Patient 12 wanted to file a police report alleging one staff member (Mental Health Worker [MHW 1]) was abusing Patient 12 during the evening shift (PM shift, from 3 p.m. to 11:30 p.m.) on 10/6/2025. During an interview on 2/4/2026 at 2:30 p.m. with NM 1, NM 1 stated the investigation of an alleged abuse was initiated immediately after receiving Patient 12’s written complaint of being bullied by MHW 1 on 10/7/2025. During an interview on 2/4/2026 at 2:41 p.m. with NM1, NM 1 stated during investigation, it was discovered that MHW 2 witnessed the incident involving Patient 12 and MHW 1, but MHW 2 did not report the incident to anyone on 10/6/2025. MHW 2 was given a final warning for not reporting the abuse. During an interview on 2/4/2026 at 3:28 p.m. with MHW 2, MHW 2 stated he (MHW 2) was assigned to stay at Unit 1 hallway when the incident happened on 10/6/2025. MHW 2 further stated Patient 12 slipped onto the floor with her (Patient 12’s) blanket still wrapped around her (Patient 12) and MHW 1 pulled Patient 12 into Patient 12’s room. MHW 2 further stated he (MHW 2) called a code grey (alert to signify a combative, aggressive or violent person requiring immediate security response) because Patient 12 was arguing with MHW 1 and asked another staff member to relieve his (MHW 2’s) post before entering Patient 12’s room. MHW 2 further stated he (MHW 2) then saw Patient 12 was in bed screaming and yelling. MHW 2 further stated he (MHW 1) used improper NCI technique, but he (MHW 2) did not think it was a potential abuse. MHW 2 further stated he (MHW 2) did not report anything to anyone because he (MHW 2) had called the code grey and believed the incident would be investigated automatically. During an interview on 2/5/2026 at 10:10 a.m. with NM 1, NM 1 stated MHW 1 completed his (MHW 1’s) shift on 10/6/2025. NM 1 stated MHW 1 was not sent home on 10/6/2025. During an interview on 2/5/2026 at 10:19 a.m. with NM 1, NM 1 stated that all staff must report any incidents of staff using improper NCI techniques on patients so management could conduct an investigation. During an interview on 2/5/2026 at 10:20 a.m. with NM 1, NM 1 stated a verbal debriefing (a guided, structured conversation held shortly after a clinical, stressful, or, unexpected event) was done with seven (7) staff members (5 RNs and 2 MHWs) on Unit 1 to go over Patient 12’s incident and what could have been done to prevent the incident from happening. NM 1 stated the debriefing was limited to the 7 staff members in Unit 1 and did not cover other BHU units (Unit 2, 3, 4, 5, 6, 7, and 8). During a review of the facility’s policy and procedure (P&P) titled, “Abuse Prevention, Screening, Identification, Training, Protection, Investigation and Reporting,” dated 10/2023, the P&P indicated, “Identification ... should staff identify any evidence of abuse or suspected abuse, they are to report it immediately to the House Supervisor and/or Nurse Manager and an occurrence report is to be completed ... Training ... [the facility] employees are trained and oriented regarding the signs and symptoms of possible abuse and their legal requirements as mandated reporters ... Protection ... it is imperative that [the facility] protects patients from abuse during investigation of allegations of abuse or neglect. This may include, but is not limited to ...reassigning employees or placing them on investigatory suspension ... their supervisor will then immediately begin the investigation process ...””

“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: 36206 Based on interview and record review, the facility’s Medical Staff as a group failed to ensure that its Medical Staff bylaws/rules and regulations were enforced and complied with to ensure quality of patient care delivery when it failed to: 1. Ensure medical staff signed a telephone or verbal seclusion (involuntary confinement of a person in a room or an area) and restraint (a physical or chemical method used by limiting movement to prevent a patient from harming themselves or others) orders within 24 hours, for one of 30 sampled patients (Patient 6), in accordance with the facility’s Medical Staff “Rules and Regulations. The physical restraint (5-point restraints, a last-resort, high-restriction method for managing patients in imminent danger or injuring themselves or others, immobilizes all four extremities, plus a chest strap) and seclusion orders were not signed until four (4) to five (5) days after Patient 6’s seclusion and restraints were initiated. This deficient practice had the potential to result in inappropriate restraints use without proper and ongoing assessment that may lead to serious injury including skin breakdown (damage to the skin and underlying tissue) from the use of physical 5-point restraints. This deficient practice may also result in further psychological harm for Patient 6 when seclusion is inappropriately used. 2. Ensure one of 30 sampled patient’s (Patient 26) “History and Physical (H&P, document that includes an assessment, health history and plan of care),” was signed within 24 hours after Patient 26’s admission on 7/8/2024, in accordance with the facility’s Medical Staff “Rules and regulations” and the facility’s policy and procedure (P&P) pertaining to “Recording, Dictation & Suspension Procedure for 1. Psychiatric Evaluation & Mental Status Report; 2. H&P Exam,” and in accordance with federal regulation regarding the enforcement of provisions of the facility’s medical rules and regulations. Patient 26’s H&P was signed 12 days (7/20/2024) after Patient 26 was admitted to the facility (7/8/2024). This deficient practice regarding the late authentication of H&P document (the H&P was only authenticated on 7/20/2024 and Patient 26 was admitted on 7/8/2024) had the potential to negatively affect the treatment plan for Patient 26’s continuity of care due to missing information that was crucial for the healthcare team to ensure a safe, informed, and continuous treatment for Patient 26. Findings: 1. During a review of Patient 6’s “Psychiatric (the branch of medicine [psychiatry] focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) and Mental Status Examination,” dated 6/26/2025, the examination indicated Patient 6 was admitted on a 5150 Hold (an involuntary 72-hour hold for someone experiencing a mental health crisis for the purpose of evaluation and treatment) due to increasing agitation (severe restlessness and irritability) with thoughts of suicide (intentionally ending one’s life). The document also indicated Patient 6 was previously diagnosed with schizoaffective disorder, bipolar type (a chronic mental health condition characterized by a combination of schizophrenia symptoms [hallucinations- a false perception of objects or events involving your senses: sight, sound, smell, touch and taste, delusions- a fixed, false belief that is firmly maintained despite incontrovertible evidence to the contrary]) and bipolar mood episodes (mania [period of abnormally elevated mood with high energy and racing thoughts] and sometimes depression [persistent feelings of sadness, emptiness, or loss of interest in activities]). During a review of Patient 6’s Physician “Orders,” dated 8/9/2025 through 8/10/2025, the Orders indicated the following: -On 8/9/2025 at 9:25 a.m., Verbal order for Physical Hold (a type of restraint, a high-level manual intervention using bodily contact to restrict a person’s movement against their will to prevent immediate harm to self or others) was obtained and verified with Psychiatrist (MD 2) by nursing staff due to Patient 6 punching walls and cutting arm with fork. MD 2 electronically signed the verbal order on 8/14/2025 at 10:36 a.m. (5 days after the physical hold verbal order was given to staff). -On 8/9/2025 at 9:51 a.m., Verbal order for Seclusion (involuntary confinement of a person in a room or an area) was obtained and verified with Psychiatrist (MD 2) by nursing staff due to Patient 6 being a danger to others. MD 2 electronically signed the verbal order on 8/14/2025 at 10:36 a.m. (5 days after the seclusion verbal order was given to staff). -On 8/9/2025 at 9:51 a.m., Verbal order for 5 points restraints (a last-resort, high-restriction method for managing patients in imminent danger or injuring themselves or others, immobilizes all four extremities [both arms and legs], plus a chest strap) was obtained and verified with Psychiatrist (MD 2) by nursing staff due to Patient 6 being a danger to self. MD 2 electronically signed the verbal order on 8/14/2025 at 10:36 a.m. (5 days after the 5 points restraints verbal order was given to staff). -On 8/10/2025 at 7:37 p.m., Verbal order for physical hold was obtained and verified with Psychiatrist (MD 2) by nursing staff due to Patient 6 attempting to assault (an intentional act that causes another person to reasonably fear imminent harmful or offensive contact, or an attempted physical attack) peer, threw two cups of water to said peer, and “destroying hospital property.” MD 2 electronically signed the verbal order on 8/14/2025 at 10:38 a.m. (4 days after the physical hold order was given to staff). -On 8/10/2025 at 7:49 p.m., Verbal order for 5 points restraints was obtained and verified with Psychiatrist (MD 2) by nursing staff due to Patient 6 attempting to assault peer, threw two cups of water to said peer, and “destroying hospital property.” MD 2 electronically signed the verbal order on 8/14/2025 at 10:38 a.m. (4 days after the 5 points restraints order was given to staff). -On 8/10/2025 at 7:49 p.m., Verbal order for Seclusion was obtained and verified with Psychiatrist (MD 2) by nursing staff due to Patient 6 attempting to assault peer, threw two cups of water to said peer, and “destroying hospital property.” MD 2 electronically signed the verbal order on 8/14/2025 at 10:38 a.m. (4 days after the seclusion order was given to staff). During a concurrent interview and record review on 2/6/2026 at 2:25 p.m. with Nurse Manager (NM 1), NM 1 stated the following: nursing staff obtained verbal/telephone orders on 8/9/2025 and 8/10/2025 to place Patient 6 on a physical hold, 5-point restraints and seclusion. NM 1 verified that the orders were electronically signed by the Psychiatrist (MD 2) only on 8/14/2025. During an interview on 2/6/2026 at 11:16 p.m. with the Psychiatrist (MD 2), MD 2 stated that physicians should sign verbal and telephone orders within 24 hours. During an interview on 2/9/2026 at 2:29 p.m. with the Chief Executive Officer (CEO), the CEO stated that the Governing Board (same as Governing Body, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) had oversight of the entire hospital. The Governing Board approves the Medical Bylaws (set the framework for the working relationship of the medical staff, hospital administration and governing body, and assures legal protections are in place) and Rules and Regulations and physicians should follow the Rules and Regulations. The CEO verified that according to the facility’s “Rules and Regulations,” physicians should sign the verbal or telephone orders within 24 hours. During a review of the facility’s Medical Staff “Rules and Regulations,” dated 6/2024, the Rules and Regulations indicated the following: Every member of the Medical Staff shall adhere to these Rules and Regulations and is responsible for apprising himself of the policies and procedures for the Hospital and of each clinical service and program on which he has privileges to treat patients and shall adhere to same. Section 3.16, Use of Restraints and Seclusion: Patients who pose an immediate threat to safety of themselves and others may be restrained or secluded without Psychiatrist’s order by the RN (registered nurse) in charge of the unit, to the extent necessary to assure their safety and the safety of others ...The patient’s attending Psychiatrist shall be contacted for an appropriate time-limited order immediately when his patient has been placed in restraints or seclusion and is safe ...The attending psychiatrist will sign the order(s) for restraint or seclusion no later than twenty-four (24) hours after the restraint or seclusion occurs. 2. During a review of Patient 26’s “Medical History and Physical Examination,” undated, the record indicated Patient 26 was admitted to the facility on 7/8/2024 for Suicidal Ideation (idea of self-harm). Patient 26’s medical history included prediabetes (a serious health condition where blood sugar levels are higher than normal but not yet high enough for a type 2 diabetes diagnosis), high cholesterol and celiac disease (difficulty breaking down food and sensitivity to gluten [protein found in some food]). Patient 26’s psychiatric history included previous suicide attempts. During a concurrent interview and record review on 2/9/2026 at 10:10 a.m. with Nurse Manager (NM) 2, Patient 26’s “H&P,” undated, was reviewed. NM 2 acknowledged the H&P was signed on 7/20/2024 (12 days after Patient 26 was admitted on 7/8/2024). NM 2 stated patients should be seen by the physician within 24 hours, and the H&P should be signed within 24 hours. During a continued concurrent interview and record review on 2/9/2026 at 2:35 p.m. with the CEO and DIR 1, Patient 26’s “H&P,” undated, was reviewed. DIR 1 stated the physician will see a patient within 24 hours, and the physician will fill out a written H&P or dictate (speak the words and a machine will write it out). DIR 1 and CEO reviewed Patient 26’s H&P and confirmed the date of admission (7/8/2024) and the date the document was signed which was on 7/20/2024. DIR 1 stated the document (H&P) should have been signed within 24 hours (of admission) and stated, “It looks like it’s late (Referring to the signed H&P indicating 7/20/2024 even though Patient 26 was admitted on 7/8/2024).” During a review of the facility’s Medical Staff “Rules and Regulations,” dated 6/2024, the Rules and Regulations indicated, “Every member of the Medical Staff shall adhere to these Rules and Regulations and is responsible for apprising himself of the policies and procedures for the Hospital and of each clinical service and program on which he has privileges to treat patients and shall adhere to same...Admitting History and Physical: A complete medical history and physical will be performed and dictated within 24 hours after admission of the patient. The Hospital will provide an internist /family practitioner/general practitioner or pediatrician member of the Medical Staff who will perform a history and physical.” During a review of the facility’s policy and procedure (P&P) titled, “Recording, Dictation & Suspension Procedure for 1. Psychiatric Evaluation & Mental Status Report; 2. H&P Exam,” dated 11/2023, the P&P indicated: “Each history and physical examination will be performed within 24 hours after admission. H&P can be typed into the EMR (electronic medical record) under H&P Note within 24 hours of admission or dictation must occur within 24 hours of admission and MD Dictation Number Note created.””

“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: 36206 Based on interview and record review the facility failed to: 1. Perform a Columbia Suicide Severity Rating Scale (CSSRS, used to assess an individual’s risk of suicide [intentionally ending one’s life]) assessment, every shift, for one of 30 sampled patients (Patient 8), who was placed on suicide precautions (implementing safety measures to protect individuals at risk of self-harm by removing sharp objects or cords, ensuring constant supervision, creating a safe environment, and restricting harmful items), in accordance with the facility’s policy and procedure regarding suicide assessment. This deficient practice had the potential for changes in suicidality (the risk of suicide, usually indicated by suicidal ideation or intent) to go undetected by staff, which may lead to self-harm due to unaddressed mental health conditions. 2. Ensure the nursing staff performed assessment (in depth evaluation conducted by a registered nurse that evaluates a patient’s current physical, mental and emotional state) and notified the physician for one of 30 sampled patients (Patient 11), in accordance with the facility’s assessment protocol, when Patient 11’s body temperature was 102.6 degrees Fahrenheit (F, unit of measure [normal range 97 - 99 F]) during vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) check on 1/14/2026. This deficient practice had potential to result in delays in care and treatment for possible infection. Findings: 1. During a review of Patient 8’s Initial Psychiatric (treatment or care for a mental health disorder or illness) Note, dated 1/31/2026, the Note indicated the following: Patient 8 had a history of schizoaffective disorder (a mental health disorder where you experience psychosis [loss of contact with reality] as well as mood symptoms) and noncompliant with treatment and medication. Patient 8 was admitted to the hospital on a 5150 Hold (a 72-hour involuntary hold for someone experiencing a mental health crisis for the purpose of evaluation and treatment) for danger to self (thought of hurting one’s self). The Psychiatric Note also indicated that patient (Patient 8) stated “she wanted to cut herself past two (2) days ...feeling hopeless depressed at times, useless, actively suicidal unable to contract for safety ...” During a review of Patient 8’s “Psychiatric Physician Admission Order,” entered on 1/31/2026, the order indicated, “Precautions: Suicide (Intentionally ending one’s life).” During a review of Patient 8’s “Reassessment for Suicide Risk/Precautions, Columbia Suicide Severity Rating Scale (CSSRS, used to assess an individual’s risk of suicide),” dated 2/3/2026, the Reassessment record indicated the following: -“Reassessment is to be completed every shift or at least every 8 hours for: All patients that are on any type of suicide precautions or heightened observations for self-injurious behaviors ...Suicide Precautions Document Q (every) shift or Q 8 hours.” -Times of reassessments performed for Patient 8 on 2/3/2026 were as follows: -1:56 a.m. (night shift, 11 p.m. - 7 a.m.), “Patient (Patient 8) is resting upon time assessment. Unable to assess SI (suicidal ideations), method, intent and plan. Will continue to monitor suicide precautions per MD (physician) order.” -Day shift (7 a.m. to 3:30 p.m.) - No Entry of suicide reassessment. -4:46 p.m. (Evening shift, 3 p.m. - 11 p.m.), “Patient (Patient 8) minimizes any SI, intent, method, bx, or plan at this time. Per MD order will continue suicide precautions.” During a concurrent interview and record review on 2/6/2026 at 10 a.m. with Nurse Manager (NM 1), NM 1 stated the following: Patient 8 was admitted on 1/31/2026 and was placed on a 5150 Hold for being a danger to herself. Patient 8 was placed on suicide precautions (implementing safety measures to protect individuals at risk of self-harm by removing sharp objects or cords, ensuring constant supervision, creating a safe environment, and restricting harmful items). NM 1 verified that on 2/3/2026, Patient 8’s CSSR assessment was not performed during the day shift (7 a.m. - 3:30 p.m.). NM 1 stated Patients on suicide precautions should be assessed every shift for suicidality and/or changes of thoughts and behaviors. NM 1 also said that if there were any changes in thoughts and behaviors of the patient, interventions should be implemented to address any changes. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Assessment and Precautions,” revised 10/2023, the P&P indicated the following: Patients at risk for suicide and/or self-destructive behavior require intensive support, close observation, frequent re-assessment, and indicated protective measures for their emotional and physical welfare at all times. Patients are assessed for suicide upon admission and re-assessment throughout their hospitalization to determine their level of risk ...RN (registered nurse) C-SSRS Screening Assessment every shift for patients under suicide precautions; every 24 hours for all other patients. 2. During a review of Patient 11’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/6/2026, the “psych eval” indicated, Patient 11 was admitted to the facility on 1/5/2026 with diagnosis including but not limited to schizoaffective disorder (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 type (mental illness that causes dramatic shifts in a person’s mood, energy and ability to think clearly). During a concurrent interview and record review on 2/3/2026 at 2:42 p.m. with Nurse Manager (NM 2), Patient 11’s “Patient Progress Notes,” dated 1/14/2026, was reviewed. The “Patient Progress Notes” indicated, on 1/24/2026 at 3:33 p.m., Patient 11’s body temperature was 102.6 degrees Fahrenheit (F, unit of measure [normal range 97 - 99 F]) and heart rate was 109 beats per minute (bpm, unit of measure; normal range is 60-100 bpm). NM 2 confirmed that Patient 11’s temperature and heart rate were elevated (high) and would require a nurse to assess Patient 11 and to notify the physician. During a concurrent interview and record review on 2/6/2026 at 9:11 a.m. with NM 2, Patient 11’s “Patient Progress Notes,” dated 1/14/2026, was reviewed. The “Patient Progress Notes” indicated, Patient 11’s vital signs were documented as within normal limits in the physical assessment performed on 1/14/2026 at 4:15 p.m. However, NM 2 stated that was incorrect because Patient 11’s temperature (102.6 degrees Fahrenheit) and heart rate (109 beats per minute) were elevated. During the same concurrent interview and record review on 2/6/2026 at 9:11 a.m. with NM 2, NM 2 stated that the nurse should have rechecked Patient 11’s temperature and assessed Patient 11 for any symptoms relating to the fever (elevated body temperature) and notify the physician. NM 2 stated elevated temperature could be an indicator of infection. NM 2 further stated Patient 11’s physician should be notified for possible treatment including but not limited to antipyretic (medications to lower fever) and antibiotics (medications to treat infection). NM 2 also said Patient 11’s nurse did not recheck Patient 11’s temperature, did not reassess Patient 11 and did not notify Patient 11’s physician for the elevated temperature. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Assessment Protocol,” dated 10/2023, the P&P indicated, “Purpose: to determine that the appropriate care, treatment, and services are being provided to meet the patient’s changing needs ... to respond to significant changes in the patient’s status or condition ... Procedure ... it is the responsibility of the RN (Registered Nurse) to analyze that data into an assessment and to make care, treatment, and service decisions based on that assessment.””

“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 observation, interview and record review, the facility failed to ensure its nursing staff maintained continuous direct visual observation and stayed within approximately one arm’s length of the patient, in accordance with the facility’s policy and procedure regarding observation and monitoring, for one of 30 sampled patients (Patient 11), who was placed on one-to-one (1:1) observation (a high-level safety intervention where a dedicated staff member is assigned to monitor a single patient at all times, typically within arm’s length or direct line-of-sight). Patient 11 was found unresponsive (unconscious, unable to be awakened, and does not react to voice, touch, or pain) while in use of Continuous Positive Airway Pressure (CPAP) machine (using a mask to deliver steady air pressure that keeps airways open during sleep) on 1/15/2026. This deficient practice had the potential to result in delay in identifying Patient 11’s change of breathing pattern or signs of respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway) while using CPAP machine, which may lead to complications such as cardiac arrest (when the heart stops beating), brain injury, and/or death. Findings: During a review of Patient 11’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/6/2026, the “psych eval” indicated, Patient 11 was admitted to the facility on 1/5/2026 with diagnosis including but not limited to schizoaffective disorder (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 type (mental illness that causes dramatic shifts in a person’s mood, energy and ability to think clearly). The “psych eval” also indicated, Patient 11 had sleep apnea (a common, serious disorder where breathing repeatedly stops and starts during sleep). During a review of Patient 11’s “Physician order (orders written by physicians to direct care and treatment),” dated 1/13/2026, the physician order indicated, one-to-one (1:1) observation (a high-level safety intervention where a dedicated staff member is assigned to monitor a single patient at all times, typically within arm’s length or direct line-of-sight) for patient safety for usage of CPAP (Continuous Positive Airway Pressure machine, using a mask to deliver steady air pressure that keeps airways open during sleep) while patient (Patient 11) was asleep. During a review of Patient 11’s “Patient Progress Notes,” dated 1/15/2026, the “Patient Progress Notes” indicated, “(on 1/15/2026) at the beginning of 0100 (1 a.m.) ... MHW (Mental Health Worker [MHW 10]) noticed the patient (Patient 11) who is on CPAP stopped breathing and turned blue around 0100 (1 a.m.) Nurse notified and code blue called 0101 (1:01 a.m.) ... CPR (cardiopulmonary resuscitation, any medical intervention used to restore circulatory and/or respiratory function that has ceased) initiated 0102 (1:02 a.m.) ... EMS (emergency medical service, ambulance crew responding to 911 call) arrived at 0110 (1:10 a.m.) and took over CPR ... pronounced time of death at 0130 (1:30 a.m.).” During an interview on 2/3/2026 at 2:08 p.m. with Nurse Manager (NM 2), NM 2 stated Patient 11 was put on CPAP machine on 1/14/2026 at around 11:30 p.m. During an interview on 2/3/2026 at 2:27 p.m. with Chief Nursing Officer (CNO), CNO stated CPAP machine was considered as medical equipment. CNO further stated per facility’s policy, one-to-one (1:1) observation was required while patient was using a CPAP machine. CNO further stated the assigned 1:1 staff was responsible for monitoring patient’s breathing for chest rise and fall and check for signs of respiratory distress while patient was sleeping with CPAP machine. During an interview on 2/3/2026 at 2:51 p.m. with NM 2, NM 2 stated the following: an internal investigation was conducted after Patient 11’s incident. It was found that Mental Health Worker (MHW) 9, MHW 10 and CN 4 performed the 1:1 observation while Patient 11 was using CPAP machine on 1/14/2026. MHW 9, MHW 10 and CN 4 relied on listening to Patient 11’s breathing instead of providing continuous direct visual monitoring for Patient 11 while under 1:1 observation. MHW 9, MHW 10 and CN 4 no longer worked for the facility. During a concurrent observation, interview, and record review on 2/3/2026 at 2:57 p.m. with NM 2, facility’s security video (no audio) with date-stamped from 1/14/2026 11:30 p.m. to 1/15/2026 at 1:02 a.m., was reviewed. The following was observed from the facility’s security video footage: -at 11:34 p.m.: Patient 11 was in bed with CPAP mask over the face. A staff turned off the light and left the room. There was a Mental Health Worker (MHW 9) sitting outside the room by the door; -at 11:43 p.m.: MHW 9 turned on room light to check on Patient 11. Patient 11 gave a thumbs up to MHW 9. MHW 9 then turned off the light and stayed by the doorway. Room was dark; -at 12:01 a.m. - 12:10 a.m.: MHW 9 was by the doorway, but MHW 9 was observed turning their back to and not facing Patient 11 multiple times; -at 12:20 a.m.: MHW 9 switched with MHW 10. MHW 10 stayed by the doorway while Patient 11 was in bed; -at 12:25 a.m. - 12:28 a.m.: MHW 10 was by the doorway, but MHW 10 was observed turning their back to and not facing Patient 11 multiple times; -at 12:29 a.m.: MHW 10 switched with Charge Nurse (CN 4). CN 4 stayed by the doorway and at 12:31 a.m. shined light by the doorway into Patient 11’s room. CN 4 did not enter Patient 11’s room; -at 12:48 a.m.: CN 4 switched with MHW 10. MHW 10 stayed by the doorway. MHW 10 was sitting in a chair with their back facing Patient 11; -at 1:01 a.m.: MHW 10 entered Patient 11’s room with a flashlight and shined in the room close to Patient 11. Then MHW 10 got another staff to go in to check on Patient 11. Room light was turned on. Patient 11 was in bed with CPAP mask on but unresponsive (unconscious, unable to be awakened, and does not react to voice, touch, or pain); -at 1:02am: multiple staff arrived in Patient 11’s room and initiated CPR on Patient 11. -NM 2 stated MHW 9, MHW 10 and CN 4 were the staff assigned to perform 1:1 observation on Patient 11 during the time of the incident. NM 2 further stated MHW 9, MHW 10, and CN 4 did not remain within arm’s length of Patient 11 and did not maintain direct visual monitoring during the 1:1 observation. NM 2 further stated Patient 11’s room was dark and the staff (MHW 9, MHW 10 and CN 4) were too far away to observe Patient 11’s breathing. During a review of the facility’s policy and procedure (P&P) titled, “Observation and Monitoring (Q15 [every fifteen minutes]/ 1:1 [one to one]),” dated 7/2025, the P&P indicated, “All patients will be routinely observed in compliance with physician orders and prescribed protocols. Staff members assigned to each patient will provide continuous monitoring, precautions, oversight and intervention to provide for their safety and security ... one-to-one observations (1:1) ... clinical criteria ... requiring medical equipment (during use of the equipment) ... for patient requiring medical equipment ... when the medical equipment is in use, the patient is to be placed on 1:1 with the assigned staff within arm’s reach of the patient and equipment at all times ... A specified and dedicated staff member will stay within approximately one arm’s length of the patient on 1:1 observation. This continuous direct visual observation will remain at all times ...””

“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: 36206 Based on interview and record review, the facility failed to check one of 30 sampled patient’s (Patient 1) allergies to medication prior to administering medications, in accordance with the facility’s policy and procedure regarding Medication Administration. This deficient practice resulted in Patient 1 receiving two medications (Atorvastatin [Lipitor] a medication used to lower “bad” cholesterol and triglycerides [fat in blood], while raising “good” cholesterol) and Fenofibrate [Tricor]a medication used to lower triglyceride levels and reduce “bad” cholesterol while raising “good” cholesterol), that were listed as allergies and had potential to cause adverse health effects for Patient 1 such as severe allergic reaction leading to skin rash and/or death. Findings: During a review of Patient 1’s “Psychiatric Discharge Summary,” dated 1/19/2026, the discharge summary indicated the following: Patient 1 was admitted on 12/31/2024 and discharged on 1/17/2026. Patient 1 was brought on a 5150 hold (a 72-hour involuntary hold) after recently becoming very violent at her place. The Psychiatric Discharge Summary also indicated “Hospital Course: The patient (Patient 1) was doing fairly well ...The patient (Patient 1) decompensated (rapid worsening of symptoms) where there were increased liver enzymes as well as CPK (creatine phosphokinase, an enzyme that aids in energy production, detects muscle damage, heart attacks or brain injury) of which she was admitted to an outside hospital for medical evaluation (on 1/17/2026) ...” During a review of Patient 1’s “Record of Admission (second admission after the discharge to an acute care hospital on 1/17/2026 for further evaluation of increased liver enzymes),” the Record of Admission indicated Patient 1 was admitted on 1/25/2026 at 6:57 p.m. (Patient 1’s readmission date after being discharged on 1/17/2026) and discharged on 1/28/2026 (second discharge of Patient 1) to a general acute care hospital. During a review of Patient 1’s “Physician Entered Orders,” dated 1/25/2026, by Internist Physician (MD 3), MD 3 entered the following medication orders: -On 1/25/2026 at 8:46 p.m., Atorvastatin (or Lipitor, a prescription medication in the statin class, used to lower “bad” cholesterol and triglycerides [fat in blood], while raising “good” cholesterol) 10 milligrams (mg, a unit of measure) at bedtime (QHS) by mouth (PO). - On 1/25/2026 at 8:47 p.m., Fenofibrate (Tricor, a medication used to lower triglyceride levels and reduce “bad” cholesterol while raising “good” cholesterol) 160 mg QHS PO. During a review of Patient 1’s Medical History and Physical (H&P, a comprehensive assessment of a patient’s health status), dated 1/26/2025 12:04 p.m., entered by Internist Physician (MD 4), the H&P indicated the following: “Patient (Patient 1) was noted to have rhabdomyolysis (a serious, potentially life-threatening syndrome involving the rapid breakdown of damaged skeletal muscle, releasing toxic intracellular contents like myoglobin into the bloodstream, which can cause acute kidney failure) and was sent to ER (outside emergency department; Patient sent to ER on 1/17/2026) ...Assessment: s/p (status post) abnormal LFT (liver function test, measure enzymes, proteins, and substances produced by the liver to assess overall health, screen for diseases, and monitor damage or medication side effects) and rhabdomyolysis: Lipitor and Fenofibrate discontinued ...hyperlipidemia (excess fats in the bloodstream) - Fenofibrate and Lipitor discontinued due to rhabdomyolysis.” During a review of Patient 1’s “Allergies,” the following allergies were listed: -On 1/26/2026 at 12:22 p.m., Lipitor was entered by Internist Physician (MD 4). Reactions: Lethargy (profound state of sluggishness, drowsiness, unusual lack of energy and mental alertness); Rhabdomyolysis. -On 1/26/2026 at 12:22 p.m., Fenofibrate was entered by (MD 4). Reactions: Lethargy; Rhabdomyolysis. During a review of Patient 1’s progress notes titled, “Medication,” the progress notes indicated the following: -On 1/26/2026 at 8:17 p.m., Fenofibrate 160 mg was given by mouth (oral). -On 1/26/2026 at 8:18 p.m., Lipitor 10 mg was given by mouth. -On 1/27/2026 at 8:33 p.m., Lipitor 10 mg was given by mouth. -On 1/27/2026 at 8:34 p.m., Fenofibrate 160 mg was given by mouth. During a concurrent interview and record review on 2/4/2026 at 1:12 p.m. with Nurse Manager (NM 1), NM 1 stated the following: Patient 1 was readmitted on 1/25/2026 at 6:57 p.m. after being discharged to a general acute care hospital on 1/17/2026 for elevated liver enzymes and diagnosed with rhabdomyolysis. MD 3 was covering for MD 4 on the evening of 1/25/2026. MD 3 entered admission orders for Patient 1. MD 3 ordered Lipitor and Fenofibrate for Patient 1 on 1/25/2026. Per Patient 1’s H&P dated 1/26/2026 at 12:04 p.m., Patient 1 was noted to have elevated liver enzymes and rhabdomyolysis and was sent to the emergency department for evaluation (1/17/2026). MD 4 noted that Lipitor and Fenofibrate were discontinued due to rhabdomyolysis. NM 1 noted there was a discrepancy between MD 3’s order for Lipitor and Fenofibrate and MD 4’s documentation that Lipitor and Fenofibrate were discontinued due to rhabdomyolysis. NM 1 stated that on 1/28/2026, Patient 1 suffered a code blue (a critical, life-threatening emergency, usually experiencing cardiac or respiratory arrest) and was transferred to a general acute care hospital and diagnosed with septic shock (where infection causes severe, widespread inflammation, leading to dangerously low blood pressure and significant organ failure), acute hypoxic respiratory failure (a life-threatening, sudden inability of the lungs to oxygenate blood), and shocked liver (acute liver damage caused by a sudden, severe reduction in blood flow or oxygen delivery to the organ). During a second concurrent interview and record review on 2/6/2026 at 1:20 p.m. with NM 1, NM 1 verified that on 1/26/2026 at 12:22 p.m., MD 4 documented that Patient 1 was allergic to Lipitor and Fenofibrate. NM 1 verified that Patient 1 received Lipitor and Fenofibrate on 1/26/2026 and 1/27/2027. NM 1 verified that MD 4 did not discontinue the medications and that nursing staff administered the medications. NM 1 stated that nursing staff should have checked for allergies prior to administering the medications. NM 1 stated that these medications had the potential to cause rhabdomyolysis. During an interview on 2/6/2026 at 1:38 p.m. with Registered Nurse (RN 1), RN 1 stated the following: Nurses should check a patient’s allergies prior to administering medications. If there were any discrepancies, the nurse should call the physician to clarify the order and notify the pharmacy. During an interview on 2/6/2026 at 2:05 p.m. with MD 4, MD 4 stated the following: Patient 1 had been diagnosed with rhabdomyolysis during her (Patient 1) most current admission at an outside hospital on 1/17/2026. MD 4 suspected that the intramuscular injections and Patient 1’s medications of Lipitor and Fenofibrate were the cause of Patient 1’s rhabdomyolysis. Patient 1 was readmitted on 1/25/2026 and MD 4 thought the outside hospital had discontinued Lipitor and Fenofibrate. MD 4 entered Lipitor and Fenofibrate as allergies for Patient 1 to ensure that staff would not give the medications for the time being and would remove the medications from the allergy list at a later time. MD 4 did not review MD 3 orders and was unaware that Lipitor and Fenofibrate had been ordered on 1/25/2026 by MD 3, and therefore, did not discontinue Lipitor and Fenofibrate. MD 4 verified that Patient 1 suffered a blue code and was transferred to an outside hospital. MD 4 stated that Patient 1 had a history of having code blues and did not think the code blue was related to taking Lipitor or Fenofibrate. During an interview on 2/6/2026 at 2:29 p.m. with the Pharmacist-In-Charge (Pharm 1), Pharm 1 stated the following: Pharm 1 described the process of dispensing medications. Pharm 1 said that on admission, either the nurse or the physician will document any allergies to medication in the medical record. Upon receiving medication orders, the pharmacist will check for allergies. The pharmacist will dispense the medications in cycles of four (4) and three (3) days. Pharm 1 dispensed 2 doses of Lipitor and Fenofibrate in the first cycle and the medications were administered to Patient 1 on 1/26/2026 and 1/27/2026. Pharm 1 stated allergies were checked for all new orders, however, Pharm 1 stated there was no process in place to check for allergies after a medication had been ordered and dispensed by pharmacy. When the pharmacist delivered the second cycle of medications, the Patient’s allergies were not re-checked, the pharmacist only check for allergies on new medication orders. Pharm 1 stated that the physician should have discontinued the medication and the nurse should have checked for allergies prior to administering the medications. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration & Documentation,” revised 10/2023, the P&P indicated the following: “Every patient is asked about drug allergies, which are noted on the medical record. Licensed nursing staff are legally responsible for knowing the medications given. This responsibility includes questioning a patient’s reaction to medications. If a licensed nursing staff has questions about an order or a patient’s reaction, nurse contacts the prescribing physician prior to administering the medication ...Licensed nursing staff compares the label on the medication package with the order on the medication record and verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. The licensed nursing staff also verifies the medication has not expired and that there are no contraindications.””

“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 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 ensure oversight to protect one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policy regarding abuse prevention and Governing Body bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), by allowing an agitated (being upset, annoyed, angry and physically disturbed) patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3’s) room with two other patients (Patients 1 and 2) present, on 4/9/2025. This deficient practice resulted in Patient 2 being triggered by Patient 3’s aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones). (Refer to A-0063) 2. The Governing Body failed to ensure oversight to ensure nursing staff complied with adherence to the facility’s policies and procedures regarding seclusion (involves the involuntary confinement of a patient in a room or area from which they cannot freely exit), restraint (devices or techniques used to limit a patient’s movement, typically to prevent harm to themselves or others), and physical hold (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body), to ensure that the facility’s staff delivered safe and quality care to four (4) of 39 sampled patients (Patient 2, Patient 5, Patient 19, and Patient 24), as evidenced by: 2.a. The facility failed to ensure seclusion and restraint physician orders were obtained, in accordance with the facility’s policy regarding restraints use, for two of 39 sampled patients (Patient 2 and Patient 5), after Patient 2 was placed in a seclusion, and Patient 5 was restrained in a physical hold (a manual restraint or manual hold used to restrict a patient’s movement for safety reasons, performed according to established techniques and protocols). This deficient practice had the potential to compromise Patient 2’s and Patient 5’s safety by increasing their (Patient 2 and Patient 5) risk for injury, trauma, and psychological distress. In addition, this deficient practice had the potential to result in restraints use without physician order and physician’s oversight and direction which may lead to unnecessary restraints use, risk for injury related to restraints use and not keeping patients free from restraints. (Refer to A-0063) 2.b. The facility failed to ensure physical hold (a manual restraint or manual hold used to restrict a patient’s movement for safety reasons, performed according to established techniques and protocols), was implemented, in accordance with the established correct techniques for staff, when performing physical holds on two of 39 sampled patients (Patient 19 and Patient 24). This deficient practice had the potential to compromise Patient 19’s and Patient 24’s safety such as risk for injury and impacting Patient 19’s and Patient 24’s dignity and right to receive care in a safe setting and therapeutic environment. (Refer to A-0063) 3. The Governing Body failed to ensure oversight so that established strategies (Example: Use of ABC [Antecedent-Behavior-Consequence] tool [an assessment to identify patient triggers such as phone call with family member] and discussion of the identified triggers during treatment planning) to diminish seclusion and restraint (S&R) use at the facility, especially on the DDMI (Developmental Disability and Mental Illness-Dual Diagnosis, unit (DDMI unit is an inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness), were implemented, monitored and documented to ensure staff compliance and adherence with established strategies for one of 58 DDMI sampled patients (Patient 27). This deficient practice had the potential to result in continued overuse of seclusion and restraint (S&R) methods, increasing the risk for physical and psychological harm to all patients in the facility including Patient 27, undermining patient safety and violating patient rights. (Refer to A-0063) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare 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 that one of one sampled medication cart (med cart #11, a portable storage unit used to organize and store medication for easy access by authorized staff in a medication room) in the medication room, located on 5 South unit (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis, individuals who have both a developmental disability and a mental illness] patients), and was used for 24 of 24 sampled patients, always remained locked, as required by the facility’s policy for maintaining medication safety and administration. This deficient practice had the potential to results in patient and staff safety violations, including unauthorized access to medication, medication theft, misuse, and tampering (altering or modifying a medication or its packaging without authorization), which could lead to medication errors, overdose, or other safety breaches, including violating the facility’s policies designed to prevent medication mishandling and safeguard patients’ safety. (Refer to A-0144) 2. The facility failed to ensure its nursing staff protected one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policy regarding abuse prevention, when staff allowed an agitated patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3’s) room with two other patients (Patients 1 and 2) present, on 4/9/2025. This deficient practice resulted in Patient 2 being triggered by Patient 3’s aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones) on 4/9/2025. (Refer to A-0145) 3. The facility failed to ensure that one of 39 sampled patient’s (Patient 27), electronic medical record (EMR, a digital collection of a patient’s medical information, including their health history, diagnoses, medications, allergies, immunizations, and treatment plans), was protected, in accordance with the facility’s policy regarding confidentiality, when a nurse did not log out from Patient 27’s digital chart and left for lunch, thereby exposing Patient 27’s medical record to unauthorized personnel. This deficient practice had the potential to violate Patient 27’s right (Patient Rights- the fundamental entitlements and protections that individuals have when receiving medical care) to confidentiality and privacy, increasing the risk of unauthorized access to sensitive medical information, which could lead to privacy violations, identity theft, and misuse of personal health data. (Refer to A-0146) 4. The facility failed to ensure a physical hold (a manual restraint or manual hold used to restrict a patient’s movement for safety reasons, performed according to established techniques and protocols) restraint, was properly implemented, in accordance with the established correct techniques for staff, when performing physical holds on two of 39 sampled patients (Patient 19 and Patient 24) when: 4.a. A mental health worker (MHW) 1 leaned his (MHW 1’s) right elbow onto Patient 19’s upper back during a physical hold on 4/22/2024. This deficient practice had the potential to result in hurting Patient 19 and affecting Patient 19’s breathing. (Refer to A-0167) 4.b. A mental health worker (MHW 1) hyperextended (occurs when the elbow joint bends backward beyond its normal range of motion) Patient 24’s left arm during a physical hold on 3/19/2024 in a seclusion room (a room or area where a person is involuntarily confined, meaning they are physically prevented from leaving), when Patient 24 was held against the wall, with two mental health workers on each side. This deficient practice had the potential to compromise Patient 24’s safety by increasing Patient 24’s risk of injury, such as nerve damage or musculoskeletal harm (any injury or disorder affecting the body’s musculoskeletal system, including muscles, bones, joints, ligaments, and tendons) such as dislocation of the shoulder. (Refer to A-0167) 5. The facility failed to ensure that the use of restraint (devices or methods used to restrict a patient’s movement, either physically or through medication) or seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior), was in accordance with a physician’s order and the facility’s policy regarding seclusion/restraints use, for four of 39 sampled patients (Patients 2, 5,19, 25) when: 5.a. Patient 2 was placed in seclusion without a physician order for three hours and five minutes. This deficient practice had the potential to put Patient 2 at risk for injury. (Refer to A-0168) 5.b. Patient 5 was placed in a physical hold (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body) without a physician order for approximately five seconds. This deficient practice had the potential to put patient 19 at risk for injury. (Refer to A-0168) 5.c. Patient 19 was physically restrained without a physician order on 4/22/2024. This deficient practice had the potential to put Patient 19 at risk for unnecessary seclusion and/or restraints and at risk for injury. (Refer to A-0168) 5.d. Patient 25 was documented to have been placed in seclusion eight (8) times from 3/12/2024 through 11/20/2024, of those eight episodes, Patient 25 was in seclusion without a physician’s order for seclusion and for one out of eight episodes, lacked an order for physical restraints. This deficient practice had the potential to place Patient 25 at risk of harm/injury and unnecessary seclusion or restraints use. (Refer to A-0168) 6. The facility failed to ensure for five of five (5) sampled staff (Mental Health Worker 1, Mental Health Worker 6, Mental Health Worker 7, Charge Nurse 2, and Charge Nurse 3), a training and demonstration of competency on restraint (methods or devices used to restrict a person’s movement or ability to move freely), seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) and physical hold (a situation where a patient’s movement is involuntarily restricted by staff, often to prevent harm to themselves or others), were successfully completed and documented, in accordance with the facility’s “Behavioral Restraint and Seclusion Assessment of Competency,” document. This deficient practice had the potential to negatively affect patients receiving care. Specifically, incomplete training and documentation of completion could result in staff’s lack of a clear understanding of the appropriate circumstances and procedures for utilizing restraints, seclusion, and physical holds, which can lead to inappropriate or unsafe use, increasing the risk of physical and psychological harm to patients including risk of injury to staff. (Refer to A-0208) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare 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 that a Registered Nurse (RN) provided supervision over the physical hold (a manual method used to restrict a person’s movement or hold them immobile, often to prevent harm to themselves or others), for two of 39 sampled patients (Patient 19 and Patient 24), ensuring that correct physical restraining techniques were utilized, in accordance with the facility’s policy regarding seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) and restraints (methods or devices used to restrict a person’s movement or ability to move freely) use, when: 1.a. Mental Health Worker (MHW 1) hyperextended Patient 24’s left arm during a physical hold on 3/19/2024 in a seclusion room (a room or area where a person is involuntarily confined, meaning they are physically prevented from leaving), when Patient 24 was pinned against the wall, with two mental health workers on each side. This deficient practice had the potential to compromise Patient 24’s safety by increasing Patient 24’s risk of injury, such as nerve damage or musculoskeletal harm such as dislocation of the shoulder. (Refer to A-0395) 1.b. Mental Health Worker (MHW 1) leaned the right elbow against the back of Patient 19 during a physical hold on 4/22/2024, while clinical staff prepared the restraints for Patient 19 to be restrained shortly after. This deficient practice had the potential to result in causing Patient 19’s difficulty breathing and injury. (Refer to A-0395) 2. The facility failed to ensure one of 39 sampled patient’s (Patient 13) wound assessment (a systematic evaluation of a wound to determine its characteristics, stage, and healing progress), was completed and documented, in accordance with the facility’s policy regarding assessment and reassessment. This deficient practice had the potential to result in an inadequate assessment of the wound, which may lead to delayed healing and increased risk of infection, and/or delayed recognition of wound complications, potentially resulting in inappropriate or insufficient treatment to Patient 13’s wounds. (Refer to A-0395) 3. The facility failed to ensure one of 39 sampled patient’s (Patient 10) treatment plans (a structured, individualized document that outlines the care team objectives, intervention and the strategies to achieve specific health goals) regarding hypothyroid issues (a condition where the thyroid gland doesn’t produce enough thyroid hormones [regulates growth and development]) and hypertension (high blood pressure), were developed and implemented upon admission, in accordance with the facility’s policy regarding treatment planning. This deficient practice had the potential of failing to implement clinically appropriate individualized goals and interventions to address Patient 10’s care needs and risks, which may result in complications such as uncontrolled hypertension and prolonged hospital stay. (Refer to A-0396) 4. The facility failed to ensure that one of one sampled medication cart (med cart #11, a portable storage unit used to organize and store medication for easy access by authorized staff in a medication room), in the medication room, located on 5 South unit (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis, individuals who have both a developmental disability and a mental illness] patients), and is used for 24 of 24 sampled DDMI patients, always remained locked, as required by the facility’s policy for maintaining medication safety and administration. This deficient practice had the potential to result in patient and staff safety violations, including unauthorized access to medication, medication theft, misuse, and tampering (altering or modifying a medication or its packaging without authorization), which could lead to medication errors, overdose, or other safety breaches, including violating the facility’s policies designed to prevent medication mishandling and safeguard patients’ safety. (Refer to A-0398) 5. The facility failed to ensure its nursing staff protected one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policy regarding abuse prevention, when staff allowed an agitated patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3’s) room with two other patients (Patients 1 and 2) present, on 4/9/2025. This deficient practice resulted in Patient 2 being triggered by Patient 3’s aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones) on 4/9/2025. (Refer to A-0398) 6. The facility failed to ensure that a proper (minimum arm’s length distance) Q (every) 15 minute observation (safety checks conducted every 15 minutes to ensure the well-being of patients) and close proximity observation, was completed for the safety and security of 12 of 39 sampled patients (Patients 7, 8, 30 ,31 ,32, 33, 34, 35, 36, 37, 38 and 39), in accordance with the facility’s policy regarding observation and monitoring, when Registered Nurse (RN) 1, who was assigned to conduct Q-15 minute observation, did not enter the patients’ rooms to make direct visual contact with the patients. This deficient practice had the potential of failing to prevent harm to patients, including self-harm, suicide (the act of intentionally causing one’s own death), and elopement (escape). (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.”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Special Medical Record Requirements for Psychiatric Hospitals was met, as evidenced by: 1. The facility failed to ensure two of 39 sampled patient’s (Patient 25 and Patient 27) behavioral plan (a personalized plan developed to address and manage specific behaviors, outlining strategies, goals, and intervention), included a behavioral analysis for after seclusion/restraint episodes and incorporated into the behavioral plan with short-term and long-terms goals aimed at reducing the frequency of seclusions and restraints (Seclusion restraint refers to the practice of isolating someone in a locked room or using physical, mechanical, or chemical means to restrict their movement and freedom of movement) episodes, in accordance with the facility’s policy regarding treatment planning. This deficient practice had the potential to result in poorly addressed triggers (specific events or stimuli that lead to behaviors such as aggression) and/or behaviors for Patient 25 and Patient 27, increasing their risk of repeated restraint episodes, injury, or escalation of aggression, compromising Patient 25’s and Patient 27’s safety, dignity, and overall well-being. In addition, the lack of behavioral analysis and individualized behavioral treatment plan could hinder effective intervention, delay behavior reduction, and impair ongoing progress in managing challenging behaviors for Patient 25 and Patient 27. (Refer to A-1640) 2. The facility failed to ensure that nursing staff documented that attempts were made to treat two of 39 sampled (Patient 24 and Patient 25), in the least restrictive manner, before placing Patient 24 and Patient 25 in physical restraints, in accordance with the facility’s policy regarding restraints use. This deficient practice had the potential to result in unnecessary use of restrictive interventions for Patient 24 and Patient 25, placing both patients at increased risk of injury and/or psychological trauma, and failure to promote dignity, thus violating Patient 24 and Patient 25 rights (the fundamental entitlements and protections that individuals have when receiving medical care). (Refer to A-1650) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare 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: 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 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 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policy regarding abuse prevention and Governing Body bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), by allowing an agitated (being upset, annoyed, angry and physically disturbed) patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3’s) room with two other patients (Patients 1 and 2) present on 4/9/2025. This deficient practice resulted in Patient 2 being triggered by Patient 3’s aggressive behavior, assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones). 2. There was no oversight to ensure nursing staff complied with adherence to the facility’s policies and procedures regarding seclusion (involves the involuntary confinement of a patient in a room or area from which they cannot freely exit), restraint (devices or techniques used to limit a patient’s movement, typically to prevent harm to themselves or others), and physical hold (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body), to ensure that the facility’s staff delivered safe and quality care to four (4) of 39 sampled patients (Patient 2, Patient 5, Patient 19, and Patient 24), as evidenced by: 2.a. The facility failed to ensure seclusion and restraint physician orders were obtained, in accordance with the facility’s policy regarding restraints use, for two of 39 sampled patients (Patient 2 and Patient 5), after Patient 2 was placed in a seclusion, and Patient 5 was restrained in a physical hold. This deficient practice had the potential to compromise Patient 2’s and Patient 5’s safety by increasing their (Patient 2 and Patient 5) risk for injury, trauma, and psychological distress. In addition, this deficient practice had the potential to result in restraints use without physician order and physician’s oversight and direction which may lead to unnecessary restraints use, risk for injury related to restraints use and not keeping patients free from restraints. 2.b. The facility failed to ensure physical hold (a manual restraint or manual hold used to restrict a patient’s movement for safety reasons, performed according to established techniques and protocols) was implemented, in accordance with the established correct techniques for staff, when performing physical holds on two of 39 sampled patients (Patient 19 and Patient 24). This deficient practice had the potential to compromise Patient 19’s and Patient 24’s safety such as risk for injury and impacting Patient 19’s and Patient 24’s dignity and right to receive care in a safe setting and therapeutic environment. 3. The facility failed to ensure that established strategies (Example: Use of ABC [Antecedent-Behavior-Consequence] tool [an assessment to identify patient triggers such as phone call with family member] and discussion of the identified triggers during treatment planning) to diminish seclusion and restraint (S&R) use at the facility, especially on the DDMI (Developmental Disability and Mental Illness-Dual Diagnosis, unit (DDMI unit is an inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness), were implemented, monitored and documented to ensure staff compliance and adherence with established strategies for one of 58 DDMI sampled patients (Patient 27). This deficient practice had the potential to result in continued overuse of seclusion and restraint (S&R) methods, increasing the risk for physical and psychological harm to all patients in the facility including Patient 27, undermining patient safety and violating patient rights. 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),” dated 3/31/2025, the Face Sheet indicated Patient 1 was admitted to the facility on 3/31/2025 at 10:30 a.m. under a 5150 legal hold (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 himself]). 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),” dated 3/30/2025, the 5150-hold paperwork indicated Patient 1 was detained for being gravely disabled due to auditory hallucinations (hearing sounds, noises, or voices that are not there) and abnormal behavior. During a review of Patient 2’s Face Sheet dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold. During a review of Patient 2’s 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others when he was found “challenging people to a fight without provocation” in the community. During a review of Patient 3’s “Face Sheet,” dated 3/28/2025, the Face Sheet indicated Patient 3 was admitted to the facility on 3/28/2025 at 12:55 p.m. voluntarily (of his own free will). During a review of Patient 3’s “Psychiatric (treatment or care for a mental health disorder or illness) and Mental Status Examination (PMSE, a formal and complete assessment of the patient and the problem related to mental health),” dated 3/29/2025 at 10:23 a.m., the PMSE indicated Patient 3 sought voluntary admission due to suicidal thoughts (thinking about killing himself). During a review of Patient 4’s “Face Sheet,” dated 4/8/2025, the Face Sheet indicated Patient 4 was admitted to the facility on 4/8/2025 at 10:50 a.m. under a 5150 legal hold. During a review of Patient 4’s 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 4 was detained for being gravely disabled due to abnormal behavior. During a review of Patient 1’s “Progress Notes,” dated 4/9/2025 at 4:35 a.m., the Progress Notes indicated, “Around [4:10 a.m.], patient (Patient 1) came out of his (Patient 1) room [with] heavy bleeding from both nostrils. [Patient 1 was] confused, unable to provide accurate information regarding what exactly happened, but stated ‘I’m sorry, someone punched me’.” The Progress Notes further indicated Patient 1 was sent to General Acute Care Hospital (GACH) 1’s Emergency Department (a hospital department that provides immediate care for patients with urgent medical conditions) at 4:33 a.m. During a review of Patient 1’s “Progress Notes,” dated 4/9/2025 at 1:51 p.m., the Progress Notes indicated Patient 1 was scheduled to be transferred to GACH 2 at 2:00 p.m. for possible oral facial (face and mouth) surgery. During a review of Patient 2’s “Progress Notes,” dated 4/9/2025 at 4:47 a.m., the Progress Notes indicated, “[Patient 1] ran out of his room with his nose bleeding. [Patient 2] stated he did not know who punched him.” During a review of Patient 2’s “Progress Notes,” dated 4/9/2025 at 3:48 p.m., the Progress Notes indicated, “[Patient 2] states, ‘I hit the other guy earlier.’” During a review of Patient 1’s “CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) Maxillofacial (upper jaw and face) Scan” report from GACH 2, dated 4/9/2025 at 8:26 p.m., the report indicated Patient 1 sustained bilateral (both) Le Fort I (a type of facial fracture that occurs horizontally through the maxilla [upper jaw], above the roots of the teeth), right possible Le Fort II fractures (a pyramidal shaped fracture along the nasal bridge and causes separation of the midface from the skull base), and bilateral maxillary sinus fractures (a break in the bones that make up the maxillary sinus [the air-filled cavities in the cheek bones]) of the anterior (front) and posterolateral (at the back and to the side) walls. During an interview with the Director of Quality Improvement and Risk Management (DQ) on 6/9/2025 at 1:51 p.m., the DQ stated that on 4/9/2025 at around 4:00 a.m., Patient 1 came out of his (Patient 1) room with his nose bleeding and stated that somebody punched him. The DQ further stated that the only other person in the room was his roommate, Patient 2, but at the time, he (Patient 2) denied knowing what happened. During an interview with the Nurse Manager (NM 1) for North and South ICU (Intensive Care Unit, a specialized hospital department that provides critical care to patients with life-threatening conditions) on 6/11/2025 at 10:16 a.m., NM 1 confirmed that Patients 1, 2, and 3 were roomed in together in the same room (Room A). NM 1 further stated that on 4/9/2025 after midnight, there was a “fight” between Patients 3 and 4 in the hallway; during the fight, another altercation between Patient 1 and Patient 2 occurred in Room A, unwitnessed by staff. During a concurrent interview and video surveillance review with the Nurse Manager (NM 1) for North and South ICU on 6/12/2025 at 9:34 a.m., two video clips of security footage from 4/9/2025, were reviewed. NM 1 stated these videos occurred at approximately 4:00 a.m. on 4/9/2025 as there were no time stamps on the footage. The following events were observed from the first clip: a. At the beginning of the video clip, Patient 4 was standing in the hallway. b. Patient 3 emerged from his room. Staff stepped in between Patients 3 and 4. One minute and 12 seconds into the video Patient 3 swung his left arm at Patient 4. Additional staff responded to the incident. c. One minute and 30 seconds in, staff brought Patient 3 back to Room A. Four staff were observed entering Room A with Patient 3. d. Two minutes and 49 seconds in, staff removed Patient 3 from Room A. During the same interview on 6/12/2025 at 9:34 a.m. with the Nurse Manager (NM 1) for North and South ICU, NM 1 stated Patient 3 was in his (Patient 3) room (Room A, where Patients 1 and 2 were staying), with staff present, for one minute and 19 seconds, based on the time elapsed in the video. NM 1 further stated that staff removed Patient 3 from his room and brought him 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 to administer emergency medications (medications given to manage severe mental health symptoms such as agitation). During the same video surveillance review on 6/12/2025 at 9:34 a.m. with the Nurse Manager (NM 1) for North and South ICU, the following events were reviewed from the second clip: a. Two minutes and 19 seconds into the video, staff brought Patient 3 out of Room A. b. Two minutes and 44 seconds in, Mental Health Worker (MHW) 2 closed the door to Room A. c. Three minutes and 40 seconds in, House Supervisor (HS) 1, who was standing in the hallway, appeared to hear something coming from Room A and opened the door. d.Three minutes and 44 seconds in, Patient 1 emerged from Room A dripping blood on the floor. Staff took him (Patient 1) to the nurses’ station. Patient 2 was seen standing in the doorway of Room A. -NM 1 stated Patients 1 and 2 were left alone in Room A for 56 seconds, based on the time elapsed in the video. During an interview with NM 1 on 6/12/2025 at 9:50 a.m., NM 1 stated that the facility’s staff were responsible for the patients. NM 1 further stated that agitated (a state of restlessness or uneasiness) patients should not be in a room with other patients and staff should remove the roommates as best as they could because there was potential that the roommates could get triggered, agitated, or get hurt. During an interview with NM 1 on 6/12/2025 at 10:24 a.m., NM 1 stated Patient 2 was a newly admitted patient and had not yet been seen by a physician. The staff was not familiar with Patient 2 and did not know what would trigger Patient 2 and what Patient 2’s behavior would be. NM 1 further stated the staff should have maintained vigilance until the staff got to know Patient 2 more. During an interview with the Chief Executive Officer (CEO) and the Associate Administrator of Hospital Operations (AAO) on 6/13/2025 at 2:28 p.m., the CEO confirmed he (CEO) was on the GB and stated that the GB had overall responsibility for the facility, for the quality of care provided by the facility to its patients, and for patient safety. The CEO confirmed the GB was also responsible for ensuring the facility followed state and federal regulations. The CEO and the AAO confirmed that patient-to-patient altercation incidents were discussed during the GB meetings but were not sure if the incident between Patients 1 and 2 was discussed at the last meeting on May 5, 2025. The GB meeting minutes for May 5 were not available for review. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” last reviewed 10/2023, indicated, “The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation (reduction of the intensity of a conflict or potentially violent situation) preferences from the initial assessment prior to [seclusion/restraint], including ... C. Separating patient from group or community ... E. Offering the use of the quiet room to decrease stimuli and regain control.” During a review of the facility’s policy and procedure (P&P) titled, “Abuse Prevention, Screening, Identification, Training, Protection, Investigation, and Reporting,” last reviewed 10/2023, indicated, “It is the policy of [Name of Facility] to protect our patients from all types of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients, or visitors ... A critical part of protecting patients from abuse is preventing abuse from occurring in the first place.” During a review of the facility’s Governing Body (GB) 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 5/6/2024, the bylaws indicated, “The primary responsibility and goal of the Board of Directors (the ‘Board’) is to further the role and purpose of the Hospital by providing oversight of the Hospital and advice to the Corporation, thereby facilitating institutional management and planning, the establishment of policies and the maintenance of quality patient care services, all in a manner that is responsive to and meets the needs of the community area, consistent with our mission and the advancement of our vision for the organization. The Board serves as the governing body of the Hospital and retains ultimate responsibility for the Hospital’s compliance with all applicable federal, state, and local laws and regulations.” 2.a. During an interview on 6/13/2025 at 2:28 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: the governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) had the overall responsibility of the facility, for the quality of care provided by the facility to its patients, and for patient safety. GB was responsible to ensure the facility complied with all federal, state, and local regulations as well as the facility’s policies and procedures (P&P). GB meetings were held quarterly to discuss topics including but not limited to 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) and patient safety. GB would monitor the facility’s QAPI activities and meet with the facility’s leadership team if there were any quality or patient safety issues. During an interview on 6/13/2025 at 2:55 p.m. with the Director of Quality Improvement and Risk Management (DQ), the DQ stated the following regarding the previously identified issues with nursing staff not obtaining and/or documenting physician orders for seclusions/restraints and/or physical hold (Restraint is the restriction of an individual’s movement using physical force, a mechanical device, or medication to manage behavior. Seclusion is the involuntary confinement of an individual in a room or area from which they cannot freely leave. Physical hold, also known as physical restraint, is a method of restricting freedom of movement by physically holding an individual) being implemented on patients in the facility: -“After the last Centers for Medicare and Medicaid Services (CMS, responsible for creating health and safety guidelines for hospitals and healthcare facilities, including introducing and enforcing clinical and quality programs ) survey conducted in January 2025, the facility identified that nursing staff was not compliant with obtaining and documenting orders for physical restraints, seclusions, or physical holds. In response, we provided facility-wide education through in-service trainings to all staff [in February 2025]. Nursing leaderships was tasked with collecting data and monitoring staff compliance to ensure that orders for seclusions and restraints were documented in patients’ electronic medical records (EMRs, digital version of paper chart). I (DQ) receive the data from nursing leadership monthly, compile it, and present the compliance rate as percentages (%). Our goal was to achieve at least 95% compliance, but we were only successful in meeting the goal in February and March of 2025. Our YDT (Year Data Target, the period from the start of the year to the current date) for 2025, is currently under 95%. Nursing leadership is ultimately responsible to ensure compliance...” During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold (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 care for themselves]). During a review of Patient 2’s “Seclusion and Restraints Assessment Packet (S&R Assessment),” dated 4/9/2025, the S&R Assessment indicated Patient 2 was placed in seclusion because he (Patient 2) “punched his roommate unwitnessed by staff [and was] irritable, testing limits, minimizing [the] situation, appearing very unpredictable and uncooperative, [and] non-redirectable.” The S&R Assessment further indicated Patient 2 was in seclusion for three hours and five minutes, entering at 4:45 a.m. and then released at 7:50 a.m. During a concurrent interview and record review with Nurse Manager (NM) 1 on 6/12/2025 at 2:41 p.m., Patient 2’s medical record, was reviewed. NM 1 confirmed that there was no physician order present in the medical record for Patient 2’s seclusion on 4/9/2025 from 4:45 a.m. to 7:50 a.m. and that there should be one [physician order] present. During a review of Patient 5’s Face Sheet dated 6/4/2025, the Face Sheet indicated Patient 5 was admitted to the facility on 6/4/2025 at 7:55 p.m. on a 5150 legal hold. During a concurrent interview and video surveillance review with Nurse Manager (NM) 1 on 6/12/2025 at 1:59 p.m., the security video footage from 6/6/2025, was reviewed. The video indicated that at 8:01 p.m. [on 6/6/2025] two staff members were holding Patient 5 in the hallway for approximately five seconds, each staff member holding each patient’s [Patient 5’s] arm. NM 1 confirmed this was a physical hold and stated the staff members were trying to prevent Patient 5 from leaving with the visitor. During a concurrent interview and record review with Nurse Manager (NM) 1 on 6/13/2025 at 9:28 a.m., Patient 5’s medical record, was reviewed. NM 1 confirmed there was no physician order in Patient 5’s medical record for the physical hold observed in the security video (dated 6/6/2025). NM 1 stated that physical holds were a form of restraint to prevent the patient from moving, and that there should have been an order for the physical hold. During an interview with Nurse Manager (NM) 1 on 6/13/2025 at 11:10 a.m., NM 1 stated that nurses could initiate seclusion or restraint, but the physician needed to order it as well to ensure that it was the appropriate or necessary intervention. During an interview on 6/13/2025 at 2:55 p.m. with the Director of Quality and Risk Management (DQ), the DQ stated the following regarding the timely physician order for seclusion and restraint (S&R, the requirement is that a healthcare provider must provide a documented order before instigating seclusion or restraints, or almost immediately after, in accordance with regulatory and facility’s policy): “Obtaining a seclusion and restraint order within minutes of initiation, and ensuring that a physical hold order is present during any period of seclusion or restraint are among the performance metrics that are being monitored and audited.” During the same concurrent interview and record review on 6/13/2025 at 2:55 p.m. with the Director of Quality and Risk Management (DQ), the DQ presented the performance measurement report (a document that tracks and analyzes various metrics to assess the quality, efficiency, and overall performance of the hospital) and stated that the results for these audits were discussed during the typical Safety Committee meetings, and the facility was actively monitoring the compliance rate with these measures, and nursing leadership was responsible for ensuring that staff adhered to these protocols and achieve compliance. The DQ did not provide a comment on the fact that compliance rates for the identified two performance metrics-obtaining a S&R order within minutes of initiation and having physical hold order during S&R-were below the 95% target. During a concurrent interview and record review on 6/13/2025 at 2:55 p.m. with the CEO and the Associate Administrator of Operations (AAO), the facility’s “Board of Directors Meeting Minutes (GB minutes, the official record of discussions, decisions, and actions taken by the hospital’s governing body),” dated 2/3/2025, were reviewed. The GB minutes indicated there was a discussion regarding the usage of seclusion and restraint during the period of October to December 2024. AAO stated the GB meeting minutes did not reflect any discussion regarding compliance monitoring of seclusion and restraint use by staff in accordance with facility’s policy and procedure. The AAO also stated the GB met in May 2025 [GB meets quarterly] but the GB meeting minutes from that meeting were not available for review at this time. During an interview on 6/13/2025 at 3:38 p.m. with the Chief Nursing Officer, CNO stated, “Our compliance rates are not great,” and then said that the house supervisor was responsible for collecting the data and inputting it into the shared files where the Director of Quality (DQ) can access the data and compile it (data collected to show nursing compliance with obtaining S&R order within minutes of initiation and having physical hold order during S&R) to produce compliance percentage (%) rates. The CNO verified that the facility’s compliance rates with the two metrics were not optimal (not the best or satisfactory) and said that additional monitoring efforts may need to be implemented to ensure better compliance. During a review of the facility’s “Bylaws of Governing Board of [the facility] (GB Bylaws),” dated 5/2024, the GB Bylaws indicated, “The primary responsibility and goal of the Board of Directors (the ‘Board” [GB]) is to further the role and purpose of the Hospital by providing oversight of the Hospital and advice to the Corporation, thereby facilitating institutional management and planning, the establishment of policies and the maintenance of quality patient care services, all in a manner that is responsive to and meets the needs of the community area, consistent with our mission and the organization. The Board serves as the governing body of the Hospital and retains ultimate responsibility for the Hospital’s compliance with all applicable federal, state, and local laws and regulations. The Board shall receive and evaluate periodic reports from the Medical Staff and its officers .... oversee performance improvement (QAPI) ... regarding the provision of quality patient care at the Hospital and establish policies regarding such matters.” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “Definition ... Restraints: A. Physical Restraint/Hold: Any manual or physical method of holding the patient against the patient’s will that restricts freedom of movement or normal access to one’s body ... Procedure ... 4. The physician or Registered Nurse (RN) can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the seclusion/restraints (S/R), and document on the Seclusion/Restraint Order form as follows: A. Time Limits: 1) Adults 18 and older up to four (4) hours; 2) Youth 9 - 17 up to two (2) hours ... B. The physician’s orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration. The S/R can be ordered for less than above stated maximum. The length of the S/R is limited by the continued need for the intervention rather than then length of the order ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained Registered Nurse may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes.” 2.b. During an interview on 6/12/2025, at 2:40 p.m., with the Director of Quality (DQ) and the Director for DDMI (Developmental Disability and Mental Illness-Dual Diagnosis (DDMI, inpatient unit that provides treatment and therapy for people who have developmental delay with mental illness) unit (Dir 1), the DQ said that no person was assigned to watch the video footage of all recordings for patients who were ordered for seclusion, restraints, or physical hold. There had been no practice of reviewing all videos involving restraints or seclusions. Dir 1 said that nobody was specifically assigned to monitor staff during the application of restraints or seclusions because it was not feasible, as all staff were trained on the unit to apply restraints, and the expectation was that staff were performing their job appropriately without constant oversight. During a review of Patient 19’s “Annual Psychiatric Assessment (a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 5/9/2024, the “Annual Psychiatric Assessment” indicated, Patient 19 was admitted to the facility’s adult locked Developmental Delay and Mental Illness (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness) with bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration) type schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) and mild intellectual disability (a disability that affects the acquisition of knowledge and skills). During a concurrent interview and record review on 6/11/2025 at 11:47 a.m. with the Program Director (DIR 1) of DDMI, a facility’s video clip of security footage, with no audio, timestamp dated on 4/22/2024, was reviewed. The video clip showed the following: -At 4:51 p.m.: Patient 19 was walking around and banging the wall in the seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) room; -At 5:21 p.m.: multiple clinical staff came into the seclusion room. A Mental Health Worker (MHW) 1 brought Patient 19 to face the wall and leaned his (MHW 1’s) right elbow onto Patient 19’s upper back while another clinical staff was holding Patient 19’s left arm. Other clinical staff were preparing 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) devices on the restraint bed for Patient 19. During the same interview on 6/11/2025 at 11:47 a.m. with DIR 1, DIR 1 stated the following: MHW 1 performed physical hold (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body) on Patient 19 incorrectly. MHW 1 was leaning too much with his (MHW 1’s) elbow onto Patient 19. There was potential that Patient 19 could get hurt by hitting the wall. DIR 1 also stated MHW 1 was terminated. During an interview on 6/12/2025 at 10:36 a.m. with Nurse Manager (NM) 1, NM 1 stated leaning elbow onto patient was incorrect NCI (Nonviolent Crisis Intervention, behavior management system designed to help to de-escalate [reduce the intensity of a conflict or potentially violent situation] and manage disruptive or out-of-control individuals in a safe and non-harmful way) technique. NM 1 stated the incorrect technique could restrict patient’s breathing and cause patient harm. During a review of Patient 24’s “Annual Psychiatric Assessment (APA, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/22/2024, the APA indicated that Patient 24 was a DDMI patient (DDMI-Developmental Disability and Mental Illness -dual diagnosis), who was admitted to the facility on 1/22/2024 due to being danger to self (threatening to kill self) and others, and had history of autism (a neurodevelopmental condition that affects how people interact with the world, particularly in social communication and interaction, and in the presence of restricted and repetitive behaviors, interests, or activities), ADHD (Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity), anxiety (a common emotion characterized by feelings of fear, worry, unease, and apprehension) and ODD (Oppositional Defiant Disorder, a pattern of defiant, angry, and irritable behavior, including arguing, refusing to comply, and intentionally annoying others). During a concurrent interview and record review on 6/12/2025 at 12:37 p.m. with the director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), Patient 24’s restraint and seclusion (R&S, interventions used in the treatment and management of disruptive and violent behaviors in psychiatry), video footage (no audio, timestamp dated 3/19/2024, was reviewed. The video footage demonstrated the following: -At 5:15 p.m., Patient 24 was held against the wall, restrained by two mental health workers (MHW 1 and MHW 2). MHW 1 was positioned on the left side of Patient 24, holding Patient 24’s left arm, hyper-extending the arm backwards and slightly upward (meaning the arm was pulled or extended beyond its normal range of motion). Patient 24 was pinned against the wall in a physical hold, for about a minute, while staff prepared the 5-point physical restraints (refer to a type of physical restraint that uses a combination of restraints on the body to limit movement, involving restraints on all four limbs (wrists and ankles) and an additional restraint around the torso, pelvis, or thighs) to secure the patient on the bed. -At 5:17 p.m. Patient 24 was restrained in 5-point restraints During the same interview on 6/12/2025 at 12:37 p.m. with the director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), Dir 1 said that hyperextension of the arm was an incorrect level of restriction applied by MHW 1 when applying a physical hold. Dir 1 also said that MHW 1 was terminated in 2024 but could not recall the specific reason for the termination. Dir 1 also said that MHW 1 could have easily dislocated Patient 24’s arm and verified that this technique was not in accordance with the NCI (The Crisis Prevention Institute’s Nonviolent Crisis Intervention [NCI] certification program which is designed to provide participants with the knowledge and skills required to respond early and effectively to prevent or defuse a behavioral escalation) training provided by the facility to staff. During an interview on 6/12/2025 at 3:01 p.m. with the Chief Nursing Officer (CNO), the CNO stated that [the CNO] personally reviewed video footages for both restraint episodes (Patient 19 on 4/22/2024 and Patient 24 on 3/19/2024). The CNO said that concerns were raised regarding Patient 19’s restraint episode, questioning the need for a physical restraint, but no concerns were identified after reviewing the video footage for Patient 24. The CNO also mentioned that the documentation in the log for Patient 24 indicated that no corrective action was necessary. Additionally, the CNO admitted that [the CNO] did not review the physical hold technique used during the restraints for either patients Patient 19 or Patient 24 and clarified that only the necessity of the physical restraint application was audited. During a review of employee (healthcare personnel) files on 6/13/2025 demonstrated that five of five (5) sampled staff (Mental Health Worker [MHW] 1, MHW 6, MHW 7, Charge Nurse [CN 2], and CN 3) personnel files, lacked documentation showing that they had completed the required annual [2024] training and competencies related to restraints, seclusion, and physical hold. During an interview on 6/13/2025 at 2:28 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: the governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) had the overall responsibility of the facility, for the quality of care provided by the facility to its patients, and for patient safety. The GB was responsible to ensure its facility complied with all federal, state, and local regulations as well as the facility’s policy and procedure. During an interview on 06/13/2025 at 2:54 p.m. with Nurse Manager (NM 1), NM1 stated that the expectation after Seclusion/Restraint/Physical Hold training was to validate the competencies through multiple methods, including verbalization (explaining the procedure and safety measures), completion of a written test (assessment of knowledge), simulation (a retraining exercise that mimics real-life scenarios in a controlled environment to demonstrate proper techniques and responses), and direct observation. The employee must also demonstrate the proper use of seclusion and restraints during an actual episode, with this being observed by an assessor to ensure skill and competency. During a review of the facility’s “Bylaws of Governing Board of [the facility] (GB Bylaws),” dated 5/2024, the GB Bylaws indicated, “The primary responsibility and goal of the Board of Directors (the ‘Board” [GB]) is to further the role and purpose of the Hospital by providing oversight of the Hospital and advice to the Corporation, thereby facilitating institutional management and planning, the establishment of policies and the maintenance of quality patient care services, all in a manner that is responsive to and meets the needs of the community area, consistent with our mission and the organization. The Board serves as the governing body of the Hospital and retains ultimate responsibility for the Hospital’s compliance with all applicable federal, state, and local laws and regulations. The Board shall receive and evaluate periodic reports from the Medical Staff and its officers .... oversee performance improvement ... regarding the provision of quality patient care at the Hospital and establish policies regarding such matters.” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated, “Seclusion and restraints (S/R) interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others ... S/R procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring ... The leadership team has developed S/R training and competencies that are required for all clinical staff prior to patient intervention ... the facility’s approved method of non-violent crisis intervention (NCI) are additional competency requirements. The use of non-violent crisis prevention techniques to ensure patient and staff safety are consistent with established standards ... Definitions ... A. Physical Restraint/Hold: any manual or physical method of holding the patient against the patient’s will that restricts freedom of movement or normal access to one’s body.” Procedure ... 7. The Registered Nurse (RN), in collaboration with unit staff, evaluates the patient’s behavior and implements appropriate NCI techniques to maintain patient and staff safety for escort to seclusion room, placement on transport gurney, and/or restraint bed. 8. If physical restraint is indicated, a minimum of two (2) but preferably four (4) NCI trained staff must participate in the physical hold application.” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Treatment Plan/Patient and Staff Debriefing/Staff Training and Competency,” dated 10/2023, the P&P indicated that: “Staff members who are authorized to apply restraint or seclusion are trained in all (restraint, seclusion, physical hold, de-escalation techniques) techniques, plus the safe use of restraint, including physical holding techniques, take down procedures, and the application and removal of mechanical restraints...” During a review of the educational material developed by the Crisis Prevention Institution (CPI, a global organization that provides evidence-based training focused on de-escalation and crisis intervention) titled, “Non-Violent Crisis Intervention Training,” dated 2023, the educational material indicated the following regarding safety interventions-Holding Skills: “CPI focuses on nonviolent crisis intervention, emphasizing verbal and non-verbal de-escalation techniques to manage potentially dangerous situations. Physical interventions, like those involving arm movements, are only considered as a last resort and should be performed safely with minimal force...utilizing techniques such as the person’s arms are against their own body or holding on the inside of the wrist and/or elbows ... Safety Interventions - Holding Skills ... Holding: A restrictive safety intervention necessary to restrict a person’s range of movement to prevent the infliction of harm to self or others ... keep upright. Avoid leaning or bending the person forward.” 3. During an interview on 6/12/2025 at 12:00p.m. with the behavioral analyst (BA 2), the BA 2 stated the following: “The behavioral analyst at the facility works exclusively with patients in the DDMI (Developmentally Disabled/Mentally Ill) unit-patients who have dual diagnosis of developmental disability and mental illness. Usually, we create and update behavioral care plans, set goals to reduce or eliminate problematic behaviors, and regularly revise these plans to reflect progress. During interdisciplinary meetings, we review patients’ behaviors and their progress, focusing solely on DDMI patients. The key difference between the general (acute psychiatric) patients and the DDMI patients [in the facility] is that DDMI patients have a tailored behavioral program, which includes behavioral interventions, detailed behavioral plans, structured scheduled, and routines designed to support their behavioral needs. Each behavioral plan or report identifies antecedents (triggers-specific events or stimuli that lead to behaviors such as aggression [throwing items, biting oneself] or property destruction such as banging walls, slamming doors). The goal is to avoid the triggers where possible and redirect the patient if triggers do occur.” During the same interview on 6/12/2025 at 12:05 p.m. with the Behavioral Analyst (BA 2), the BA 2 said that clinical staff played a vital role in behavior management as they collect data using the ABC tool-(Antecedent-Behavior-Consequence-a method that documents what happens before behavior [antecedent], the behavior itself, and what follows] consequence]). The BA 2 said that the explanations should be as explicit and detailed as possible to ensure accurate information was documented, which was essential for effective intervention planning and progress tracking, especially when reviewing behaviors that trigger Seclusion & Restraints (S&R, seclusion is the involuntary confinement of a person in a room or area from which they are physically prevented from leaving. Restraint refers to any method, whether manual, physical, mechanical, or chemical, that restricts a person’s freedom of movement or ability to move their body freely) use. During an interview on 6/13/2025 at 10:29 a.m. with the Behavioral Analyst (BA 1, who is in charge of supervising all behavioral specialists/facilitators), the BA 1 stated that seclusion & restraints (S&R) triggers were reviewed because, “we want to know what led to the incident of restraints...” The BA 1 also said that including [documentation of] restraints triggers in behavioral reports/behavioral care plans, had not been the practiced at the facility. The BA 1 also said that the behavioral therapists followed the standards from tools used in ABA therapy (Applied Behavioral Analysis Performance Standards), and the facility did not have formal policies and or protocols indicating how these reports should be documented. During an interview on 6/13/2025 at 11:24 a.m., with the director of the Developmentally Disabled/Mentally Ill (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness) program (Dir 1), the Dir 1 stated that there were no separate policies and procedures specifically designed for DDMI patients but acknowledged that DDMI patients required a slightly different approach to treatment and care while staying in the facility. Dir 1 also stated the following about the DDMI unit: -DDMI patients were typically referred by a vendor such as regional center (the primary point of entry for individuals with developmental disabilities and their families to access a wide range of services and support define), or a department of child and family services (DCFS, a government agency responsible for protecting children from abuse and neglect, and for providing support to at-risk families). -Placement was managed by the regional centers, and/or DCFS, and the facility had no decision-making authority in placing DDMI patients, according to the agreement with the regional centers and the DCFS. -DDMI patients required the submission of behavioral intervention plans (a powerful tool used in Applied Behavior Analysis [ABA] therapy to understand and address challenging behaviors in children and adults) and a 30-Day Behavioral Progress Report (a comprehensive document that evaluates the patient’s behaviors, progress toward goals, interventions used, and recommendations for ongoing treatment over a 30-day period). -DDMI patients received behavioral therapy-specifically, Applied Behavior Analysis (ABA, a scientific approach to understanding and improving specific behaviors using reinforcement strategies, positive or negative, to promote adaptive behaviors and reduce problematic ones) as was required by the regional centers. During a review of the facility’s Patient Safety Committee minutes (the official written record of a meeting, documenting discussions, decisions, and action items), dated 1/2025-5/2025, the excessive use of seclusion (the involuntary confinement of a patient alone in a room or area from which they are physically prevented from leaving) and restraints (methods or devices used to restrict a person’s movement or ability to act freely) was discussed as a standing agenda (a topic that is consistently included in a meeting). The minutes further indicated that the committee also discussed implementation of strategies to reduce the use of restraints or seclusion, especially on the DDMI unit (Developmentally Disabled/Mentally Ill unit-patients who have dual diagnosis of developmental disability and mental illness). During a review of Patient 27’s electronic medical record (EMR, digital version of paper chart), the “Behavioral Restraint/Seclusion Order Assessment,” dated 4/30/2025 through 6/2/2025, were reviewed. The records indicated that Patient 27 had 18 episodes of seclusions and restraints (S&R, seclusion restraint refers to the practice of isolating someone in a locked room or using physical, mechanical, or chemical means to restrict their movement and freedom of movement) since admission on 4/30/2025 through 6/12/2025. During an interview on 6/13/2025 at 1:50 p.m. with Nurse Manager (NM 2) regarding the facility’s strategies and efforts to reduce Seclusion and Restraint (S&R) use among patients in the DDMI Unit, NM 2 said the following: “Usually, the director of Quality (DQ) would extract data from the restraint log, and bring up the patients with the highest use of restraints and/or seclusions, during the patient safety meetings. We typically review the information during these meetings, discuss various strategies to reduce the use of restraints; pharmacy, nursing leadership, behavioral leadership participate in these meetings. All strategies are individualized. Behavioral analysts can help implement and modify nursing treatment plans and behavioral plans for DDMI patients.” During an interview on 6/13/2025 at 2:09 p.m. with the Director of DDMI unit (Dir 1), the Dir 1 said, “In treatment planning meetings (Interdisciplinary Meetings, IDT), we talk about triggers for seclusion and restraint use, we try to understand if the issue is a medical issue, or a behavioral one... we talk to the physician about the issues... We review S&R use during treatment planning for all patients, and these reviews are individual and done after each S&R episode...” During an interview on 6/13/2025 at 2:28 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: the governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) had the overall responsibility of the facility, for the quality of care provided by the facility to its patients, and for patient safety. The GB was responsible to ensure its facility complied with all federal, state, and local regulations as well as the facility’s policy and procedure. During an interview on 6/13/2025 at 2:42 p.m. with the Director of Quality (DQ), the DQ said that in January 2025, the Patient Safety Committee discussed implementing strategies to reduce seclusion and restraints (S&R) use, especially on DDMI units. The DQ said that certain changes had been made to the ABC collection tool (ABC tool refers to Antecedent-Behavior-Consequence [ABC] analysis, a method used to understand and modify behavior by examining the events preceding, during, and following a specific action) and staff was provided additional education. During the same interview on 6/13/2025 at 2:42 p.m. with the Director of Quality (DQ), the DQ also said that the reduction of restraint and seclusions (S&R) use had been a monthly agenda item and was discussed during the Patient Safety meetings monthly. The DQ said, “Some improvements have been made in how data is collected, including a revision of the ABC tool, which was updated sometime last November (2024). One strategy to reduce the S&R use is to include restraints episodes discussion for each patient during treatment planning on a weekly basis.” The DQ did not know specific changes that were made to the ABC tool. The DQ said that no audits were conducted to verify the effectiveness of implementation of strategies to reduce S&R use, especially in DDMI units. The DQ said that behavioral therapy was under nursing, and nursing leadership was responsible for monitoring the compliance with documentation and behavior management protocols. During a concurrent interview and record review on 6/13/2025 at 2:55 p.m. with the CEO and the Associate Administrator of Operations (AAO), the facility’s “Board of Directors Meeting Minutes (GB minutes, the official record of discussions, decisions, and actions taken by the hospital’s governing body),” dated 2/3/2025, were reviewed. The GB minutes indicated there was a discussion regarding the usage of seclusion and restraint during the period of October to December 2024. AAO stated the GB meeting minutes did not reflect any discussion regarding compliance monitoring of seclusion and restraint use by staff in accordance with facility’s policy and procedure. The AAO also stated the GB met in May 2025 [GB meets quarterly] but the GB meeting minutes from that meeting were not available for review at this time. During a review of Patient 27’s Psychiatric and Mental Status Examination,” dated 5/27/2025 (an annual psychiatric mental examination for 5/26/2025), Patient 27 was admitted on 1/17/2024 [to the DDMI unit] on a 5150 hold (a legal procedure where a person can be involuntarily detained for up to 72 hours in a psychiatric facility for evaluation and stabilization if they are deemed to be a danger to themselves or others, or gravely disabled [unable to care for one’s self] due to a mental health disorder) because of running into traffic and noncompliance with medications. During a concurrent interview and record review on 6/13/2025 at 3:10 p.m. with Nurse Manager (NM 1), Patient 27’s electronic medical record (EMR) titled, “Behavioral Restraint/Seclusion Order Assessment,” dated 6/2/2025 and the “ABC Analysis” tool (refers to the systematic observation and recording of Antecedents (triggers), Behaviors, and Consequences to understand and modify behavior), was reviewed. The “Behavioral Restraint/Seclusion Order Assessment,” dated 6/2/2025 indicated that Patient 27 was placed in a physical hold at 4:52 p.m. and then seclusion at 4:55 p.m. The ABC Analysis tool indicated that there was no documentation of Patient 27 being in a physical hold on 6/2/2025 at 4:52 p.m. and being in seclusion at 4:55 p.m. During a concurrent interview and record review on 6/13/2025 at 3:10 p.m. with Nurse Manager (NM) 1, NM 1 reviewed the Behavioral Weekly Progress Report [dated 6/4/2025], 30-day Behavioral Progress Reports, and the Interdisciplinary Treatment (IDT) Plan [dated 6/4/2025], developed for Patient 27 , and said that the S&R episodes on 6/2/2025 were not mentioned/included in any of the reviewed reports and IDT- Interdisciplinary treatment planning for Patient 27. During the same interview on 6/13/2025 at 3:10 p.m. with Nurse Manager (NM) 1, NM 1 said that all clinical staff could add to the ABC tool- (includes nursing staff, mental health workers, behavioral analysts). During an interview on 6/13/2025 at 3:38 p.m. with the Chief Nursing Officer (CNO), the CNO said that no compliance monitoring had been conducted to ensure adherence to the newly implemented strategies to reduce seclusion and restraint (S&R) use in the facility. The CNO also mentioned that compliance monitoring would need to be initiated moving forward. During a concurrent interview and record review on 6/13/2025 at 4:20 p.m. with the CEO and the Associate Administrator of Operations (AAO), the CEO said the following: the Governing Board (GB) was aware of the seclusion and restraint (S&R) excessive use issue and had been convening meetings to discuss strategies to decrease the S&R use. The CEO also said that, in fact, the GB members only recently met and specifically discussed S&R use during their last meeting, and many important points and potential solutions emerged from that discussion. The CEO said that S&R use remained an ongoing issue that continued to require attention and action. The facility did not provide revised, old, or new policies specific to the DDMI unit. Currently, there were no policies in place specifically addressing the DDMI patients or the unique needs of that unit. Additionally, the facility did not provide the previously used ABC (Antecedent-Behavior Consequence) tool nor any documentation or records regarding updates or modifications that had been implemented since November 2024. The Chief Nursing Officer (CNO), and the Director of DDMI unit confirmed that the facility had no policies specific to the DDMI unit. During a review of the facility’s “Bylaws of Governing Board of [the facility] (GB Bylaws),” dated 5/2024, the GB Bylaws indicated, “The primary responsibility and goal of the Board of Directors (the ‘Board” [GB]) is to further the role and purpose of the Hospital by providing oversight of the Hospital and advice to the Corporation, thereby facilitating institutional management and planning, the establishment of policies and the maintenance of quality patient care services, all in a manner that is responsive to and meets the needs of the community area, consistent with our mission and the organization. The Board serves as the governing body of the Hospital and retains ultimate responsibility for the Hospital’s compliance with all applicable federal, state, and local laws and regulations. The Board shall receive and evaluate periodic reports from the Medical Staff and its officers .... oversee performance improvement ... regarding the provision of quality patient care at the Hospital and establish policies regarding such matters.””

“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: 46238 Based on observation, interview and record review, the facility failed to ensure that one of one sampled medication cart (med cart #11, a portable storage unit used to organize and store medication for easy access by authorized staff in a medication room) in the medication room, located on 5 South unit (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis, individuals who have both a developmental disability and a mental illness] patients), and was used for 24 of 24 sampled patients, always remained locked, as required by the facility’s policy for maintaining medication safety and administration. This deficient practice had the potential to results in patient and staff safety violations, including unauthorized access to medication, medication theft, misuse, and tampering (altering or modifying a medication or its packaging without authorization), which could lead to medication errors, overdose, or other safety breaches, including violating the facility’s policies designed to prevent medication mishandling and safeguard patients’ safety. Findings: During an observation on 6/10/2025 at 11:27 a.m. in the medication room on 5 South (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis] patients), with two nurse managers (NM 1 and NM 3), medication cart # 11 (a portable storage unit used to organize and dispense medications for the unit’s patients), was observed to be located within the medication room. The cart was found to be unlocked. NM 3 stated that the medication cart must be kept locked when not in use, even when it is parked in the locked medication room. During the same interview on 6/10/2025 at 11:27 a.m. with Nurse Manager (NM) 3, NM 3 said that usually, the key to the cart remained with the assigned medication nurse for the day, but all licensed personnel also had the key to access the medication room. NM 3 also said that EVS (Environmental Services) personnel, responsible for cleanliness and sanitation, had access to the medication room as well, and may enter it at any time. NM 3 stated that an unlocked medication cart can pose a risk of unauthorized access to patients’ medications. NM 1 then also said that the medication nurse was on a lunch break at the time of the observation [on 6/10/2025 at 11:28 a.m.]. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration and Documentation,” dated 10/2023, the P&P indicated that the medication room and the medication cart must be locked when unattended by licensed nursing staff.”

“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 interview and record review, the facility failed to ensure its nursing staff protected one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policy regarding abuse prevention, when staff allowed an agitated patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3’s) room with two other patients (Patients 1 and 2) present, on 4/9/2025. This deficient practice resulted in Patient 2 being triggered by Patient 3’s aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones) on 4/9/2025. On 6/12/2025 at 3:52 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), Associate Administrator of Operations (AAO), Chief Nursing Officer (CNO), Director of Quality Improvement and Risk Management (DQ), Program Director (DIR 1) of Developmental Delay and Mental Illness (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness), Director of Social Services (DIR 2), Nurse Manager (NM 1) for North and South ICU (intensive care unit, inpatient unit that provides treatment and therapy for adults who have mental, emotional and behavioral disorders), Nurse Manger (NM 2) for Central and Infection Control Practitioner, and Nurse Manager (NM 3) for East ICU and Youth (inpatient unit that provides treatment and therapy for adolescents who have mental, emotional and behavioral disorders). 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 allowed an agitated (being upset, annoyed, angry and physically disturbed) patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3’s) room with two other patients (Patient 1 and 2) present on 4/9/2025. This led to Patient 2 being triggered (activated) by Patient 3’s aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior. As a result, Patient 2 assaulted (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1 and led to Patient 1 sustaining (suffering) midface (central part of the face, between upper eyelids and the upper lips, including the cheeks and the nose) fractures (broken bones) on 4/9/2025. A review of facility’s security footage indicated the following: on 4/9/2025 at around 4 a.m., there was a patient-to-patient altercation (Patient 3 and Patient 4) when Patient 3 was seen swinging his (Patient 3’s) left arm to Patient 4. Nursing staff responded, separated both patients (Patient 3 and 4) and brought Patient 3 to his room (Room A). Patient 1 and Patient 2 were in same room (Room A) with Patient 3. Patient 3 was in Room A for 1 minute and 19 seconds, with multiple staff present, before staff brought Patient 3 back out of Room A. 25 seconds after Patient 3 left Room A, a Mental Health Worker (MHW) 1 looked in to Room A for about four (4) seconds then closed the door to Room A. Patient 1 and Patient 2 were left alone in Room A at this time for 56 seconds. Then a House Supervisor heard something, opened the door of Room A and Patient 1 came out of Room A, visibly bleeding with blood dripping on the floor. Patient 2 was seen standing by the door of Room A. Patient 1 reported to nursing staff that someone punched him (Patient 1). Patient 2 reported to nursing staff that he (Patient 2) hit Patient 1. Patient 1 was sent to a general acute care hospital after the incident and received a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) maxillofacial (the area of the head, neck, face, and jaws) scan. On 4/9/2025, the CT scan indicated Patient 1 sustained bilateral (both) Le Fort I (Le Fort I fracture is a type of facial fracture that occurs horizontally through the maxilla [upper jaw], above the roots of the teeth), right possible Le Fort II fractures (a pyramidal shaped fracture along the nasal bridge and causes separation of the midface from the skull base), and bilateral maxillary sinus fractures (a break in the bones that make up the maxillary sinus [the air-filled cavities in the cheek bones]) of the anterior (front) and posterolateral (at the back and to the side) walls. During an interview on 6/12/2025 at 9:50 a.m. with the Nurse Manager (NM 1) for North and South ICU, NM 1 stated staff should remove the roommates as best as they could because there was potential the roommates could get triggered, agitated and get hurt. On 6/13/2025 at 4:43 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), Associate Administrator of Operations (AAO), Chief Nursing Officer (CNO), Director of Quality Improvement and Risk Management (DQ), Program Director (DIR 1) of DDMI, Director of Social Services (DIR 2), Nurse Manager (NM 1) for North and South ICU, Nurse Manger (NM 2) for Central and Infection Control Practitioner, Nurse Manager (NM 3) for East ICU and Youth, and Director of Human Resources (HRD). 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, starting 6/12/2025, in the event of an incident of patient aggression, clinical staff would separate patients immediately and the aggressor(s) was to be placed in a separate area(s) away from other patients to maintain safety of all patients from direct harm by the aggressor(s) and also from being triggered to act out themselves. Clinical staff would debrief any patients who could be triggered by the incident and report any patients that were triggered and who might need further assessment/interventions to the Registered Nurse (RN) as soon as feasible after the incident when the aggressor(s) had been removed from the area. The RN would assess the patients involved in the incident as well as patients triggered by the incidents for the need for further interventions and take appropriate action as needed as soon as feasible after the incident when the patients were re-directable. The RN would document the assessment on the “Assault/ Violence Risk (Broset Violence Checklist [a 6-item tool used to predict the risk of imminent violence within 24 hours in individuals] Assessment) on the daily nursing flowchart. Patient might only be returned to the milieu (a person’s social environment) once it had been determined to be safe to do so. Education began on 6/12/2025 with all clinical staff including nursing, social services, activity therapy and behavioral team that were on duty on 6/12/2025 PM shift (3 p.m. to 11 p.m.). This education was also repeated before the shift started for the NOC shift (11 p.m. to 7 a.m.) and would continue to be repeated on all shifts at the beginning of each shift until all scheduled staff had been educated. Any staff that were not scheduled, on vacation or on a leave, would be educated upon their return. The education included an educational memorandum titled “Protecting Patients After Patient Aggression/Altercation.” Staff were required to sign an acknowledgement of receipt they received the memo and understood its content. The IJ removal plan also included monitoring activities to ensure there was a dedicated staff member assigned to monitor the hallway to ensure patient safety. The House Supervisor/Nurse Manager during the shift would complete the monitoring tool titled “Post Patient to Patient Altercation Monitoring Tool” to ensure its compliance after each incident occurred. Findings: During a review of Patient 1’s “Face Sheet (front page of the chart that contains a summary of basic information about the patient),” dated 3/31/2025, the Face Sheet indicated Patient 1 was admitted to the facility on 3/31/2025 at 10:30 a.m. under a 5150 legal hold (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 himself]). 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),” dated 3/30/2025, the 5150 hold paperwork indicated Patient 1 was detained for being gravely disabled due to auditory hallucinations (hearing sounds, noises, or voices that are not there) and abnormal behavior. During a review of Patient 2’s Face Sheet, dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold. During a review of Patient 2’s 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others when he (Patient 2) was found “challenging people to a fight without provocation” in the community. During a review of Patient 3’s “Face Sheet,” dated 3/28/2025, the Face Sheet indicated Patient 3 was admitted to the facility on 3/28/2025 at 12:55 p.m. voluntarily (of his own free will). During a review of Patient 3’s “Psychiatric (treatment or care for a mental health disorder or illness) and Mental Status Examination (PMSE, a formal and complete assessment of the patient and the problem related to mental health),” dated 3/29/2025 at 10:23 a.m., the PMSE indicated Patient 3 sought voluntary admission due to suicidal thoughts (thinking about killing himself). During a review of Patient 4’s “Face Sheet,” dated 4/8/2025, the Face Sheet indicated Patient 4 was admitted to the facility on 4/8/2025 at 10:50 a.m. under a 5150 legal hold. During a review of Patient 4’s 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 4 was detained for being gravely disabled due to abnormal behavior. During a review of Patient 1’s “Observation Record,” dated 4/9/2025, the Record indicated Patient 1 was awake and in his room from 2:15 a.m. to 4:00 a.m. During a review of Patient 2’s “Observation Record,” dated 4/9/2025, the Record indicated Patient 2 was awake and in his room from 2:30 a.m. to 4:00 a.m. During an interview with the Director of Quality and Risk Management (DQ) on 6/9/2025 at 1:51 p.m., the DQ stated that on 4/9/2025 at around 4:00 a.m., Patient 1 came out of his (Patient 1) room with his nose bleeding and stated that somebody punched him. The DQ further stated that the only other person in the room was his roommate, Patient 2, but at the time, he (Patient 2) denied knowing what happened. During an interview with Nurse Manager (NM) 1 on 6/11/2025 at 10:16 a.m., NM 1 confirmed that Patients 1, 2, and 3 were roomed in together in the same room (Room A). NM 1 further stated that on 4/9/2025 after midnight, there was a “fight” between Patients 3 and 4 in the hallway; during the fight, another altercation between Patient 1 and Patient 2 occurred in Room A, unwitnessed by staff. During a concurrent interview and video surveillance review with Nurse Manager (NM) 1 on 6/12/2025 at 9:34 a.m., two video clips of security footage from 4/9/2025, were reviewed. NM 1 stated these videos occurred at approximately 4:00 a.m. on 4/9/2025 as there were no time stamps on the footage. The following events were observed from the first clip: 1. At the beginning of the video clip, Patient 4 was standing in the hallway. 2. Patient 3 emerged from his room. Staff stepped in between Patients 3 and 4. One minute and 12 seconds into the video Patient 3 swung his left arm at Patient 4. Additional staff responded to the incident. 3. One minute and 30 seconds in, staff brought Patient 3 back to Room A (where Patients 1 and 2 were staying). Four staff were observed entering Room A with Patient 3. 4. Two minutes and 49 seconds in, staff removed Patient 3 from Room A. During the same interview on 6/12/2025 at 9:34 a.m. with Nurse Manager (NM) 1, NM 1 stated Patient 3 was in his room, with staff present, for one minute and 19 seconds, based on the time elapsed in the video. NM 1 further stated that staff removed Patient 3 from his room and brought him 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 to administer emergency medications (medications given to manage severe mental health symptoms such as agitation). During the same video surveillance review on 6/12/2025 at 9:34 a.m., the following events were reviewed from the second clip: 1. Two minutes and 19 seconds into the video, staff brought Patient 3 out of Room A. 2. Two minutes and 44 seconds in, Mental Health Worker (MHW) 2 closed the door to Room A. 3. Three minutes and 40 seconds in, House Supervisor (HS) 1, who was standing in the hallway, appeared to hear something coming from Room A and opened the door. 4.Three minutes and 44 seconds in, Patient 1 emerged from Room A dripping blood on the floor. Staff took him (Patient 1) to the nurses’ station. Patient 2 was seen standing in the doorway of Room A. -NM 1 stated Patients 1 and 2 were left alone in Room A for 56 seconds, based on the time elapsed in the video. During an interview with Nurse Manager (NM) 1 on 6/12/2025 at 9:50 a.m., NM 1 stated that the facility’s staff were responsible for the patients. NM 1 further stated that agitated patients should not be in a room with other patients, and staff should remove the roommates as best as they could because there was potential that the roommates could get triggered, agitated, or get hurt. During an interview with Nurse Manager (NM) 1 on 6/12/2025 at 10:24 a.m., NM 1 stated Patient 2 was a newly admitted patient and had not yet been seen by a physician. The staff was not familiar with Patient 2 and did not know what would trigger Patient 2 and what Patient 2’s behavior would be. NM 1 further stated the staff should have maintained vigilance until the staff got to know Patient 2 more. During a review of Patient 1’s “Progress Notes,” dated 4/9/2025 at 4:35 a.m., the Progress Notes indicated, “Around [4:10 a.m.], patient [Patient 1] came out of his room [with] heavy bleeding from both nostrils. [Patient 1 was] confused, unable to provide accurate information regarding what exactly happened, but stated ‘I’m sorry, someone punched me’.” The Progress Notes further indicated Patient 1 was sent to General Acute Care Hospital (GACH) 1’s Emergency Department (a hospital department that provides immediate care for patients with urgent medical conditions) at 4:33 a.m. During a review of Patient 1’s “Progress Notes,” dated 4/9/2025 at 1:51 p.m., the Progress Notes indicated Patient 1 was scheduled to be transferred to GACH 2 at 2:00 p.m. for possible oral facial (face and mouth) surgery. During a review of Patient 2’s “Progress Notes,” dated 4/9/2025 at 4:47 a.m., the Progress Notes indicated, “[Patient 1] ran out of his room with his nose bleeding. [Patient 2] stated he (Patient 2) did not know who punched him.” During a review of Patient 2’s “Progress Notes,” dated 4/9/2025 at 3:48 p.m., the Progress Notes indicated, “[Patient 2] states, [‘I hit the other guy earlier.’]” During a review of Patient 1’s “CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) Maxillofacial (upper jaw and face) Scan” report from GACH 2, dated 4/9/2025 at 8:26 p.m., the report indicated Patient 1 sustained bilateral (both) Le Fort I (a type of facial fracture that occurs horizontally through the maxilla [upper jaw], above the roots of the teeth), right possible Le Fort II fractures (a pyramidal shaped fracture along the nasal bridge and causes separation of the midface from the skull base), and bilateral maxillary sinus fractures (a break in the bones that make up the maxillary sinus [the air-filled cavities in the cheek bones]) of the anterior (front) and posterolateral (at the back and to the side) walls. During a review of Patient 1’s “ENT (a physician that specializes in medical conditions of the ear, nose, throat, and neck) Consultation Note,” from GACH 2, dated 4/10/2025 at 4:04 a.m., the Note indicated the ENT physician recommended conservative non-operative management (no surgery required) and cleared Patient 1 to return to the facility (where Patient 1 got punched by Patient 2). During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” last reviewed 10/2023, indicated, “The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences from the initial assessment prior to [seclusion/restraint], including ... C. Separating patient from group or community ... E. Offering the use of the quiet room to decrease stimuli and regain control.” During a review of the facility’s policy and procedure (P&P) titled, “Abuse Prevention, Screening, Identification, Training, Protection, Investigation, and Reporting,” last reviewed 10/2023, indicated, “It is the policy of College Hospital to protect our patients from all types of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients, or visitors ... A critical part of protecting patients from abuse is preventing abuse from occurring in the first place.””

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d) Patient Rights: Confidentiality of Records This Standard is not met as evidenced by: 46238 Based on observation, interview and record review the facility failed to ensure that one of 39 sampled patient’s (Patient 27), electronic medical record (EMR, a digital collection of a patient’s medical information, including their health history, diagnoses, medications, allergies, immunizations, and treatment plans), was protected, in accordance with the facility’s policy regarding confidentiality, when a nurse did not log out from Patient 27’s digital chart and left for lunch, thereby exposing Patient 27’s medical record to unauthorized personnel. This deficient practice had the potential to violate Patient 27’s right (Patient Rights- the fundamental entitlements and protections that individuals have when receiving medical care) to confidentiality and privacy, increasing the risk of unauthorized access to sensitive medical information, which could lead to privacy violations, identity theft, and misuse of personal health data. Findings: During an observation on 6/10/2025 at 11:27 a.m. in the medication room on 5 South (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis] patients), with two nurse managers (NM 1 and NM 3), a computer (nursing workstation) was observed to be located on top of the medication room cart (cart# 11) inside the locked medication room. Personal information of Patient 27 was visible on the screen, displaying the digital record of the medication administration record (MAR), including details of the last documented medications administered. NM 3 proceeded to log out Patient 27’s digital record and stated that this was confidential information, and nurses should log out of the patient’s chart to protect patient’s confidential medical information from unauthorized use. NM 1 stated that a nurse who was logged into Patient 27’s electronic medical record (EMR, a digital collection of a patient’s medical information, including their health history, diagnoses, medications, allergies, immunizations, and treatment plans) was on lunch at the time of the observation. During an interview on 6/10/2027 at 11:28 a.m. with nurse manager (NM) 3, NM 3 said that all licensed personnel also had the key to access the medication room. NM 3 also said that EVS (Environmental Services personnel, responsible for cleanliness and sanitation), had access to the medication room at well, and may enter it at any time. During a review of Patient 27’s Psychiatric (treatment or care for a mental health disorder or illness) and Mental Status Examination,” dated 5/27/2025 (an annual psychiatric mental examination for 5/26/2025), was reviewed. The Psychiatric and Mental Status Examination report indicated Patient 27 was admitted on 1/17/2024 on a 5150 hold (a legal procedure where a person can be involuntarily detained for up to 72 hours in a psychiatric facility for evaluation and stabilization if they are deemed to be a danger to themselves or others, or gravely disabled due to a mental health disorder) because of running into traffic and noncompliance with medications. During a review of the facility’s policy and procedure (P&P) titled, “Confidentiality,” dated 10/2023, the P&P indicated the following, “All nursing staff shall keep all patient information private. Neither written nor verbal information may be shared with staff not involved in the patient’s treatment nor any other person.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure physical hold (a manual restraint or manual hold used to restrict a patient’s movement for safety reasons, performed according to established techniques and protocols) restraint, was properly implemented, in accordance with the established correct techniques for staff, when performing physical holds on two of 39 sampled patients (Patient 19 and Patient 24) when: 1. A mental health worker (MHW) 1 leaned his (MHW 1’s) right elbow onto Patient 19’s upper back during a physical hold on 4/22/2024. This deficient practice had the potential to result in hurting Patient 19 and affecting Patient 19’s breathing. 2. A mental health worker (MHW 1) hyperextended (occurs when the elbow joint bends backward beyond its normal range of motion) Patient 24’s left arm during a physical hold on 3/19/2024 in a seclusion room (a room or area where a person is involuntarily confined, meaning they are physically prevented from leaving), when Patient 24 was held against the wall, with two mental health workers on each side. This deficient practice had the potential to compromise Patient 24’s safety by increasing Patient 24’s risk of injury, such as nerve damage or musculoskeletal harm such as dislocation of the shoulder. Findings: 1. During a review of Patient 19’s “Annual Psychiatric Assessment (a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 5/9/2024, the “Annual Psychiatric Assessment” indicated, Patient 19 was admitted to the facility’s adult locked Developmental Delay and Mental Illness (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness) with bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration) type schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception of objects or events involving your senses: sight, sound, smell, touch and taste] and/or delusions [a fixed, false belief that is not amenable to change even when presented with contradictory evidence]) and mild intellectual disability (a disability that affects the acquisition of knowledge and skills). During a concurrent interview and record review on 6/11/2025 at 11:47 a.m. with Program Director (DIR 1) of DDMI, a facility’s video clip of security footage, with no audio, timestamp dated on 4/22/2024, was reviewed. The video clip showed the following: -At 4:51 p.m.: Patient 19 was walking around and banging the wall in the seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) room; -At 5:15 p.m.: a clinical staff came to talk to Patient 19; -At 5:20 p.m.: Patient 19 continued pacing and banging the wall in the seclusion room; -At 5:21 p.m.: multiple clinical staff came into the seclusion room. A Mental Health Worker (MHW) 1 brought Patient 19 to face the wall and leaned his (MHW 1’s) right elbow onto Patient 19’s upper back while another clinical staff was holding Patient 19’s left arm. Other clinical staff were preparing 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) devices on the restraint bed for Patient 19. During the same interview on 6/11/2025 at 11:47 a.m. with Program Director (DIR 1) of DDMI, DIR 1 stated the following: MHW 1 performed physical hold (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body) on Patient 19 incorrectly. MHW 1 was leaning too much with his (MHW 1’s) elbow onto Patient 19. There was potential that Patient 19 could get hurt by hitting the wall. DIR 1 also stated MHW 1 was terminated. During an interview on 6/12/2025 at 10:36 a.m. with Nurse Manager (NM) 1, NM 1 stated leaning elbow onto patient was incorrect NCI (Nonviolent Crisis Intervention, behavior management system designed to help to de-escalate [reduce the intensity of a conflict or potentially violent situation] and manage disruptive or out-of-control individuals in a safe and non-harmful way) technique. It could restrict patient’s breathing with excessive force and cause patient harm. It was important for clinical staff to use correct NCI trained technique to safely handle the patient through physical intervention. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated, “Seclusion and restraints (S/R) interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others ... S/R procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring ... The leadership team has developed S/R training and competencies that are required for all clinical staff prior to patient intervention ... the facility’s approved method of non-violent crisis intervention (NCI) are additional competency requirements. The use of non-violent crisis prevention techniques to ensure patient and staff safety are consistent with established standards ... Procedure ... 7. The Registered Nurse (RN), in collaboration with unit staff, evaluates the patient’s behavior and implements appropriate NCI techniques to maintain patient and staff safety for escort to seclusion room, placement on transport gurney, and/or restraint bed. 8. If physical restraint is indicated, a minimum of two (2) but preferably four (4) NCI trained staff must participate in the physical hold application.” During a review of the educational material developed by the Crisis Prevention Institution (CPI, a global organization that provides evidence-based training focused on de-escalation and crisis intervention) titled, “Non-Violent Crisis Intervention Training,” dated 2023, the educational material indicated, “Safety Interventions - Holding Skills ... Holding: A restrictive safety intervention necessary to restrict a person’s range of movement to prevent the infliction of harm to self or others ... keep upright. Avoid leaning or bending the person forward.” 2. During a review of Patient 24’s “Annual Psychiatric Assessment (APA, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/22/2024, the APA indicated that Patient 24 was a DDMI patient (DDMI-Developmental Disability and Mental Illness -dual diagnosis), who was admitted to the facility on 1/22/2024 due to being danger to self (threatening to kill self) and others, and had history of autism (a neurodevelopmental condition that affects how people interact with the world, particularly in social communication and interaction, and in the presence of restricted and repetitive behaviors, interests, or activities), ADHD (Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity), anxiety (a common emotion characterized by feelings of fear, worry, unease, and apprehension) and ODD (Oppositional Defiant Disorder, a pattern of defiant, angry, and irritable behavior, including arguing, refusing to comply, and intentionally annoying others). During a concurrent interview and review on 6/12/2025 at 12:37 p.m. with the director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), Patient 24’s restraint and seclusion (S&R, interventions used in the treatment and management of disruptive and violent behaviors in psychiatry), video footage (no audio), timestamp dated 3/19/2024, was reviewed. The video footage indicated the following: -At 5:15 p.m., Patient 24 was held against the wall, restrained by two mental health workers (MHW 1 and MHW 2). MHW 1 was positioned on the left side of Patient 24, holding Patient 24’s left arm, hyper-extending the arm backwards and slightly upward (meaning the arm was pulled or extended beyond its normal range of motion). Patient 24 was pinned against the wall in a physical hold, for about a minute, while staff prepared the 5-point physical restraints (refer to a type of physical restraint that uses a combination of restraints on the body to limit movement., involving restraints on all four limbs (wrists and ankles) and an additional restraint around the torso, pelvis, or thighs) to secure the patient on the bed). -At 5:17 p.m. Patient 24 was restrained in 5-point restraints During the same interview on 6/12/2025 at 12:37 p.m. with the director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), Dir 1 said that hyperextension of the arm was an incorrect level of restriction applied by MHW 1 when applying a physical hold. Dir 1 also said that MHW 1 was terminated in 2024 but could not recall the specific reason for the termination. Dir 1 also said that MHW 1 could have easily dislocated Patient 24’s arm and verified that this technique was not in accordance with the NCI (The Crisis Prevention Institute’s Nonviolent Crisis Intervention [NCI] certification program which is designed to provide participants with the knowledge and skills required to respond early and effectively to prevent or defuse a behavioral escalation) training provided by the facility to staff. During a review of Mental Health Worker (MHW 1) 1’s “Behavioral Restraint and Seclusion Assessment of Competency - MHW,” dated 10/03/2024, the record indicated that MHW 1 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints, through verbal or written test, there was no validation completed through simulation (the use of realistic models, scenarios, and technologies to replicate real-life medical situations in a controlled environment) and observation. The record also indicated that the employee must adequately demonstrate competency related to the use of seclusion and/or restraint during an actual episode as observed by an assessor (a qualified staff who evaluate the quality and safety use of restrictive practices, physical hold, including physical and mechanical restraints, and seclusion). During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated that: “A. Physical Restraint/Hold: any manual or physical method of holding the patient against the a patient’s will that restricts freedom of movement or normal access to one’s body.” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Treatment Plan/Patient and Staff Debriefing/Staff Training and Competency,” dated 10/2023, the P&P indicated that: “Staff members who are authorized to apply restraint or seclusion are trained in all (restraint, seclusion, physical hold, de-escalation techniques) techniques, plus the safe use of restraint, including physical holding techniques, take down procedures, and the application and removal of mechanical restraints...” During a review of the educational material developed by the Crisis Prevention Institution (CPI, a global organization that provides evidence-based training focused on de-escalation and crisis intervention) titled, “Non-Violent Crisis Intervention Training,” dated 2023, the educational material indicated the following regarding safety interventions-Holding Skills: “CPI focuses on nonviolent crisis intervention, emphasizing verbal and non-verbal de-escalation techniques to manage potentially dangerous situations. Physical interventions, like those involving arm movements, are only considered as a last resort and should be performed safely with minimal force...utilizing techniques such as the person’s arms are against their own body or holding on the insight of the wrist and/or elbows...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure that the use of restraint (devices or methods used to restrict a patient’s movement, either physically or through medication) or seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior), was in accordance with a physician’s order and the facility’s policy regarding seclusion/restraints use, for four of 39 sampled patients (Patients 2, 5,19, 25) when: 1. Patient 2 was placed in seclusion without a physician order for three hours and five minutes. This deficient practice had the potential to put Patient 2 at risk for injury. 2. Patient 5 was placed in a physical hold (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body) without a physician order for approximately five seconds. This deficient practice had the potential to put patient 19 at risk for injury. 3. Patient 19 was physically restrained without a physician order on 4/22/2024. This deficient practice had the potential to put Patient 19 at risk for unnecessary seclusion and/or restraints and at risk for injury. 4. Patient 25 was documented to have been placed in seclusion eight (8) times from 3/12/2024 through 11/20/2024, of those eight episodes, Patient 25 was in seclusion without a physician’s order for seclusion and for one out of eight episodes, lacked an order for physical restraints. This deficient practice had the potential to place Patient 25 at risk of harm and unnecessary seclusion or restraints use. Findings: 1. During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold (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 care for themselves]). 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),” dated 4/8/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others when he (Patient 2) was found “challenging people to a fight without provocation” in the community. During a review of Patient 2’s Progress Notes, dated 4/9/2025 at 4:47 a.m., the Progress Notes indicated, “[Patient 1] ran out of his (Patient 1) room with his nose bleeding. [Patient 2] stated he did not know who punched him (Patient 1) ... [Patient 2] is put into locked seclusion (the involuntary confinement of a patient alone in a locked room, preventing them from leaving, to manage violent or self-destructive behavior) at [4:50 a.m.]” During a review of Patient 2’s “Seclusion and Restraints Assessment Packet (S&R Assessment),” dated 4/9/2025 at 7:50 a.m., the S&R Assessment indicated Patient 2 was placed in seclusion because he “punched his roommate (Patient 1) unwitnessed by staff [and was] irritable, testing limits, minimizing [the] situation, appearing very unpredictable and uncooperative, [and] non-redirectable.” The S&R Assessment further indicated Patient 2 was in seclusion for three hours and five minutes, entering at 4:45 a.m. and then released at 7:50 a.m. During a concurrent interview and record review with Nurse Manager (NM) 1 on 6/12/2025 at 2:41 p.m., Patient 2’s medical record, was reviewed. NM 1 confirmed that there was no physician order present in the medical record for Patient 2’s seclusion on 4/9/2025 from 4:45 a.m. to 7:50 a.m. and that there should be one present (physician order). During an interview with Nurse Manager (NM) 1 on 6/13/2025 at 11:10 a.m., NM 1 stated that nurses could initiate seclusion or restraint, but the physician needed to order it as well to ensure that it was the appropriate or necessary intervention. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” last reviewed 10/2023, the P&P indicated, “The Physician or RN can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the S/R [seclusion/restraint], and document on the Seclusion/Restraint Order as follows: ... B. The physician’s orders specify the reason for the restraint and seclusion usage, the type of restraint, and their duration. ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained RN may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes.” 2. During a review of Patient 5’s Face Sheet, dated 6/4/2025, the Face Sheet indicated Patient 5 was admitted to the facility on 6/4/2025 at 7:55 p.m. on a 5150 legal hold. During a review of Patient 5’s 5150 hold paperwork, dated 6/4/2025, the paperwork indicated Patient 5 was placed on a 5150 legal hold for being a danger to herself due to erratic and suicidal (thoughts of taking one’s own life) behavior. During a review of Patient 5’s “Emergency Use of Medications Assessment Flowsheet,” dated 6/6/2025 at 8:40 p.m., the Flowsheet indicated, “At [7:30 p.m.], [Patient 5] had a visit from [Visitor]. [Patient 5] was calm with [Visitor]. At [8:00 p.m.], when [Visitor] was about to leave, [Patient 5] was being defiant and refusing to go back to room, stating ‘I’m leaving with [Visitor].’ [Patient 5] was educated on how [Patient 5] cannot leave at this moment due to [Patient 5] being on involuntary hold. [Patient 5] refused to understand and locked arms with [Visitor]. 1 to 1 therapeutic communication was used. [Patient 5] was reoriented to reality and to comply with visits and to go back into the room. [Patient 5] refused to let go of [Visitor] and stated, ‘I’m going with [Visitor], don’t touch me or I will fight.’ Code grey (an emergency situation involving a combative or aggressive patient) was called, patient was asked to walk back to the room.” During a concurrent interview and video surveillance review with Nurse Manager (NM) 1 on 6/12/2025 at 1:59 p.m., the security video from 6/6/2025, was reviewed. The video indicated at 8:01 p.m., two staff members were holding Patient 5 in the hallway for approximately five seconds, one holding each arm. NM 1 confirmed this was a physical hold and stated they (the two staff members) were trying to prevent Patient 5 from leaving with the visitor. During a concurrent interview and record review with Nurse Manager (NM) 1 on 6/13/2025 at 9:28 a.m., Patient 5’s medical record, was reviewed. NM 1 confirmed there was no physician order for the physical hold observed in the security video. NM 1 stated that physical holds were a form of restraint, was used to prevent the patient from moving, and that there should have been an order for the physical hold. During an interview with Nurse Manager (NM) 1 on 6/13/2025 at 11:10 a.m., NM 1 stated that nurses can initiate seclusion or restraint, but the physician needs to order it as well to ensure that it was the appropriate or necessary intervention. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” last reviewed 10/2023, the P&P indicated, “Restraint: Physical Restraint/Hold: Any manual or physical method of holding the patient against the patient’s will that restricts freedom of movement or normal access to one’s body ... The Physician or RN can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the S/R, and document on the Seclusion/Restraint Order as follows: ... B. The physician’s orders specify the reason for the restraint and seclusion usage, the type of restraint, and their duration. ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained RN may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes.” 3. During a review of Patient 19’s “Annual Psychiatric Assessment (a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 5/9/2024, the “Annual Psychiatric Assessment” indicated, Patient 19 was admitted to the facility’s adult locked Developmental Delay and Mental Illness (DDMI, inpatient unit that provides treatment and therapy for people who have developmental delay with mental illness) with bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration) type schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) and mild intellectual disability (a disability that affects the acquisition of knowledge and skills). During a concurrent interview and record review on 6/11/2025 at 11:47 a.m. with Program Director (DIR 1) of DDMI, a facility’s video clip of security footage with no audio, timestamp dated on 4/22/2024, was reviewed. The video clip showed the following: -At 4:51 p.m.: Patient 19 was walking around and banging the wall in the seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) room; -At 5:15 p.m.: a clinical staff came to talk to Patient 19; -At 5:20 p.m.: Patient 19 continued pacing and banging the wall in the seclusion room; -At 5:21 p.m.: multiple clinical staff came into the seclusion room. A Mental Health Worker (MHW) 1 brought Patient 19 to face the wall and leaned his (MHW 1’s) right elbow onto Patient 19’s upper back while another clinical staff was holding Patient 19’s left arm. Other clinical staff were preparing 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) devices on the restraint bed for Patient 19. During the same interview on 6/11/2025 at 11:47 a.m. with Program Director (DIR 1) of DDMI, DIR 1 stated the clinical staff performed physical hold on Patient 19 prior to placing Patient 19 on 5-point restraints. During a concurrent interview and record review on 6/12/2025 at 2:31 p.m. with Nurse Manager (NM) 2, Patient 19’s physician order, dated 4/22/2024, was reviewed. The physician order indicated there was a seclusion and a 5-point restraint ordered on 4/22/2024. NM 2 stated there should be a separate physician order for physical hold when staff were putting hands on patient. NM 2 stated there was no physical hold order for the seclusion/restraints episode on 4/22/2024. During an interview on 6/13/2025 at 10:43 a.m. with Director (DIR 1) of DDMI, DIR 1 stated the following: nursing staff must obtain a physician order when putting patients on seclusion, physical hold and restraint so physician would know what was going on with the patient, the physician could then decide and agree with the interventions and give direction if any interventions was needed. Without a physician order, it would be considered as holding patient illegally without physician’s permission. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “Definition ... Restraints: A. Physical Restraint/Hold: Any manual or physical method of holding the patient against the patient’s will that restricts freedom of movement or normal access to one’s body ... Procedure ... 4. The physician or Registered Nurse (RN) can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the seclusion/restraints (S/R), and document on the Seclusion/Restraint Order form as follows: A. Time Limits: 1) Adults 18 and older up to four (4) hours; 2) Youth 9 - 17 up to two (2) hours ... B. The physician’s orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration. The S/R can be ordered for less than above stated maximum. The length of the S/R is limited by the continued need for the intervention rather than then length of the order ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained Registered Nurse may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes.” 4. During a review of Patient 25’s “Psychiatric and Mental Status Examination (PMSE, a comprehensive assessment performed by a psychiatrist to diagnose and treat mental health conditions, while a mental status examination [MSE] is a structured way to observe and document a patient’s current psychological state during a clinical encounter),” dated 3/12/2024, the PMSE indicated that Patient 25 was admitted on a 5150 (a temporarily hold for evaluation and crisis intervention- involuntary 72-hour psychiatric hospitalization of an individual who, due to a mental health disorder, is deemed a danger to themselves, a danger to others, or gravely disabled) due to danger to others. The PMSE also indicated that Patient 25 had history of autism (neurodevelopmental condition that affects how individuals interact with the world, particularly in social communication and interaction, and in their patterns of behavior and interests) and explosive disorder (a mental health condition characterized by sudden and frequent episodes of impulsive, aggressive, violent behavior or angry verbal outbursts). During a review of Patient 25’s electronic medical record (EMR, digital version of paper chart), the “Behavioral Restraint/Seclusion Order Assessment,” dated 3/12/2024 through 11/12/2024, was reviewed. The records indicated that Patient 25 had eight (8) episodes of restraint and seclusions. During a concurrent interview and record review on 6/11/2025 at 11:30 a.m. with Nurse Manager (NM 1), Patient 25’s electronic medical record (EMR) titled, “Behavioral Restraint/Seclusion Order Assessment,” dated 3/12/2024 through 11/12/2024, was reviewed. The record indicated that Patient 25 was placed in seclusion/restraints 8 times since the admission to the facility on 3/12/2024: -3/15/2024-Patient 25 was placed on physical hold at 5:10 p.m., seclusion at 5:10 p.m., and physical restraints at 5:10 p.m. No order for physical restraints was placed in Patient 25’s EMR. -3/24/2024-Patient 25 was placed on physical hold at 3:45 p.m., seclusion at 3:55 p.m., and restraints at 3:55 p.m. No physician’s order for seclusion was placed in Patient 25’s EMR -3/30/2024-Patient 25 was placed on physical hold at 10:15 a.m., seclusion at 10:18 a.m., and restraints at10:18 a.m. No physician’s order for seclusion was found to be placed in Patient 25’s EMR. -4/13/2024-Patient 25 was placed on physical hold at 6:15 p.m., seclusion at 11:14 a.m., and restraints at 6:15 p.m. No physician’s order for seclusion was documented in Patient 25’s EMR. -4/28/2024-Patient 25 was placed on physical hold at 8:10 a.m., seclusion at 8:20 a.m., and restraints at 8:20 a.m. No physician’s order for seclusion was found in Patient 25’s EMR. -5/5/2024-Patient 25 was placed on physical hold at 10:05 a.m., seclusion at 10:10 a.m., and restraints at 10:10 a.m. No physician’s order for seclusion was documented in Patient 25’s EMR. -5/12/2024-Patient 25 was placed on physical hold at 2:25 p.m., seclusion 2:45 p.m., and restrained at 2:45 p.m. No order for seclusion was placed in Patient 25’s EMR. -8/4/2024 -Patients 25 was placed on physical hold at 3:05 p.m., seclusion at 3:10 p.m., and restraints at 3:10 p.m. No order for seclusion was found to be placed in Patient 25’s EMR -Seven out of eight (8) reviewed episodes of Patient 25 being in seclusion from 3/12/2024 through 11/12/2024, lacked corresponding physician’s orders for seclusion and one out of eight (8) reviewed episodes of Patient 25 being in restraints, lacked an order for physical restraints. NM 1 stated that a separate order for a physical hold, seclusion and restraint was required and should be placed within minutes after placing a patient in physical hold, seclusion or restraints, in accordance with the facility’s policy regarding seclusion and restraints use. During an interview on 6/12/2025 at 3:19 p.m. with Nurse Manager (NM) 1, NM 1 said that all orders for physical restraints/seclusions, or physical holds must be obtained and documented within minutes after placing the patient in seclusion, restraints, or a physical hold. NM 1 also said that there should be no more gaps in documentation when it comes to placing these orders and added that the facility had already implemented extensive education on this requirement, and compliance was continuously monitored through ongoing audits. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “Definition ... Restraints: A. Physical Restraint/Hold: Any manual or physical method of holding the patient against the patient’s will that restricts freedom of movement or normal access to one’s body ... Procedure ... 4. The physician or Registered Nurse (RN) can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the seclusion/restraints (S/R), and document on the Seclusion/Restraint Order form as follows: A. Time Limits: 1) Adults 18 and older up to four (4) hours; 2) Youth 9 - 17 up to two (2) hours ... B. The physician’s orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration. The S/R can be ordered for less than above stated maximum. The length of the S/R is limited by the continued need for the intervention rather than then length of the order ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained Registered Nurse may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility failed to ensure for five of five (5) sampled staff (Mental Health Worker 1, Mental Health Worker 6, Mental Health Worker 7, Charge Nurse 2, and Charge Nurse 3), a training and demonstration of competency on restraint (methods or devices used to restrict a person’s movement or ability to move freely), seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) and physical hold (a situation where a patient’s movement is involuntarily restricted by staff, often to prevent harm to themselves or others), were successfully completed and documented, in accordance with the facility’s “Behavioral Restraint and Seclusion Assessment of Competency,” document. This deficient practice had the potential to negatively affect patients receiving care. Specifically, incomplete training and documentation of completion could result in staff’s lack of a clear understanding of the appropriate circumstances and procedures for utilizing restraints, seclusion, and physical holds, which can lead to inappropriate or unsafe use, increasing the risk of physical and psychological harm to patients including risk of injury to staff. Findings: During a review of Mental Health Worker 1’s (MHW 1) “Behavioral Restraint and Seclusion Assessment of Competency - MHW,” dated 03/07/2024, the record indicated that MHW 1 only demonstrated understanding and competence on the application and use of restraint (methods or devices used to restrict a person’s movement or ability to move freely) or seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through simulation (a retraining exercise that mimics real-life scenarios in a controlled environment to demonstrate proper techniques and responses), there was no validation completed through verbal or written test and observation. The record also indicated that it was required that the employee must adequately demonstrate competency related to the use of seclusion and/or restraint during an actual episode as observed by an assessor (a qualified staff who evaluate the quality and safety use of restrictive practices, physical hold, including physical and mechanical restraints, and seclusion). It also indicated that there was no other competency plan required for MHW 1. This was validated by Nurse Manager (NM) 1 on 6/13/2025. During a review of Mental Health Worker 6’s (MHW 6) “Behavioral Restraint and Seclusion Assessment of Competency - MHW,” dated 03/12/2025, the record indicated that MHW 6 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through verbal or written test, there was no validation completed through simulation and observation. The record also indicated that there was no other competency plan required for MHW 6. This was validated by Nurse Manager (NM) 1 on 6/13/2025. During a review of Mental Health Worker 7’s (MHW 7) “Behavioral Restraint and Seclusion Assessment of Competency - MHW,” dated 10/03/2024, the record indicated that MHW 7 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through verbal or written test, there was no validation completed through simulation and observation. The record also indicated that the employee must adequately demonstrate competency related to the use of seclusion and/or restraint during an actual episode as observed by an assessor (a qualified staff who evaluate the quality and safety use of restrictive practices, physical hold, including physical and mechanical restraints, and seclusion). It also indicated that there was no other competency plan required for MHW 7. This was validated by Nurse Manager (NM) 1 on 6/13/2025. During a review of Charge Nurse 2’s (CN 2) “Behavioral Restraint and Seclusion Assessment of Competency - RN,” dated 05/20/2025, the record indicated that CN 2 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through simulation, there was no validation completed thru verbal or written test and observation. It also indicated that there was no other competency plan required for CN 2. This was validated by Nurse Manager (NM) 1 on 6/13/2025. During a review of Charge Nurse 3’s (CN 3) “Behavioral Restraint and Seclusion Assessment of Competency - RN,” dated 06/13/2024, the record indicated that CN 3 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through verbal or written test and simulation, there was no validation completed thru observation. The record also indicated that the employee must adequately demonstrate competency related to the use of seclusion and/ or restraint during an actual episode as observed by an assessor (a qualified staff who evaluate the quality and safety use of restrictive practices, physical hold, including physical and mechanical restraints, and seclusion). It also indicated that there was no other competency plan required for CN 3. This was validated by NM 1 on 6/13/2025. During an interview on 06/13/2025 at 2:54 p.m. with Nurse Manager (NM) 1, NM1 stated that it was an expectation that when training and validating staff competency on restraint, seclusion and physical hold, staff must demonstrate competency via verbalization and/or written test, simulation and observation. The employee must also demonstrate the use of seclusion and restraint during an actual episode as observed by an assessor. During a concurrent interview and record review on 06/13/2025 at 3:33 p.m. with the Chief Nursing Officer (CNO), Mental Health Worker 1’s (MHW 1) “Behavioral Restraint and Seclusion Assessment of Competency - MHW,”- dated 03/07/2024, Mental Health Worker 6’s (MHW 6) “Behavioral Restraint and Seclusion Assessment of Competency - MHW,”- dated 03/12/2025, Mental Health Worker 7’s (MHW 7) “Behavioral Restraint and Seclusion Assessment of Competency - MHW,”- dated 10/03/2024, Charge Nurse 2’s (CN 2) “Behavioral Restraint and Seclusion Assessment of Competency - RN,”- dated 05/20/2025 and Charge Nurse 3’s (CN 3) “Behavioral Restraint and Seclusion Assessment of Competency - RN,”- dated 06/13/2024, were reviewed. The Chief Nursing Officer (CNO) concurred that five of five (5) sampled staff’s (Mental Health Worker 1, Mental Health Worker 6, Mental Health Worker 7, Charge Nurse 2, and Charge Nurse 3), training documentation and demonstration of competency on restraint, seclusion and physical hold were incomplete. CNO stated that there was a recent change in the “Behavioral Restraint and Seclusion Assessment of Competency” form, and there may have been confusion as to how it was supposed to be completed and documented. During a review of the facility’s “Behavioral Restraint and Seclusion Assessment of Competency,” document, undated, the document indicated that the assessor will initial and date the competency assessment form only after the following indicators were met by staff: -The employee has adequately (via verbalization, simulation, and/or written test) demonstrated the use of seclusion and/or restraint for his/her job classification -The employee has adequately demonstrated competency related to the use of seclusion and/or restraint during actual episode as observed by Assessor.”

“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 interview and record review, the facility failed to: 1. Ensure that a Registered Nurse (RN) provided supervision over the physical hold (a manual method used to restrict a person’s movement or hold them immobile, often to prevent harm to themselves or others), for two of 39 sampled patients (Patient 19 and Patient 24), ensuring that correct physical restraining techniques were utilized, in accordance with the facility’s policy regarding seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) and restraints (methods or devices used to restrict a person’s movement or ability to move freely) use, when: 1.a. Mental Health Worker (MHW 1) hyperextended Patient 24’s left arm during a physical hold on 3/19/2024 in a seclusion room (a room or area where a person is involuntarily confined, meaning they are physically prevented from leaving), when Patient 24 was pinned against the wall, with two mental health workers on each side. This deficient practice had the potential to compromise Patient 24’s safety by increasing Patient 24’s risk of injury, such as nerve damage or musculoskeletal harm such as dislocation of the shoulder. 1.b. Mental Health Worker (MHW 1) leaned the right elbow against the back of Patient 19 during a physical hold on 4/22/2024, while clinical staff prepared the restraints for Patient 19 to be restrained shortly after. This deficient practice had the potential to result in causing Patient 19’s difficulty breathing and injury. 2. Ensure one of 39 sampled patient’s (Patient 13) wound assessment (a systematic evaluation of a wound to determine its characteristics, stage, and healing progress), was completed and documented, in accordance with the facility’s policy regarding assessment and reassessment. This deficient practice had the potential to result in an inadequate assessment of the wound, which may lead to delayed healing and increased risk of infection, and/or delayed recognition of wound complications, potentially resulting in inappropriate or insufficient treatment to Patient 13’s wounds. Findings: 1.a. During a review of Patient 24’s “Annual Psychiatric Assessment (APA, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/22/2024, the APA indicated that Patient 24 was a DDMI patient (DDMI-Developmental Disability and Mental Illness dual diagnosis), who was admitted to the facility on 1/22/2024 due to being danger to self (threatening to kill self) and others, and had history of autism (a neurodevelopmental condition that affects how people interact with the world, particularly in social communication and interaction, and in the presence of restricted and repetitive behaviors, interests, or activities), ADHD (Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity),anxiety (a common emotion characterized by feelings of fear, worry, unease, and apprehension) and ODD (Oppositional Defiant Disorder, a pattern of defiant, angry, and irritable behavior, including arguing, refusing to comply, and intentionally annoying others). During a concurrent interview and record review on 6/12/2025 at 12:37 p.m. with the director of DDMI (Development Disability & Mental Illness -Dual Diagnosis] program (Dir 1), Patient 24’s restraint and seclusion (S&R, interventions used in the treatment and management of disruptive and violent behaviors in psychiatry) video footage (no audio), timestamp dated 3/19/2024, was reviewed. The video footage indicated the following: -At 5:15 p.m., Patient 24 was held against the wall, restrained by two mental health workers (MHW 1 and MHW 2). MHW 1 was positioned on the left side of Patient 24, holding Patient 24’s left arm, hyper-extending the arm backwards and slightly upward (meaning the arm was pulled or extended beyond its normal range of motion). Patient 24 was pinned against the wall in a physical hold, for about a minute, while staff prepared the 5-point physical restraints (refer to a type of physical restraint that uses a combination of restraints on the body to limit movement., involving restraints on all four limbs (wrists and ankles) and an additional restraint around the torso, pelvis, or thighs) to secure the patient (Patient 24) on the bed). -At 5:16 p.m., shift supervisor (CN 1) approached the two MHWs (MHW 1 and MHW 2) while the MHW’s had Patient 24 pinned against the wall, and MHW 1 hyperextended Patient 24’s arm (pulling or bending the arm beyond its normal range of motion). CN 1 appeared to try to look at Patient 24 and/or speak with the patient [Patient 24] (video footage had no sound) but then stepped aside to assist with preparing to apply the physical restraints on the bed. -At 5:17 p.m., Patient 24 was restrained using 5-point restraints. During the same interview on 6/12/2025 at 12:37 p.m. with the Director of DDMI (Development Disability & Mental Illness -Dual Diagnosis] program (Dir 1), Dir 1 said that hyperextension of the arm was an incorrect level of restriction applied by MHW 1 when applying a physical hold. Dir 1 also said that MHW 1 was terminated in 2024 but could not recall the specific reason for the termination. Dir 1 also said that MHW 1 could have easily dislocated Patient 24’s arm and verified that this technique was not in accordance with the NCI (The Crisis Prevention Institute’s Nonviolent Crisis Intervention [NCI] certification program which is designed to provide participants with the knowledge and skills required to respond early and effectively to prevent or defuse a behavioral escalation) training provided by the facility to staff. During an interview on 6/13/2025 at 2:40 p.m. with the Director of DDMI (Development Disability & Mental Illness -Dual Diagnosis] program (Dir 1), the Dir 2 said the following: “There is no staff specifically assigned to monitor or supervise staff (mental Health workers, licensed vocational nurses, and registered nurses) performing a physical hold or applying restraints. This is not feasible, as all staff members are trained on the unit to apply restraints and perform physical hold safely. The expectation is that staff are doing their job correctly and in accordance with established protocols, ensuring patient safety and proper restraint use without the need for constant supervision.” During an interview on 6/13/2025 at 3:01 p.m. with the Chief Nursing Officer (CNO), the CNO stated that in the past, she (the CNO) reviewed the video footage (3/19/2024) which showed Patient 24 in a physical hold and then restrained, and she (the CNO) confirmed that no corrective actions were identified following the review of the footage. The CNO further mentioned that the footage was only reviewed to assess the need for restraint application and to observe the technique used during the physical hold (specifically, hyperextension of the left arm while pinned to the wall by the Mental Health Worker [MHW 1]). The CNO said that the review of the video footage did not include an assessment of the restraint technique itself to identify or recommend corrective actions. During a review of the educational material developed and provided to staff by the facility titled, “Restraints and Seclusion,” (date not specified), the educational material indicated the following: “A registered nurse is responsible for supervising the Licensed Vocational Nurses (LVNs) and Mental Health Workers (MHW), for the safe use of restraints, which includes proper physical holding techniques...” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated that: “A. Physical Restraint/Hold: any manual or physical method of holding the patient against a patient’s will that restricts freedom of movement or normal access to one’s body.” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Treatment Plan/ Patient and Staff Debriefing/ Staff Training and Competency,” dated 10/2023, the P&P indicated, “ c) Evaluate if appropriate techniques were used to de-escalate the patient and/or contain the incident; d) Identify alternative actions to prevent or minimize future need for S/R.” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated, “Seclusion and restraints (S/R) interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others ... S/R procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring ... The leadership team has developed S/R training and competencies that are required for all clinical staff prior to patient intervention ... the facility’s approved method of non-violent crisis intervention (NCI) are additional competency requirements. The use of non-violent crisis prevention techniques to ensure patient and staff safety are consistent with established standards ... Procedure ... 7. The Registered Nurse (RN), in collaboration with unit staff, evaluates the patient’s behavior and implements appropriate NCI techniques to maintain patient and staff safety for escort to seclusion room, placement on transport gurney, and/or restraint bed. During a review of the educational material developed by the Crisis Prevention Institution (CPI, a global organization that provides evidence-based training focused on de-escalation and crisis intervention) titled, “Non-Violent Crisis Intervention Training,” dated 2023, the educational material indicated, “Safety Interventions - Holding Skills ... Holding: A restrictive safety intervention necessary to restrict a person’s range of movement to prevent the infliction of harm to self or others ... keep upright. Avoid leaning or bending the person forward.” 1.b. During a review of Patient 19’s “Annual Psychiatric Assessment (a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 5/9/2024, the “Annual Psychiatric Assessment” indicated, Patient 19 was admitted to the facility’s adult locked Developmental Delay and Mental Illness (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness) unit with bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration) type schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) and mild intellectual disability. During a concurrent interview and record review on 6/11/2025 at 11:47 a.m. with the Program Director (DIR 1) of DDMI, the facility’s video clip of security footage, with no audio, timestamp dated on 4/22/2024, was reviewed. The video clip showed the following: -At 4:51 p.m.: Patient 19 was walking around and banging the wall in the seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) room; -At 5:15 p.m.: a clinical staff came to talk to Patient 19; -At 5:20 p.m.: Patient 19 continued pacing and banging the wall in the seclusion room; -At 5:21 p.m.: multiple clinical staff came into the seclusion room. A Mental Health Worker (MHW) 1 brought Patient 19 to face the wall and leaned his (MHW 1’s) right elbow onto Patient 19’s upper back while another clinical staff was holding Patient 19’s left arm. Other clinical staff were preparing 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) devices on the restraint bed for Patient 19. During the same interview on 6/11/2025 at 11:47 a.m. with the Program Director (DIR 1) of DDMI, DIR 1 stated the following: MHW 1 performed physical hold (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body) on Patient 19 incorrectly. DIR 1 stated MHW 1 was leaning too much with his (MHW 1’s) elbow onto Patient 19. There was potential that Patient 19 could get hurt by hitting the wall. DIR 1 also stated there were multiple clinical staff including the Registered Nurse Shift Supervisor (RNS 2) present at that time, but no one checked on MHW 1 and identified MHW 1’s incorrect holding technique. During an interview on 6/12/2025 at 10:36 a.m. with Nurse Manager (NM) 1, NM 1 stated that leaning elbow onto patient was incorrect NCI (Nonviolent Crisis Intervention, behavior management system designed to help to de-escalate and manage disruptive or out-of-control individuals in a safe and non-harmful way) technique. It could restrict patient’s breathing with excessive force and cause patient harm. NM 1 also said it was important to use correct NCI trained technique to safely handle the patients through physical intervention. During a concurrent interview and record review on 6/13/2025 at 11:35 a.m. with DIR 1, Patient 19’s “S&R (Seclusion and Restraints) Assessment Packet,” dated 4/22/2025, was reviewed. The S&R Assessment Packet” indicated, Patient 19 was placed in a seclusion room at 4:50 p.m. and placed in restraints at 5:20 p.m. Patient 19 was released from seclusion and restraints at 6:20 p.m. The “S&R Assessment Packet” also indicated, a post S&R Staff Conference was conducted by RN Shift Supervisor (RNS) 2 at 5:20 p.m. with clinical staff including but not limited to Mental Health Worker (MHW) 1 and under section “Patterns - Are there any questions related to how staff responded to the incident (did staff follow policy & procedure? Are there any concerns relate to how staff responded to the incident?),” RNS 2 marked “yes” next to “were physical restraints applied appropriately?” During the same interview on 6/13/2025 at 11:35 a.m. with DIR 1, DIR 1 stated the following: the post S&R Staff Conference was conducted by the Registered Nurse after each seclusion and/or restraints episode to identify and address any issue. Any issue identified would be brought to the staff’s attention to correct and improve. DIR 1 stated RNS 2 did not identify that MHW 1 performed a physical hold incorrectly. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Treatment Plan/ Patient and Staff Debriefing/ Staff Training and Competency,” dated 10/2023, the P&P indicated, “Purpose: debriefing both the patient and the staff has two purposes: 1. It is an attempt to learn if there was a cause or trigger to the episode requiring seclusion or restraint (S/R). This would allow for the modification of the patient’s treatment plan with the intent that restraint or seclusion may be avoided for this patient in the future or, if not avoided completely, to identify how it could be handled more effectively. 2. The information is used in performance improvement activities ...Policy: Patients and staff involved in a seclusion and/or restraint episode are provided the opportunity to participate in a debriefing session as soon as possible and appropriate after the seclusion/restraint episodes, but always within 24 hours. Procedure ... 3. Debriefing of Staff: 1) The Shift Supervisor or designee conducts a debriefing of the staff who were immediately involved in the S/R as soon as possible after the incident but not to exceed right (8) hours. 2) The debriefing should, at a minimum: a) identify if any staff obtained injury during the intervention; b) identify precipitating triggers to behaviors which led to the S/R; c) Evaluate if appropriate techniques were used to de-escalate the patient and/or contain the incident; d) Identify alternative actions to prevent or minimize future need for S/R.” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated, “Seclusion and restraints (S/R) interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others ... S/R procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring ... The leadership team has developed S/R training and competencies that are required for all clinical staff prior to patient intervention ... the facility’s approved method of non-violent crisis intervention (NCI) are additional competency requirements. The use of non-violent crisis prevention techniques to ensure patient and staff safety are consistent with established standards ... Procedure ... 7. The Registered Nurse (RN), in collaboration with unit staff, evaluates the patient’s behavior and implements appropriate NCI techniques to maintain patient and staff safety for escort to seclusion room, placement on transport gurney, and/or restraint bed. 8. If physical restraint is indicated, a minimum of two (2) but preferably four (4) NCI trained staff must participate in the physical hold application.” During a review of the educational material developed by the Crisis Prevention Institution (CPI, a global organization that provides evidence-based training focused on de-escalation and crisis intervention) titled, “Non-Violent Crisis Intervention Training,” dated 2023, the educational material indicated, “Safety Interventions - Holding Skills ... Holding: A restrictive safety intervention necessary to restrict a person’s range of movement to prevent the infliction of harm to self or others ... keep upright. Avoid leaning or bending the person forward.” During a review of the educational material developed and provided to staff by the facility titled, “Restraints and Seclusion” (date not specified), the educational material indicated the following: “A registered nurse is responsible for supervising the Licensed Vocational Nurses (LVNs) and Mental Health Workers (MHW), for the safe use of restraints, which includes proper physical holding techniques...” 2. During a review of Patient’s 13’s “Medical history and Physical Examination (A formal and complete assessment of the patient and the problem),” dated 04/09/2025, the record indicated that Patient 13 was suicidal (thoughts of taking one’s own life), and was placed on a hold (a legal procedure where a person can be involuntarily detained for up to 72 hours in a psychiatric facility for evaluation and stabilization if they are deemed to be a danger to themselves or others, or gravely disabled [unable to care for one’s self] due to a mental health disorder) for danger to self. During further review of Patient 13’s “Medical history and Physical Examination,” the record indicated that Patient 13 had self-induced laceration (a tear or cut in the skin and/or underlying tissue) on left forearm and bilateral thighs from a kitchen knife due to a recent breakup. Included in Patient 13’s record under “Assessment and Plan,” it indicated that the self-induced laceration of the left forearm and both thighs would be treated with topical antibiotics. During a concurrent interview and record review on 06/13/2025 at 9:33 a.m. with Nurse Manager (NM) 3, Patient 13’s medical record titled, “Patient Progress Notes,” dated 04/09/2025 - 04/14/2025, was reviewed. The Patient Progress Notes for Patient 13 did not indicate that a wound assessment was completed. NM 3 stated that Patient 13 was admitted with cuts from a kitchen knife to her left forearm and bilateral thigh. During the same interview on 06/13/2025 at 9:33 a.m. with Nurse Manager (NM) 3, NM 3 said that per policy, wound assessment must be completed and documented every shift. However, the progress note did not indicate that a wound assessment was completed every shift. NM 3 further said that wound assessment was important for monitoring progress, effective treatment and prevention of complications. During a review of the facility’s Policy and Procedure (P&P) titled, “Assessment and Reassessment,” with last revised date of 10/2023, the P&P indicated that the “purpose of assessment and reassessment is to determine that the appropriate care, treatment, and services are being provided to meet the patient’s changing needs; To evaluate the patient’s response to these services; To respond to significant changes in the patient’s status or condition. Each patient will be assessed/reassessed by a registered nurse each shift. It is the responsibility of the RN to analyze that data into an assessment and to make care. treatment, and service decisions based on that assessment. The content of the assessment/ reassessment includes medical issues, pain and infection control issues.””

“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: 42937 Based on interview and record review, the facility failed to ensure one of 39 sampled patient’s (Patient 10) treatment plans (a structured, individualized document that outlines the care team objectives, intervention and the strategies to achieve specific health goals) regarding hypothyroid issues (a condition where the thyroid gland doesn’t produce enough thyroid hormones [regulates growth and development]) and hypertension (high blood pressure), were developed and implemented upon admission, in accordance with the facility’s policy regarding treatment planning. This deficient practice had the potential of failing to implement clinically appropriate individualized goals and interventions to address Patient 10’s care needs and risks, which may result in complications such as uncontrolled hypertension and prolonged hospital stay. Findings: During a review of Patient’s 10 “Medical History and Physical Examination (a formal and complete assessment of the patient and the problem),” dated 1/02/2025, the record indicated that Patient 10 was brought in on a 5150 hold (a 72-hour involuntary psychiatric [mental health issues] hold that allows for the temporary detention of an individual deemed a danger to themselves or others, or gravely disabled [unable to care for one’s self] due to a mental health disorder) after recently becoming very violent. During a review of Patient’s 10 “Psychiatric and Mental Status Examination,” dated 1/01/2025, the record indicated that Patient 10 was admitted for increased aggression, with past medical history of hypothyroidism and hypertension. The record also indicated a plan to continue Patient 10’s medication of Synthroid (a medication used to treat hypothyroidism) and metoprolol (a medication that lowers the blood pressure and heart rate). During a review of Patient’s 10 “Order Chronology,” dated 12/31/2024 - 1/02/2025, the record indicated that Synthroid and Metoprolol medication was ordered to start on 01/01/2025 During a concurrent interview and record review on 6/12/2025 at 10:29 a.m. with Nurse Manager (NM) 3, Patient 10’s medical record titled, “Master Problem List,” with initial treatment date of 01/03/2025, was reviewed. The record indicated that a Hypothyroidism and Hypertension problems were not identified on admission and was only added to the problem list on 01/22/2025. NM 3 stated that, the admitting nurse should have identified and included hypothyroidism and hypertension in the interdisciplinary treatment plan and problem list on admission. During the same interview on 6/12/2025 at 10:29 a.m. with Nurse Manager (NM) 3, NM 3 stated that a patient’s treatment plan was reviewed and updated by the treatment team every 7 days. NM 3 also said that including identified medical problems in the treatment plan, was important because it served as a roadmap for both the patient and healthcare providers, ensuring a clear and effective approach to managing a patients’ health and helped meet treatment goals. During a review of the facility’s Policy and Procedure (P&P) titled, “Interdisciplinary Treatment Planning,” with last revised date of 10/2023, the P&P indicated the following: -The initial preliminary treatment plan should be initiated with a physician’s order upon admission. -Within eight (8) hours of patient admission, the RN shall initiate the Interdisciplinary Treatment Plan, including the Master Problem List. The list shall include an admitting diagnosis and any active medical problems if specific interventions are required. Medical problems which are stable and do not require any change in intervention (i.e. hypothyroidism that is appropriately managed with a pre-admission medication regimen) will be identified as stable on the problem list. -Within 72 hours (3 days) of admission. the Interdisciplinary Treatment Team shall fi.111her develop the patient’s treatment plan based on a comprehensive assessment of the patient’s presenting problems. physical health. emotional. social. and behavioral status. The Team will consist of the physician. the RN. the Social Worker and representatives from other clinical disciplines (i.e. Activity Therapy. Pharmacy) as appropriate. Attendance of the patient (or designee) in the treatment planning meeting is strongly encouraged. It is the responsibility of the Treatment Team to review and integrate pertinent data gathered through clinical assessments ( i.e. initial medical screening, admission assessment. risk assessment. history & physical. psychiatric evaluation. etc...) into the patient’s individualized plan of care. Any changes in the patient’s diagnosis will be identified. -At least every 7 days. or as frequently as indicated by the patient’s anticipated length of stay. acuity. and treatment issues. the Treatment Plan shall be reviewed and updated.”

“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: 42937 Based on observation, interview and record review, the facility failed to: 1. Ensure that one of one sampled medication cart (med cart #11, a portable storage unit used to organize and store medication for easy access by authorized staff in a medication room) in the medication room, located on 5 South unit (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis, individuals who have both a developmental disability and a mental illness] patients), and is used for 24 of 24 sampled patients, always remained locked, as required by the facility’s policy for maintaining medication safety and administration. This deficient practice had the potential to results in patient and staff safety violations, including unauthorized access to medication, medication theft, misuse, and tampering (altering or modifying a medication or its packaging without authorization), which could lead to medication errors, overdose, or other safety breaches, including violating the facility’s policies designed to prevent medication mishandling and safeguard patients’ safety. 2. Ensure its nursing staff protected one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policy regarding abuse prevention, when staff allowed an agitated patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3’s) room with two other patients (Patients 1 and 2) present, on 4/9/2025. This deficient practice resulted in Patient 2 being triggered by Patient 3’s aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones) on 4/9/2025. 3. Ensure that a proper (minimum arm’s length distance) Q (every) 15 minute observation (safety checks conducted every 15 minutes to ensure the well-being of patients) and close proximity observation, was completed for the safety and security of 12 of 39 sampled patients (Patients 7, 8, 30 ,31 ,32, 33, 34, 35, 36, 37, 38 and 39), in accordance with the facility’s policy regarding observation and monitoring, when Registered Nurse (RN) 1, who was assigned to conduct Q-15 minute observation, did not enter the patients’ rooms to make direct visual contact with the patients. This deficient practice had the potential of failing to prevent harm to patients, including self-harm, suicide (the act of intentionally causing one’s own death), and elopement (escape). Findings: 1. During an observation on 6/10/2025 at 11:27 a.m. in the medication room on 5 South (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis] patients), with two nurse managers (NM 1 and NM 3), medication cart # 11 (a portable storage unit used to organize and dispense medications for the unit’s patients), was observed to be located within the medication room. The cart was found to be unlocked. NM 3 stated that the medication cart must be kept locked when not in use, even when it is parked in the locked medication room. During the same interview on 6/10/2025 at 11:27 a.m. with Nurse Manager (NM) 3, NM 3 said that usually, the key to the cart remained with the assigned medication nurse for the day, but all licensed personnel also had the key to access the medication room. NM 3 also said that EVS (Environmental Services) personnel, responsible for cleanliness and sanitation, had access to the medication room as well, and may enter it at any time. NM 3 stated that an unlocked medication cart can pose a risk of unauthorized access to patients’ medications. NM 1 then also said that the medication nurse was on a lunch break at the time of the observation [on 6/10/2025 at 11:28 a.m.]. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration and Documentation,” dated 10/2023, the P&P indicated that the medication room and the medication cart must be locked when unattended by licensed nursing staff ...” 2. During a review of Patient 1’s “Face Sheet (front page of the chart that contains a summary of basic information about the patient),” dated 3/31/2025, the Face Sheet indicated Patient 1 was admitted to the facility on 3/31/2025 at 10:30 a.m. under a 5150 legal hold (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 himself]). 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),” dated 3/30/2025, the 5150 hold paperwork indicated Patient 1 was detained for being gravely disabled due to auditory hallucinations (hearing sounds, noises, or voices that are not there) and abnormal behavior. During a review of Patient 2’s Face Sheet, dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold. During a review of Patient 2’s 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others when he (Patient 2) was found “challenging people to a fight without provocation” in the community. During a review of Patient 3’s “Face Sheet,” dated 3/28/2025, the Face Sheet indicated Patient 3 was admitted to the facility on 3/28/2025 at 12:55 p.m. voluntarily (of his own free will). During a review of Patient 3’s “Psychiatric (treatment or care for a mental health disorder or illness) and Mental Status Examination (PMSE, a formal and complete assessment of the patient and the problem related to mental health),” dated 3/29/2025 at 10:23 a.m., the PMSE indicated Patient 3 sought voluntary admission due to suicidal thoughts (thinking about killing himself). During a review of Patient 4’s “Face Sheet,” dated 4/8/2025, the Face Sheet indicated Patient 4 was admitted to the facility on 4/8/2025 at 10:50 a.m. under a 5150 legal hold. During a review of Patient 4’s 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 4 was detained for being gravely disabled due to abnormal behavior. During a review of Patient 1’s “Observation Record,” dated 4/9/2025, the Record indicated Patient 1 was awake and in his room from 2:15 a.m. to 4:00 a.m. During a review of Patient 2’s “Observation Record,” dated 4/9/2025, the Record indicated Patient 2 was awake and in his room from 2:30 a.m. to 4:00 a.m. During an interview with the Director of Quality and Risk Management (DQ) on 6/9/2025 at 1:51 p.m., the DQ stated that on 4/9/2025 at around 4:00 a.m., Patient 1 came out of his (Patient 1) room with his nose bleeding and stated that somebody punched him. The DQ further stated that the only other person in the room was his roommate, Patient 2, but at the time, he (Patient 2) denied knowing what happened. During an interview with Nurse Manager (NM) 1 on 6/11/2025 at 10:16 a.m., NM 1 confirmed that Patients 1, 2, and 3 were roomed in together in the same room (Room A). NM 1 further stated that on 4/9/2025 after midnight, there was a “fight” between Patients 3 and 4 in the hallway; during the fight, another altercation between Patient 1 and Patient 2 occurred in Room A, unwitnessed by staff. During a concurrent interview and video surveillance review with Nurse Manager (NM) 1 on 6/12/2025 at 9:34 a.m., two video clips of security footage from 4/9/2025, were reviewed. NM 1 stated these videos occurred at approximately 4:00 a.m. on 4/9/2025 as there were no time stamps on the footage. The following events were observed from the first clip: -At the beginning of the video clip, Patient 4 was standing in the hallway. -Patient 3 emerged from his room. Staff stepped in between Patients 3 and 4. One minute and 12 seconds into the video Patient 3 swung his left arm at Patient 4. Additional staff responded to the incident. -One minute and 30 seconds in, staff brought Patient 3 back to Room A (where Patients 1 and 2 were staying). Four staff were observed entering Room A with Patient 3. -Two minutes and 49 seconds in, staff removed Patient 3 from Room A. During the same interview on 6/12/2025 at 9:34 a.m. with Nurse Manager (NM) 1, NM 1 stated Patient 3 was in his room, with staff present, for one minute and 19 seconds, based on the time elapsed in the video. NM 1 further stated that staff removed Patient 3 from his room and brought him 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 to administer emergency medications (medications given to manage severe mental health symptoms such as agitation). During the same video surveillance review on 6/12/2025 at 9:34 a.m., the following events were reviewed from the second clip: -Two minutes and 19 seconds into the video, staff brought Patient 3 out of Room A. -Two minutes and 44 seconds in, Mental Health Worker (MHW) 2 closed the door to Room A. -Three minutes and 40 seconds in, House Supervisor (HS) 1, who was standing in the hallway, appeared to hear something coming from Room A and opened the door. -Three minutes and 44 seconds in, Patient 1 emerged from Room A dripping blood on the floor. Staff took him (Patient 1) to the nurses’ station. Patient 2 was seen standing in the doorway of Room A. -NM 1 stated Patients 1 and 2 were left alone in Room A for 56 seconds, based on the time elapsed in the video. During an interview with Nurse Manager (NM) 1 on 6/12/2025 at 9:50 a.m., NM 1 stated that the facility’s staff were responsible for the patients. NM 1 further stated that agitated patients should not be in a room with other patients, and staff should remove the roommates as best as they could because there was potential that the roommates could get triggered, agitated, or get hurt. During an interview with Nurse Manager (NM) 1 on 6/12/2025 at 10:24 a.m., NM 1 stated Patient 2 was a newly admitted patient and had not yet been seen by a physician. The staff was not familiar with Patient 2 and did not know what would trigger Patient 2 and what Patient 2’s behavior would be. NM 1 further stated the staff should have maintained vigilance until the staff got to know Patient 2 more. During a review of Patient 1’s “Progress Notes,” dated 4/9/2025 at 4:35 a.m., the Progress Notes indicated, “Around [4:10 a.m.], patient [Patient 1] came out of his room [with] heavy bleeding from both nostrils. [Patient 1 was] confused, unable to provide accurate information regarding what exactly happened, but stated ‘I’m sorry, someone punched me’.” The Progress Notes further indicated Patient 1 was sent to General Acute Care Hospital (GACH) 1’s Emergency Department (a hospital department that provides immediate care for patients with urgent medical conditions) at 4:33 a.m. During a review of Patient 1’s “Progress Notes,” dated 4/9/2025 at 1:51 p.m., the Progress Notes indicated Patient 1 was scheduled to be transferred to GACH 2 at 2:00 p.m. for possible oral facial (face and mouth) surgery. During a review of Patient 2’s “Progress Notes,” dated 4/9/2025 at 4:47 a.m., the Progress Notes indicated, “[Patient 1] ran out of his room with his nose bleeding. [Patient 2] stated he (Patient 2) did not know who punched him.” During a review of Patient 2’s “Progress Notes,” dated 4/9/2025 at 3:48 p.m., the Progress Notes indicated, “[Patient 2] states, ‘I hit the other guy earlier.’” During a review of Patient 1’s “CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) Maxillofacial (upper jaw and face) Scan” report from GACH 2, dated 4/9/2025 at 8:26 p.m., the report indicated Patient 1 sustained bilateral (both) Le Fort I (a type of facial fracture that occurs horizontally through the maxilla [upper jaw], above the roots of the teeth), right possible Le Fort II fractures (a pyramidal shaped fracture along the nasal bridge and causes separation of the midface from the skull base), and bilateral maxillary sinus fractures (a break in the bones that make up the maxillary sinus [the air-filled cavities in the cheek bones]) of the anterior (front) and posterolateral (at the back and to the side) walls. During a review of Patient 1’s “ENT (a physician that specializes in medical conditions of the ear, nose, throat, and neck) Consultation Note,” from GACH 2, dated 4/10/2025 at 4:04 a.m., the Note indicated the ENT physician recommended conservative non-operative management (no surgery required) and cleared Patient 1 to return to the facility (where Patient 1 got punched by Patient 2). During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” last reviewed 10/2023, indicated, “The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences from the initial assessment prior to [seclusion/restraint], including ... C. Separating patient from group or community ... E. Offering the use of the quiet room to decrease stimuli and regain control.” During a review of the facility’s policy and procedure (P&P) titled, “Abuse Prevention, Screening, Identification, Training, Protection, Investigation, and Reporting,” last reviewed 10/2023, indicated, “It is the policy of College Hospital to protect our patients from all types of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients, or visitors ... A critical part of protecting patients from abuse is preventing abuse from occurring in the first place.” 3. During a review of the facility’s “Nursing Census,” dated 2/18/2025, the Nursing Census indicated patients to their assigned rooms as follows: Patient 30 to Room 109-A, Patient 31 to Room 109-B, Patient 32 to Room 109-C, Patient 7 to Room 110-A, Patient 33 to Room 110-B, Patient 34 to Room 110-C, Patient 35 to Room 111-A , Patient 36 to Room 111-B, Patient 8 to Room 111-C, Patient 37 to Room 112-A, Patient 38 to Room 112-B, and Patient 39 to Room 112-C. During a review of Patient 30’s Mental Status Examination (MSE, a structured assessment used to evaluate a patient’s current mental state), dated 2/09/2025, the MSE indicated that Patient 30 suffered from schizoaffective disorder bipolar type (a mental health condition characterized by a combination of schizophrenia [a chronic and severe mental disorder that disrupts a person’s ability to think, feel, and behave clearly] symptoms and bipolar disorder [a mental health condition that causes extreme shifts in mood, energy, activity levels, and concentration] symptoms. It involves experiencing psychotic symptoms like hallucinations [a sensory perception that seems real but is not, occurring without external stimuli] or delusions [a fixed, false belief that is not amenable to change even when presented with contradictory evidence] alongside mood episodes of mania [a state of abnormally elevated, expansive, or irritable mood, often accompanied by increased energy, activity, and impaired judgment] and sometimes depression [a mood disorder characterized by persistent feelings of sadness, loss of interest in activities, and changes in thinking and behavior that interfere with daily life]). During a review of Patient 31’s MSE, dated 2/05/2025, the MSE indicated that Patient 31 was being readmitted on a 5150 (72-hour hold, a legal procedure that allows for the involuntary 72-hour psychiatric hold of an individual who is deemed a danger to themselves or others, or is gravely disabled [unable to care for one’s self] due to a mental health disorder) after she (Patient 31) reported having active suicidal ideations (having thoughts, fantasies, or contemplations about ending one’s life) with a plan to overdose (ingestion or application of a drug or other substance in quantities much greater than are recommended). During a review of Patient 32’s MSE, dated 2/16/2025, the MSE indicated that Patient 32 was brought in by family for psychiatric evaluation. Patient 32’s MSE also indicated Patient 32 was placed on a 5150 hold for danger to others, with history of schizophrenia, had poor compliance with medication and was a poor historian, she (Patient 32) was also unable to provide any information. During a review of Patient 7’s MSE, dated 11/22/2024, the MSE indicated that Patient 7 brought in on a conservatorship (a legal arrangement where a court appoints someone [the conservator] to manage the financial and/or personal affairs of an individual [the conservatee] who is deemed unable to do so themselves due to incapacity. This typically involves adults who are unable to care for their own needs due to physical or mental limitations). Patient 7’s MSE indicated that Patient 7 would not continue with her (Patient 7) medications and decompensated (to become worse) into now auditory hallucinations (when one perceives sounds that are not actually present in their environment), wanted to overdose on pills, and hit her (Patient 7) head against the wall. During a review of Patient 33’s MSE, dated 2/16/2025, the MSE indicated that Patient 33 was depressed and confused and had mood lability (rapid and unpredictable shifts in emotions). Patient 33’2 MSE further indicated “She (Patient 33) came in on a 5150 hold. She says she is very confused and disorganized. She says that she is suicidal but then she gets frustrated on interviews.” During a review of Patient 34’s MSE, dated 2/17/2025, the MSE indicated that Patient 34 was being admitted to the hospital with increased depression, anxiety (a feeling of unease, fear or worry), frustration and feeling hopeless, helpless, and lack of motivation. Patient 34’s MSE also indicated that “she has been struggling with the voices in her head telling her (Patient 34) to kill herself. She currently is having urge to end life by overdose or cut her wrist.” During a review of Patient 35’s MSE, dated 2/17/2025, the MSE indicated that Patient 35 was having difficulty to cope with day-to-day responsibility, had not slept well for several days, and with decreased self-care. During a review of Patient 36’s MSE, dated 2/18/2025, the MSE indicated that Patient 36 lived alone, admitted on a 5150 after expressing thoughts of suicide. During a review of Patient 8’s MSE, dated 1/22/2025, the MSE indicated that Patient 8 came into the hospital on a 5150 hold. Patient 8’s MSE indicated “she (Patient 8) was exhibiting symptoms of psychosis (a mental state where a person loses contact with reality, experiencing symptoms like hallucinations and delusions), she was hyper religious, holding her (Patient 8) hands in prayer, being selectively mute, acting very bizarre and confused. She is confused, disorganized. She has suicidal intent to overdose on medications.” During a review of Patient 37’s MSE, dated 2/14/2025, the MSE indicated that Patient 37 was admitted on a 5150. Patient 37’s MSE indicated Patient 37 had been self-medicating with Methamphetamines (a powerful and addictive stimulant drug that affects the central nervous system) and had thoughts about wanting to hurt himself (Patient 37) by cutting himself with a knife. During a review of Patient 38’s MSE, dated 2/11/2025, the MSE indicated that Patient 38 was admitted on a 5150 hold after assaulting his (Patient 38) mother following an argument regarding patient (Patient 38) not taking his (Patient 38) medication. During a review of Patient 39’s MSE, dated 2/11/2025, the MSE indicated that Patient 39 presented to the hospital on a 5150 hold for danger to others. The report indicated patient (Patient 39) became aggressive at the group home, where he was prior to admission to the hospital, and tried to hurt others with his (Patient 39) keys, swinging at staff because patient (Patient 39) believed that they (the staff) were talking bad about him (Patient 39) behind his back. During a concurrent interview and record review on 6/11/2025 at 2:34 p.m. with Nurse Manager (NM) 1 a security footage from 2/18/2025, was reviewed. NM 1 stated these videos occurred at approximately 11:40 p.m. on 2/18/2025 in 1-South. The following was reviewed from the video: -Registered Nurse (RN) 1 doing Q 15 observation rounding; -RN 1 first went to room 110, opened the door, remained standing by the door, did not enter the patient room; -RN 1 went to room 112, opened the door, remained standing by the door, did not enter the patient room; -RN 1 went to room 111, shined a flashlight through the patient door window, did not open door to patient room; -RN 1 then went to room 109, opened door, remained standing by the door, did not enter the patient room. During the same interview on 6/11/2025 at 2:34 p.m. with Nurse Manager (NM) 1, NM 1 stated that RN 1 was doing the Q (every) 15-minute observation (safety checks conducted every 15 minutes to ensure the well-being of patients). NM 1 said RN 1 did not perform the Q 15-minute observation correctly. NM 1 further stated RN 1 should have walked into the room and be near the patient for the observation. NM 1 stated, in this case, RN 1 did not go into the patient rooms. It was an expectation when doing Q 15 observation that staff should go inside the room and have a close look at each patient as part of the safety check. During a review of the facility’s policy and procedure (P&P) titled, “Observation and Monitoring,” last reviewed 10/2023, the P&P indicated the following: -Q 15 MINUTE OBSERVATIONS are minimum level of observation for all patients. -Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress. -Staff will be vigilant for potential risk factors identified for specific patients (levels of precautions). -Sleeping patients will be observed at close enough proximity to confirm they are in no physical distress. Staff will observe the patient at a minimum arm’s length distance to ensure the ability to clearly see the patient’s identity and respiration.”

“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: 46238 Based on interview and record review, the facility failed to ensure two of 39 sampled patient’s (Patient 25 and Patient 27) behavioral plan (a personalized plan developed to address and manage specific behaviors, outlining strategies, goals, and intervention), included a behavioral analysis for after seclusion/restraint episodes and incorporated into the behavioral plan with short-term and long-terms goals aimed at reducing the frequency of seclusions and restraints (Seclusion restraint refers to the practice of isolating someone in a locked room or using physical, mechanical, or chemical means to restrict their movement and freedom of movement) episodes, in accordance with the facility’s policy regarding treatment planning. This deficient practice had the potential to result in poorly addressed triggers (specific events or stimuli that lead to behaviors such as aggression) and/or behaviors for Patient 25 and Patient 27, increasing their risk of repeated restraint episodes, injury, or escalation of aggression, compromising Patient 25’s and Patient 27’s safety, dignity, and overall well-being. In addition, the lack of behavioral analysis and individualized behavioral treatment plan could hinders effective intervention, delay behavior reduction, and impair ongoing progress in managing challenging behaviors for Patient 25 and Patient 27. Findings: 1. During a review of Patient 25’s “Psychiatric and Mental Status Examination (PMSE, a comprehensive assessment performed by a psychiatrist to diagnose and treat mental health conditions, while a mental status examination [MSE] is a structured way to observe and document a patient’s current psychological state during a clinical encounter ),” dated 3/12/2024, the PMSE indicated that Patient 25 was admitted on a 5150 (a temporarily hold for evaluation and crisis intervention- involuntary 72-hour psychiatric hospitalization of an individual who, due to a mental health disorder, is deemed a danger to themselves, a danger to others, or gravely disabled [unable to care for one’s self]) due to danger to others. The PMSE also indicated that Patient 25 had history of autism (neurodevelopmental condition that affects how individuals interact with the world, particularly in social communication and interaction, and in their patterns of behavior and interests) and explosive disorder (a mental health condition characterized by sudden and frequent episodes of impulsive, aggressive, violent behavior or angry verbal outbursts). During a review of Patient 25’s electronic medical record (EMR), the “Behavioral Restraint/Seclusion Order Assessment,” dated 3/12/2024 through 3/12/2024 through 11/12/2024, was reviewed. The records indicated that Patient 25 had 11 episodes of seclusions and restraints (S&R, seclusion restraint refers to the practice of isolating someone in a locked room or using physical, mechanical, or chemical means to restrict their movement and freedom of movement). During a concurrent interview and record review on 6/11/2026, at 11:00 a.m. with Nurse Manager (NM 1), Patient 25’s electronic medical record (EMR) titled, “Behavioral Restraint/Seclusion Order Assessment,” dated 3/12/2024 through 11/12/2024, was reviewed. The record indicated that Patient 25 was placed in physical hold (the act of staff physically holding a patient to restrict their movement)/seclusion/restraints on the following dates: 1. 3/15/2024-Patient 25 was placed in a physical hold at 5:10 p.m., seclusion at 5:10 p.m., and restraints (5-point restraints, restraints on all four limbs [wrists and ankles] and an additional restraint around the torso, pelvis or thighs) at 5:10 p.m. 2. 3/24/2024-Patient 25 was placed in a physical hold at 3:45 p.m., seclusion at 3:55 p.m., and restraints at 3:55 p.m. 3. 3/30/2024-Patient 25 was placed in a physical hold at 10:15 a.m., seclusion at 10:18 a.m., and restraints at10:18 a.m. 4. 4/9/2024 (no information provided) 5. 4/13/2024-Patient 25 documented to be placed in a physical hold at 6:15 p.m., seclusion at 11:14 a.m., and restraints at 6:15 p.m. 6. 4/20/2024 (no information provided) 7. 4/21/2024 -Patient 25 was placed in a physical hold at 5:55 p.m., seclusions 6:00 p.m., and restraints 6:20 p.m. 8. 4/28/2024-Patient 25 was placed in a physical hold at 8:10 a.m., seclusion at 8:20 a.m., and restraints at 8:20 a.m. 9. 5/5/2024-Patient 25 was placed in a physical hold at 10:05 a.m., seclusion at 10:10 a.m., and restraints at 10:10 a.m. 10. 5/12/2024-Patient 25 was placed in a physical hold at 2:25 p.m., seclusion 2:45 p.m., and restrained at 2:45 p.m. 11. 8/4/2024 -Patients 25 was placed in a physical hold at 3:05 p.m., seclusion at 3:10 p.m., and restraints at 3:10 p.m. During the same concurrent interview and record review on 6/11/2026, at 11:00 a.m. with Nurse Manager (NM 1), NM 1 reviewed the Behavioral Weekly Progress Reports, 30-day Behavioral Progress Reports, and Interdisciplinary Treatment (IDT, a comprehensive plan of care developed collaboratively by a team of professionals from different disciplines to address a patient’s mental health needs) Plans [a week after each restraint episode] developed for Patient 25 throughout the admission stay at the facility [3/12/2024-11/20/2024]. NM 1 said that these restraint episodes were not mentioned/included in any of the reviewed reports and IDT Plans for Patient 25. During an interview on 6/13/2025 at 10:29 a.m. with the Behavioral Analyst (BA 1), the BA 1 said that the 30-Day Behavioral Progress Reports represent a functional behavioral assessment, with monthly goals primarily aimed at reducing challenging behaviors in patients with developmental disabilities in the DDMI unit. The BA 1 stated that restraints triggers were reviewed because “we want to know what led to the incident of restraints,” but noted that including restraints triggers in these reports had not been the practice at the facility. The BA 1 also said that the behavioral therapists followed the standards from tools used in ABA therapy (Applied Behavior Analysis, a scientific approach to understanding and improving specific behaviors using reinforcement strategies, positive or negative, to promote adaptive behaviors and reduce problematic ones), and the facility did not have formal policies dictating how these reports should be documented. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Treatment Planning,” dated 10/2023, the P&P indicated the following: “Each patient admitted to the hospital shall have a written treatment plan that is appropriate to the patient’s specific assessed needs. The treatment plan should be revised and maintained on the patient’s response to identified interventions... The treatment plan should be individualized to meet patient’s unique needs and circumstances as identified through assessment data and... and shall be appropriate to the patients’ needs, strengths, limitations, and goals... An interdisciplinary Treatment Team shall plan, review, and evaluate the treatment plan at least weekly, or as often as indicated...The Master Treatment Plan shall be initiated for each active problem... Contain long-term goal(s) ...and shot term goals ... have interventions that directly related to the goals...” 2. During a review of Patient 27’s Psychiatric and Mental Status Examination (PMSE),” dated 5/27/2025 (an annual psychiatric mental examination for 5/26/2025), the PMSE indicated Patient 27 was admitted on 1/17/2024 on a 5150 hold (a legal procedure where a person can be involuntarily detained for up to 72 hours in a psychiatric facility for evaluation and stabilization if they are deemed to be a danger to themselves or others, or gravely disabled due to a mental health disorder) because of running into traffic and noncompliance with medications. During a review of Patient 27’s electronic medical record (EMR), the “Behavioral Restraint/Seclusion Order Assessment,” dated 4/30/2025 through 6/2/2025, were reviewed. The records indicated that Patient 27 had 18 episodes of seclusions and restraints (S&R, seclusion restraint refers to the practice of isolating someone in a locked room or using physical, mechanical, or chemical means to restrict their movement and freedom of movement) since admission on 4/30/2025 through 6/2/2025. During an interview on 6/13/2025 at 10:29 a.m. with the Behavioral Analyst (BA 1), the BA 1 said that the 30-Day Behavioral Progress Reports represented a functional behavioral assessment, with monthly goals primarily aimed at reducing challenging behaviors in patients with developmental disabilities in the DDMI unit. The BA 1 stated that restraints triggers were reviewed because “we want to know what led to the incident of restraints,” but noted that including restraints triggers in these reports had not been the practice at the facility. The BA 1 also said that the behavioral therapists followed the standards from tools used in ABA therapy, and the facility did not have formal policies dictating how these reports should be documented. During a concurrent interview and record review on 6/13/2025 at 3:10 p.m. with Nurse Manager (NM 1), Patient 27’s electronic medical record (EMR, a digital collection of a patient’s health information that is stored and managed electronically) titled, “Behavioral Restraint/Seclusion Order Assessment,” dated 6/2/2025 and the “ABC Analysis” tool (refers to the systematic observation and recording of Antecedents (triggers), Behaviors, and Consequences to understand and modify behavior), was reviewed. The “Behavioral Restraint/Seclusion Order Assessment,” dated 6/2/2025, indicated that Patient 27 was placed in a physical hold at 4:52 p.m. and then seclusion at 4:55 p.m. The ABC Analysis tool indicated no documentation of Patient 27 being in a physical hold on 6/2/2025 at 4:52 p.m. and being in seclusion at 4:55 p.m. During the same concurrent interview and record review on 6/13/2025, at 3:10 p.m. with Nurse Manager (NM 1), NM 1 reviewed the Behavioral Weekly Progress Report [dated 6/4/2025], 30-day Behavioral Progress Reports, and the Interdisciplinary Treatment (IDT) Plan [dated 6/4/2025], developed for Patient 27 , and said that the S&R episodes on 6/2/2025 was not mentioned/included in any of the reviewed reports and IDT Plans for Patient 27. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Treatment Planning,” dated 10/2023, the P&P indicated the following: “Each patient admitted to the hospital shall have a written treatment plan that is appropriate to the patient’s specific assessed needs. The treatment plan should be revised and maintained on the patient’s response to identified interventions... The treatment plan should be individualized to meet patient’s unique needs and circumstances as identified through assessment data and... and shall be appropriate to the patients’ needs, strengths, limitations, and goals... An interdisciplinary Treatment Team shall plan, review, and evaluate the treatment plan at least weekly, or as often as indicated...The Master Treatment Plan shall be initiated for each active problem... Contain long-term goal(s) ...and shot term goals ... have interventions that directly related to the goals...””

“Document Therapeutic Efforts CFR(s): The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that nursing staff documented that attempts were made to treat two of 39 sampled (Patient 24 and Patient 25), in the least restrictive manner, before placing Patient 24 and Patient 25 in physical restraints, in accordance with the facility’s policy regarding restraints use. This deficient practice had the potential to result in unnecessary use of restrictive interventions for Patient 24 and Patient 25, placing both patients at increased risk of injury and/or psychological trauma, and failure to promote dignity, thus violating Patient 24 and Patient 25 rights (the fundamental entitlements and protections that individuals have when receiving medical care). Findings: 1. During a review of Patient 24’s “Annual Psychiatric Assessment (APA, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/22/2024, the APA indicated that Patient 24 was a DDMI patient (DDMI-Developmental Disability and Mental Illness dual diagnosis), who was admitted to the facility on 1/22/2024 due to being danger to self (threatening to kill self) and others, and had history of autism (a neurodevelopmental condition that affects how people interact with the world, particularly in social communication and interaction, and in the presence of restricted and repetitive behaviors, interests, or activities), ADHD (Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity),anxiety (a common emotion characterized by feelings of fear, worry, unease, and apprehension) and ODD (Oppositional Defiant Disorder, a pattern of defiant, angry, and irritable behavior, including arguing, refusing to comply, and intentionally annoying others). During a concurrent interview and review on 6/12/2025 at 12:37 p.m. with the Director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), Patient 24’s restraint and seclusion (S&R, interventions used in the treatment and management of disruptive and violent behaviors in psychiatry), video footage (no audio), timestamp dated 3/19/2024, was reviewed. The video footage demonstrated the following: -At 5:13 p.m.-Patient 24 received chemical restraint (the use of medication to manage or restrict a person’s behavior, freedom of movement, or ability to interact with their environment, when that medication is not part of their standard treatment for a diagnosed condition) and was released from the seclusion room. Patient 24 then got up from the bed, after clinical staff let go, and Patient 24 left the seclusion room (the isolation of a disturbed psychiatric patient in a robust locked room). -At 5:15 p.m., Patient 24 was returned to the seclusion room, accompanied by multiple staff. Two Mental Health Workers (MHW 1 and MHW 2) were observed performing a physical hold (involves staff physically holding a person to restrict their movement or ability to access their body) on Patient 24, by restraining Patient 24 to the wall in the seclusion room. -At 5:17 Patient 24 was applied the physical restraint (the use of a manual hold or device to restrict a person’s movement, either by immobilizing their body or limiting their access to it. It’s a form of restrictive practice, used as a last resort when less restrictive interventions have failed) and was left in the seclusion room with a 1:1 /sitter for observation (caregiver or staff member who provides constant, one-on-one supervision and support to a patient). During the same interview on 6/12/2025 at 12:37 p.m. with the Director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), the Dir 1 stated that the video footage did not show what happened to Patient 24 in the hallway after administration of the chemical restraint at 5:13 p.m. and before the patient (Patient 24) returned to the seclusion room at 5:17 p.m. The Dir 1 also said that he (Dir 1) would need to review Patient 24’s medical record titled, “Restraint and Seclusion (S&R)” (assessment packet for nurses) to clarify the sequence of events. During a concurrent interview and record review on 6/13/2025 at 10:51 a.m. with the Director of the DDMI unit (Dir 1), Patient 24’ Restraint and Seclusion (S&R) form, dated 3/19/2025, was reviewed. The S&R form, indicated that Patient 24 was given 2 milligrams (mg, measuring unit of weight used for medication dosing) of Ativan (a medication used to sedate, calm, or treat anxiety [a feeling of unease], often given for agitation [a state of restlessness]) intramuscularly (IM, into the muscle). The S&R form did not contain any recorded explanation or documentation to justify the application of physical restraints at 5:17 p.m. on 3/19/2024, which were applied on Patient 24 about 2-3 minutes after administering Ativan IM. During the same interview on 6/13/2025 at 10:51 a.m. with the Director of the DDMI unit (Dir 1), the Dir 1 said that when a chemical restraint (Ativan, emergency medication) was administered first, the patient was given time and let go by the staff (Patient 24 was released to the hallway at 5:13 p.m. after receiving 2 mg of Ativan IM). Dir 1 said that perhaps, Patient 24 started to act out or exhibited unsafe behavior, so additional measures such as bringing the patient (Patient 24) back into the seclusion room at 5:17 p.m. to apply physical restraints was necessary, depending on Patient 24’s behavior. However, the Dir 1 stated, there was nothing documented in Patient 24’s S&R form and the documentation was lacking a reasonable explanation for what happened in the hallway after the 2 mg of Ativan was given to Patient 24 at 5:13 p.m. During the same interview on 6/13/2025 at 10:51 a.m. with the director of DDMI unit (Dir 1), the Dir 1 stated that a form titled, “Emergency Use of Medication Assessment Flowsheet (a documentation form that records the assessment and justification administering emergency medication, including the reasons for restraint use),” was not completed by nursing staff on 3/19/2024 when 2 mg of Ativan IM was given to Patient 24 at 5:13 p.m. The Dir 1 said that the form should have been completed by nursing staff. The Dir 1 said that typically, the “Emergency Use of Medication Assessment Flowsheet,” form was completed after administering any emergency medication; and the Restraint and Seclusion (S&R) form, was completed after utilizing physical restraints and/or seclusion. During an interview on 6/13/2025 at 11:02 a.m. with the director of the DDMI unit (Dir 1), the Dir 1 said: “Nursing staff must document both the use of restraints and seclusion (S&R) and the Emergency use of Medication Assessment form (2 separate forms). Nurses should always attempt less restrictive measures with patients, and physical restraints should be used only as a last resort. The documentation should include a thorough explanation of the medication given and the reasons for administration, as well as the description of the behavior that prompted its use, what happened afterwards, and why the patient was physically restrained if physical restraint was still required. All of this should be documented in the patient’s records. The nurse should specifically document the behavior that led to the use of physical restraints (after previously administering chemical restraint) and why the patient was not given enough time for the medication to take effect.” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medications,” dated 11/2024, the P& P indicated the following: “ ...The clinical indications or “target symptoms” are to be listed in the emergency medication order ...the RN will document the clinical situation which led to the need for the use of emergency medication in the progress notes. The patient’s response to the medication is to be documented by a licensed member of the nursing staff in the medical record ... The staff will encourage and assist the patient to return to the milieu as soon as possible .... The RN will document behaviors which led to the need for the use of emergency medication in the Emergency Use of Medication Assessment Flowsheet (form 6793) ...The monitoring of the patient will be documented in the form 6793 ...” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated the following: “The Facility is committed to prevent, reduce, and eliminate S7R use through early identification and intervention of high-risk behaviors or events. S7R interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others. Nonphysical interventions are the preferred method of intervention, and the use of S&R is considered to be an exception and not a standard of practice ...” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated the following: “The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to Seclusion and Restraint (S&R), including: a. redirecting the patient’s focus b. employing verbal de-escalation c. separating patient from group or community d. engaging the patient in 1:1 activity to promote safe expression of feelings e. offering the use of the quiet room to decrease stimuli and regain control f. offering food or drink g. administering medication as ordered by the physician to help patient more effectively function h. documents the alternative attempted or the rationale for not using alternatives ...” 2. During a review of Patient 25’s “Psychiatric and Mental Status Examination (PMSE, a comprehensive assessment performed by a psychiatrist to diagnose and treat mental health conditions, while a mental status examination [MSE] is a structured way to observe and document a patient’s current psychological state during a clinical encounter ),” dated 3/12/2024, the PMSE indicated that Patient 25 was admitted on a 5150 (a temporarily hold for evaluation and crisis intervention- involuntary 72-hour psychiatric hospitalization of an individual who, due to a mental health disorder, is deemed a danger to themselves, a danger to others, or gravely disabled [unable to care for one’s self]) due to danger to others. The PMSE also indicated that Patient 25 had history of autism (neurodevelopmental condition that affects how individuals interact with the world, particularly in social communication and interaction, and in their patterns of behavior and interests) and explosive disorder (a mental health condition characterized by sudden and frequent episodes of impulsive, aggressive, violent behavior or angry verbal outbursts). During a concurrent interview and record review on 6/11/2025 at 11:30 a. m. with Nurse Manager (NM 1), Patient 25’s electronic medical record (EMR) titled, “Behavioral Restraint/Seclusion Order Assessment,” dated 3/12/2024 through 11/12/2024, was reviewed. The record indicated that Patient 25 was placed in physical hold/seclusion/restraints 11 times since the admission to the facility on 3/12/2024 [through 11/20/2024]. The record also indicated that Patient 25 was given emergency medications (chemical restraint-the use of medication administered rapidly to quickly sedate or calm a patient experiencing severe agitation or behavior that poses a danger to themselves or others): 1. 3/30/2024-Patient 25 was placed in physical hold at 10:15 a.m., seclusion at 10:18 a.m., and restraints at 10:18 a.m. (Emergency medications given: Haldol 5 milligram [mg, a unit of measurement], Ativan 2 mg, and Benadryl 50 mg-no time of administration documented). 2. 4/13/2024-Patient 25 documented to be administered emergency medications (Haldol 5 milligrams [mg], Ativan 2 mg and Benadryl 50 mg given at 6:05 p.m.), then placed in a physical hold at 6:15 p.m., and restraints at 6:15 p.m. (restrained only 10 minutes after administering emergency medications) 3. 4/21/2024 -Patient 25 was placed in a physical hold at 5:55 p.m., seclusion 6:00 p.m., emergency medication (Ativan 2 mg, Haldol 10 mg, and Benadryl 50 mg) given at 6:10 p.m. (only 10 minutes prior to placing Patient 25 in physical restraints) and restraints at 6:20 p.m. 4. 4/28/2024-Patient 25 was placed in physical hold at 8:10 a.m., emergency medication (Ativan 1 mg, Haldol 5 mg, Benadryl 50 mg) at 8:14 a.m., seclusion at 8:20 a.m., and restraints at 8:20 a.m. (Patient 25 was placed in restraints only 6 minutes after administration of emergency medications). 5. 5/12/2024-Patient 25 was placed in physical hold at 2:25 p.m., seclusion 2:45 p.m., and restrained at 2:45 p.m.-emergency medication given (Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg) no time of administration documented. 6. 8/4/2024 -Patients 25 was placed in physical hold at 3:05 p.m., seclusion at 3:10 p.m., and restraints at 3:10 p.m.-emergency medication given (Ativan 2 mg, Zyprexa 10 mg), no time for administration documented. During the same record review on 6/11/2025 at 11:30 a.m. with Nurse Manager (NM) 1, Patient 25’s S&R records indicated that three (3) out of 6 seclusion and restraints (S&R) episodes involving the administration of chemical restraint/emergency medication, had no separately completed form titled, “Emergency Use of Medication Assessment Flowsheet (a documentation form that records the assessment and justification administering emergency medication, including the reasons for restraint use),” and three (3) out of 6 remaining (S&R) episodes involving the administration of emergency medications had no time of administration recorded. The S&R forms reviewed also contained no explanation as to why Patient 25 was restrained shortly after being given emergency medications, without allowing sufficient time for the medications to take effect. This information was verified with NM 1 during the record review. During an interview on 6/13/2025 at 10:51 a.m. with the Director of DDMI unit (Dir 1), the Dir 1 stated that a form titled “Emergency Use of Medication Assessment Flowsheet,” must be completed by nursing staff when emergency medications are administered to a patient. Dir 1 also said that if the emergency medication was administered after the patient was already restrained, then it’s sufficient to document the time of administration in the same Seclusion and Restraint (S&R) form. During an interview on 6/13/2025 at 11:02 a.m., with the Director of the DDMI unit (Dir 1), the Dir 1 said: “Nursing staff must document both the use of restraints and seclusion (S&R) and the Emergency use of Medication Assessment form (2 separate forms). Nurses should always attempt less restrictive measures first, and physical restraints should be used only as a last resort. The documentation should include a thorough explanation of the emergency medication given and the reasons for administration, as well as the description of the behavior that prompted its use, what happened afterwards, and why the patient was physically restrained if physical restraint was still required. All of this should be documented in the patient’s records. The nurse should specifically document the behavior that led to the use of physical restraints (after previously administering chemical restraint) and why the patient was not given enough time for the medication to take effect. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medications,” dated 11/2024, the P& P indicated the following: “ ...The clinical indications or “target symptoms” are to be listed in the emergency medication order ...the RN will document the clinical situation which led to the need for the use of emergency medication in the progress notes. The patient’s response to the medication is to be documented by a licensed member of the nursing staff in the medical record ... The staff will encourage and assist the patient to return to the milieu as soon as possible .... The RN will document behaviors which led to the need for the use of emergency medication in the Emergency Use of Medication Assessment Flowsheet (form 6793) ...The monitoring of the patient will be documented in the form 6793 ...” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated the following: “The Facility is committed to prevent, reduce, and eliminate S&R use through early identification and intervention of high-risk behaviors or events. S&R interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others. Nonphysical interventions are the preferred method of intervention, and the use of S&R is considered to be an exception and not a standard of practice ...” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold,” dated 10/2023, the P&P indicated the following: “The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to Seclusion and Restraint (S&R), including: a. redirecting the patient’s focus b. employing verbal de-escalation c. separating patient from group or community d. engaging the patient in 1:1 activity to promote safe expression of feelings e. offering the use of the quiet room to decrease stimuli and regain control f. offering food or drink g. administering medication as ordered by the physician to help patient more effectively function h. documents the alternative attempted or the rationale for not using alternatives ...””

“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 for Patient Rights was met as evidenced by: 1. The facility failed to provide information about conditions of admission (COA, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) to the legal guardian for five of 30 sampled patients (Patients 2, 3, 10, 11 and 14), who were identified as a minor (children under age of 18) upon admission, in accordance with the facility’s policy and procedure regarding admitting procedures. This deficient practice resulted in the legal guardians for Patients 2, 3, 10, 11 and 14 not receiving information regarding conditions of admission, and not knowing their patient rights including arbitration (a procedure in which a dispute is submitted), billing, release of information, and financial responsibilities during hospitalization which may negatively affect the patients’ involvement in their care and treatment. (Refer to A-0117). 2. The facility failed to inform family members of the use of restraints (chemical restraints, a medication that is not being used as a standard treatment for the patient’s medical or psychiatric condition and that results in restriction of the patient’s freedom of moment) for one of 30 sampled patients (Patient 18), in accordance with the facility’s policy and procedure regarding restraints use. This deficient practice resulted in family members not being informed of the treatment provided at the facility including understanding the risks and benefits of the treatment (use of chemical restraint on Patient 18) and being able to help make informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). (Refer to A-0131) 3. The facility failed to ensure the medication informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was completed prior to medication administration for one of 30 sampled patients (Patient 10), in accordance with the facility’s policy and procedure regarding medication consent, when the consent for prescribed Melatonin (medication that helps to regulate sleep and other bodily function) was missing the psychiatrist (physician who specializes in mental health) information. This deficient practice resulted in Patient 10 receiving Melatonin without a complete consent. It also had the potential to result in Patient 10’s parent not being fully informed of the risks and benefits, of Patient 10 taking Melatonin, before giving consent for the treatment. (Refer to A-0131) 4. The facility failed to ensure its nursing staff obtained a complete seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving)/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) order for seclusion/ restraint use for each of three of 30 sampled patients (Patient 10, 14 and 15), in accordance with facility’s policy and procedure regarding seclusion and restraints when: 4.a. Patient 10 was placed in seclusion without a seclusion order for three hours and five minutes and was placed on 5-point restraints (restraints applied to patient’s bilateral wrists, ankles, and chest) without a renewal order for one hour and five minutes on 6/15/2024. 4.b. Patient 14 was placed in seclusion and restrained for three hours and fifty minutes without a physician order on 3/5/2024. 4.c. Nursing staff initiated seclusion for Patient 15 without a physician order on 4/19/2024 at 5:45 p.m. and the renewal seclusion/restraint order was also incomplete on 4/20/2024 at 1:45 a.m. These deficient practices resulted in Patients 10, 14 and 15 being placed in seclusion and restrained without a proper physician order, which had the potential of placing the patients (Patients 10, 14 and 15) at risk for unnecessary and inappropriate seclusion/restraint use and at risk for injury. (Refer to A-0168) 5. The facility failed to ensure physician orders included the indication for 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) use for one of 30 sampled patients (Patient 16), in accordance with the facility’s policy regarding restraints use. This deficient practice had the potential for restraints to be applied unnecessarily, thus putting Patient 16 at risk for injury. (Refer to A-0168) 6. The facility failed to ensure its nursing staff assessed and monitored three of 30 sampled patients (Patient 11, 13, and 16) for behavior, circulation (flow of fluid, blood in the body), sensation (seeing, hearing, or smelling), movement, or were offered range of motion (movement of a joint), toileting, fluids, food, or hygiene, while placed on restraints (a device attached to the patient’s body that restricts freedom of movement), in accordance with the facility’s policy and procedures regarding seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) and 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), when the assigned Registered Nurse for each respective patient: 6.a. did not perform hourly assessment for Patient 11, who was placed in walking restraints (restraint applied to patient’s ankles to prevent patient from AWOL [absent without official leave, leaving the hospital without discharge order from physician]), on 2/13/2024 from 4:30 p.m. to 10:55 p.m. (10 hours 25 mins). 6.b. did not perform hourly assessment for Patient 13, who was placed in walking restraints on 2/28/2024, from 12:15 a.m. to 8:49 a.m. (8 hours 34 mins). 6.c. did not perform assessment for Patient 16, who was placed in ankle restraints, from 9:30 a.m. to 2:45 p.m., on 1/21/2025 (5 hours and 15 minutes). These deficient practices had the potential for the inability of staff to identify complications of restraints use for Patients 11, 13 and 16, and placed the patients (Patients 11, 13, and 16) at risk for injury such as loss of circulation or sensation to limbs, skin breakdown, and needs including hydration, toileting and hygiene not being met as needed. (Refer to A-0175) 7. The facility failed to ensure two of two sampled Qualified Registered Nurse (QRN, trained Registered Nurse) completed the face-to-face assessment (an in person assessment completed by a physician, qualified Registered Nurse or other Licensed Independent Practitioner [LIP] of patient in seclusion [any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving ]/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], within one hour of initiation to evaluate patient’s medical condition and response to intervention) within an hour after the initiation of seclusion/restraint for two of 30 sampled patients (Patients 1 and 13), in accordance with the facility’s policy and procedure regarding seclusion and restraint when: 7.a. The QRN (QRN 3) did not take vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) during the face-to-face assessment of Patient 1 on 5/13/2023. This deficient practice had the potential for QRN not accurately identifying Patient 1’s response to the treatment (chemical restraint, a medication that is not being used as a standard treatment for the patient’s medical or psychiatric condition and that results in restriction of the patient’s freedom of moment) and put Patient 1 at risk for respiratory distress (difficulty breathing) and/or other complications. (Refer to A-0179) 7.b. The QRN did not perform face-to-face assessment for Patient 13 when Patient 13 was placed in walking restraint (restraint applied to patient’s ankles to prevent patient from AWOL [absent without official leave, leaving the hospital without discharge order from physician]) on 2/28/2024. This deficient practice had the potential for Patient 13 not being properly assessed if the restraint (walking restraint/ankle restraint) was applied appropriately or if there is a need for the restraint use, which may put Patient 13 at risk for injury such as skin breakdown, compromised circulation (the flow of blood in the body), etc. (Refer to A-0179) 8. The facility failed to ensure two of two qualified Registered Nurses (QRN, trained Registered Nurse- QRN 2 and QRN 5) communicated with/notified the physician after face-to-face assessment (an in person assessment completed by a physician, qualified Registered Nurse or other Licensed Independent Practitioner [LIP] of patient in seclusion [any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving ]/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] within one hour of initiation to evaluation patient’s medical condition and response to intervention) was completed for two of 30 sampled patients (Patients 14 and 15), in accordance with the facility’s policy and procedure regarding seclusion and restraint. This deficient practice had the potential to put Patients 14 and 15 at risk for unnecessary seclusion and restraint as well as delay of care when the physicians are not informed by the QRN regarding the outcome of the face-to-face evaluation of Patients 14 and Patient 15’s appropriateness for seclusion/restraint and need for other treatment or intervention. (Refer to A-0182) 9. The facility failed to ensure one of three sampled Qualified Registered Nurses (QRN 3) was currently certified to perform face-to face-evaluations (determines if use of restraints is justified to prevent the patient from causing harm to self or others) for patients who were placed on restraints (a device attached to the patient’s body that restricts freedom of movement), in accordance with the facility’s “Seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) and Restraint Physical Hold Policy,” and the policy and procedure regarding “Qualified Registered Nurse Training for Seclusion & Restraint.” This deficient practice had the potential for inaccurate face-to-face evaluations performed, which may result in harm committed by patients to themselves or to others. (Refer to A-0208) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to provide information about conditions of admission (COA, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) to the legal guardian for five of 30 sampled patients (Patients 2, 3, 10, 11 and 14), who were identified as a minor (children under age of 18) upon admission, in accordance with the facility’s policy and procedure regarding admitting procedures. This deficient practice resulted in the legal guardians for Patients 2, 3, 10, 11 and 14 not receiving information regarding conditions of admission, and not knowing their patient rights including arbitration (a procedure in which a dispute is submitted), billing, release of information, and financial responsibilities during hospitalization which may negatively affect the patients’ involvement in their care and treatment. Findings: 1. During a review of Patient 2’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 12/10/2024, the Psych Eval indicated, Patient 2, a 15-year-old, was admitted to the facility on a 5585-hold (allows a minor 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) with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), depressed (mood disorder that causes a persistent feeling of sadness and loss of interest in life), severe with psychotic (a severe mental disorder with hallucinations [an experience involving the apparent perception of something not present]) features. During a review of Patient 2’s “Integrated Admission Assessment (patient data collected by the facility upon admission),” dated 12/10/2024, the “Integrated Admission Assessment” indicated, Patient 2 was under Department of Child, Family and Adult Services (DCFS, service and system that protects children from abuse and neglect, and provides services to children and families in need) custody (the legal right of care for and control a person or property). During an interview on 1/23/2025 at 2:13 p.m. with the Admitting Representative (AR), AR stated the following: the conditions of admission (COA, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) forms consisted of information including consent for treatment and patient’s financial responsibilities. The COA forms were given to patient to sign upon admission. If a patient was below 18 years old, the legal guardian or parent would be the one signing the COA forms. If the legal guardian or parent were not available upon admission, admitting staff would present the COA forms to the legal guardian or parent at discharge. It was important to provide the COA forms so the signer would know the rights (Patient Rights) and allow him or her to ask questions. During an interview on 1/24/2025 at 8:53 a.m. with the Patient Admitting Supervisor (PAS), PAS stated the following: the COA forms talked about arbitration (a procedure in which a dispute is submitted), consent to treat, billing insurance and physician relationship with the hospital. The COA forms were given upon admission to the patient or the legal guardian if patient was a minor. If the COA forms were not signed upon admission, the admitting staff would obtain the signatures from the legal guardian upon discharge when the legal guardian or parent picked up the patient. Currently there was no process in place to make any attempts to deliver the COA information or obtain signature by admitting department during patient’s stay. PAS stated, “that is something we can work on.” During a concurrent interview and record review on 1/24/2025 at 11 a.m. with the Nurse Manager (NM 4) of Developmental Delay/ Disable and Mentally Ill Services (DDMI, hospital wing services patients with development disabilities, autism spectrum disorders [ASD, a developmental disability caused by differences in the brain] and mental health issues), Patient 2’s “Conditions of Admission (COA)” forms, dated 12/9/2024, was reviewed. The COA forms indicated, “General Admission Consent to Care ... Legal Relationship Between Hospital and Physician ... Release of Information ... Financial Agreement ... Assignment of Insurance Benefits ... Third Party Liability and Billing ... Personal Valuables ... Consent to Photograph ... Discharge ... Arbitration ... the undersigned certifies that he/she has read the foregoing conditions of admission, received a copy thereof, clarified any doubts as to its meaning and accepts its terms, and is the patient, the patients legal representatives, or duly authorized by the patient as the patient’s general; agent to execute the conditions of admissions.” The COA forms also indicated, “Parent unavailable” under the signature of patient/guardian/conservator section. NM 4 stated Patient 2 was under the custody of DCFS and the facility should have contacted DCFS and gave DCFS the COA forms for signature. During a review of the facility’s policy and procedure (P&P) titled, “Patient Admitting Checklist of Legal Documentation,” dated 11/2023, the P&P indicated, “All patient admitting representatives are to ensure that any patient admitting to [the facility] receives and/ or signs for receipt of all legal documentation ... Upon admission, the following items must be given to the patient and/ or signature must be obtained: Conditions of Admission: This document outlines [the facility] general consent to care; legal relationship between hospital and physician; release of information; financial agreement; assignment of insurance benefits; third party liability and billing; personal valuables; consent to photograph; and discharge ... Adolescent or Adult Checklist: with every admission a checklist is generated to ensure that all of the above mentioned forms or handouts are properly delivered to a patient. The patient or parent acknowledge receipt of these items of signing the checklist. The patient admitting representative is required witnessing the patient’s or parent’s signature ... if minor patient arrives without parent/legal guardian, unit is to contact the Admitting Department when the parent/legal guardian is visiting or is picking patient up upon discharge.” 2. During a review of Patient 3’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 5/2/2024, Patient 3, a 16-year-old, was admitted to the facility on a 5585-hold (allows a minor 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) with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), depressed (mood disorder that causes a persistent feeling of sadness and loss of interest in life), severe with psychotic (a severe mental disorder with hallucinations [an experience involving the apparent perception of something not present]) features. During a review of Patient 3’s “face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance),” dated 5/1/2024, the face sheet indicated, Patient 3 had a guardian with a listed phone number.” During a review of Patient 3’s “Conditions of Admission (COA, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service),” dated 5/1/2024, the COA forms indicated, “General Admission Consent to Care ... Legal Relationship Between Hospital and Physician ... Release of Information ... Financial Agreement ... Assignment of Insurance Benefits ... Third Party Liability and Billing ... Personal Valuables ... Consent to Photograph ... Discharge ... Arbitration ... the undersigned certifies that he/she has read the foregoing conditions of admission, received a copy thereof, clarified any doubts as to its meaning and accepts its terms, and is the patient, the patients legal representatives, or duly authorized by the patient as the patient’s general; agent to execute the conditions of admissions.” The COA forms also indicated, “Guardian unavailable” under the signature of patient/guardian/conservator section. During an interview on 1/23/2025 at 2:13 p.m. with the Admitting Representative (AR), AR stated the following: the conditions of admission (COA) forms consisted of information including consent for treatment and patient’s financial responsibilities. The COA forms were given to patient to sign upon admission. If a patient was below 18 years old, the legal guardian or parent would be the one signing the COA forms. If the legal guardian or parent were not available upon admission, admitting staff would present the COA forms to the legal guardian or parent at discharge. It was important to provide the COA forms so the signer would know the Patient rights and allow him or her to ask questions. During an interview on 1/24/2025 at 8:53 a.m. with the Patient Admitting Supervisor (PAS), PAS stated the following: the COA forms talked about arbitration, consent to treat, billing insurance and physician relationship with the hospital. The COA forms were given upon admission to the patient or the legal guardian if patient was a minor. If the COA forms were not signed upon admission, the admitting staff would obtain the signatures from the legal guardian upon discharge when the legal guardian or parent picked up the patient. Currently there was no process in place to make any attempts to deliver the COA information or obtain signature by admitting department during patient’s stay. PAS stated, “that is something we can work on.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Admitting Checklist of Legal Documentation,” dated 11/2023, the P&P indicated, “All patient admitting representatives are to ensure that any patient admitting to [the facility] receives and/ or signs for receipt of all legal documentation ... Upon admission, the following items must be given to the patient and/ or signature must be obtained: Conditions of Admission: This document outlines [the facility] general consent to care; legal relationship between hospital and physician; release of information; financial agreement; assignment of insurance benefits; third party liability and billing; personal valuables; consent to photograph; and discharge ... Adolescent or Adult Checklist: with every admission a checklist is generated to ensure that all of the above mentioned forms or handouts are properly delivered to a patient. The patient or parent acknowledge receipt of these items of signing the checklist. The patient admitting representative is required witnessing the patient’s or parent’s signature ... if minor patient arrives without parent/legal guardian, unit is to contact the Admitting Department when the parent/legal guardian is visiting or is picking patient up upon discharge.” 3. During a review of Patient 10’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 2/24/2024, the Psych Eval indicated, Patient 10, a 14-year-old, was admitted to the facility with diagnosis of disruptive mood dysregulation disorder (a mental health condition characterized by persistent irritability, anger, and frequent intense temper outbursts). During a review of Patient 10’s “face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance),” dated 2/24/2024, the face sheet indicated, Patient 10’s parent was listed as the emergency contact with phone number. During an interview on 1/23/2025 at 2:13 p.m. with the Admitting Representative (AR), AR stated the following: the conditions of admission (COA, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) forms consisted of information including consent for treatment and patient’s financial responsibilities. The COA forms were given to patient to sign upon admission. If a patient was below 18 years old, the legal guardian or parent would be the one signing the COA forms. If the legal guardian or parent were not available upon admission, admitting staff would present the COA forms to the legal guardian or parent at discharge. It was important to provide the COA forms so the signer would know the Patient rights and allow him or her to ask questions. During an interview on 1/24/2025 at 8:53 a.m. with the Patient Admitting Supervisor (PAS), PAS stated the following: the COA forms talked about arbitration, consent to treat, billing insurance and physician relationship with the hospital. The COA forms were given upon admission to the patient or the legal guardian if patient was a minor. If the COA forms were not signed upon admission, the admitting staff would obtain the signatures from the legal guardian upon discharge when the legal guardian or parent picked up the patient. Currently there was no process in place to make any attempts to deliver the COA information or obtain signature by admitting department during patient’s stay. PAS stated, “that is something we can work on.” During a concurrent interview and record review on 1/24/2025 at 1:46 p.m. with the Nurse Manager (NM 3), Patient 10’s “Conditions of admission (COA)” forms, dated 2/24/2024, was reviewed. The COA forms indicated, “General Admission Consent to Care ... Legal Relationship Between Hospital and Physician ... Release of Information ... Financial Agreement ... Assignment of Insurance Benefits ... Third Party Liability and Billing ... Personal Valuables ... Consent to Photograph ... Discharge ... Arbitration ... the undersigned certifies that he/she has read the foregoing conditions of admission, received a copy thereof, clarified any doubts as to its meaning and accepts its terms, and is the patient, the patients legal representatives, or duly authorized by the patient as the patient’s general; agent to execute the conditions of admissions.” The COA forms also indicated, “Parent unavailable” under the signature of patient/guardian/conservator section. NM 3 stated there was no signature from Patient 10’s parent upon admission and discharge on the COA forms. During a review of the facility’s policy and procedure (P&P) titled, “Patient Admitting Checklist of Legal Documentation,” dated 11/2023, the P&P indicated, “All patient admitting representatives are to ensure that any patient admitting to [the facility] receives and/ or signs for receipt of all legal documentation ... Upon admission, the following items must be given to the patient and/ or signature must be obtained: Conditions of Admission: This document outlines [the facility] general consent to care; legal relationship between hospital and physician; release of information; financial agreement; assignment of insurance benefits; third party liability and billing; personal valuables; consent to photograph; and discharge ... Adolescent or Adult Checklist: with every admission a checklist is generated to ensure that all of the above mentioned forms or handouts are properly delivered to a patient. The patient or parent acknowledge receipt of these items of signing the checklist. The patient admitting representative is required witnessing the patient’s or parent’s signature ... if minor patient arrives without parent/legal guardian, unit is to contact the Admitting Department when the parent/legal guardian is visiting or is picking patient up upon discharge.” 4. During a review of Patient 11’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/22/2024, Patient 11, a 16-year-old, was admitted to the facility with diagnoses including but not limited to major depression (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) with psychotic features (delusions and hallucinations), anxiety disorder (a group of mental disorders characterized by significant feelings of fear) and autistic spectrum disorders (a developmental disability caused by differences in the brain). During a review of Patient 11’s “Integrated Admission Assessment (patient data collected by the facility upon admission),” dated 1/23/2024, the Integrated Admission Assessment indicated, Patient 11’s parent was the custodial (the legal right of care for and control a person or property) parent. During an interview on 1/23/2025 at 2:13 p.m. with the Admitting Representative (AR), AR stated the following: the conditions of admission (COA, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) forms consisted of information including consent for treatment and patient’s financial responsibilities. The COA forms were given to patient to sign upon admission. If a patient was below 18 years old, the legal guardian or parent would be the one signing the COA forms. If the legal guardian or parent were not available upon admission, admitting staff would present the COA forms to the legal guardian or parent at discharge. It was important to provide the COA forms so the signer would know the rights and allow he or she to ask questions. During a concurrent interview and record review on 1/23/2025 at 2:18 p.m. with the Admitting Representative (AR), Patient 11’s “Conditions of Admission (COA)” forms, dated 1/22/2024, was reviewed. The COA forms indicated, “General Admission Consent to Care ... Legal Relationship Between Hospital and Physician ... Release of Information ... Financial Agreement ... Assignment of Insurance Benefits ... Third Party Liability and Billing ... Personal Valuables ... Consent to Photograph ... Discharge ... Arbitration ... the undersigned certifies that he/she has read the foregoing conditions of admission, received a copy thereof, clarified any doubts as to its meaning and accepts its terms, and is the patient, the patients legal representatives, or duly authorized by the patient as the patient’s general; agent to execute the conditions of admissions.” The COA forms also indicated, “Parent unavailable” under the signature of patient/guardian/conservator section. AR stated Patient 11’s parent was not available upon admission to sign the COA forms. AR also stated there was no attempt documented in obtaining Patient 11’s parent signature during hospitalization and upon discharge. During an interview on 1/24/2025 at 8:53 a.m. with the Patient Admitting Supervisor (PAS), PAS stated the following: the COA forms talked about arbitration, consent to treat, billing insurance and physician relationship with the hospital. The COA forms were given upon admission to the patient or the legal guardian if patient was a minor. If the COA forms were not signed upon admission, the admitting staff would obtain the signatures from the legal guardian upon discharge when the legal guardian or parent picked up the patient. Currently there was no process in place to make any attempts to deliver the COA information or obtain signature by admitting department during patient’s stay. PAS stated, “that is something we can work on.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Admitting Checklist of Legal Documentation,” dated 11/2023, the P&P indicated, “All patient admitting representatives are to ensure that any patient admitting to [the facility] receives and/ or signs for receipt of all legal documentation ... Upon admission, the following items must be given to the patient and/ or signature must be obtained: Conditions of Admission: This document outlines [the facility] general consent to care; legal relationship between hospital and physician; release of information; financial agreement; assignment of insurance benefits; third party liability and billing; personal valuables; consent to photograph; and discharge ... Adolescent or Adult Checklist: with every admission a checklist is generated to ensure that all of the above mentioned forms or handouts are properly delivered to a patient. The patient or parent acknowledge receipt of these items of signing the checklist. The patient admitting representative is required witnessing the patient’s or parent’s signature ... if minor patient arrives without parent/legal guardian, unit is to contact the Admitting Department when the parent/legal guardian is visiting or is picking patient up upon discharge.” 5. During a review of Patient 14’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 3/3/2024, the Psych Eval indicated, Patient 14, a 17-year-old, was admitted to the facility with diagnosis of psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). During a review of Patient 14’s “Integrated Admission Assessment (patient data collected by the facility upon admission),” dated 3/5/2024, the Integrated Admission Assessment indicated, Patient 14’s parent was the custodial parent with full custody (the legal right of care for and control a person or property). During an interview on 1/23/2025 at 2:13 p.m. with the Admitting Representative (AR), AR stated the following: the conditions of admission (COA, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) forms consisted of information including consent for treatment and patient’s financial responsibilities. The COA forms were given to patient to sign upon admission. If a patient was below 18 years old, the legal guardian or parent would be the one signing the COA forms. If the legal guardian or parent were not available upon admission, admitting staff would present the COA forms to the legal guardian or parent at discharge. It was important to provide the COA forms so the signer would know the rights and allow he or she to ask questions. During an interview on 1/24/2025 at 8:53 a.m. with the Patient Admitting Supervisor (PAS), PAS stated the following: the COA forms talked about arbitration, consent to treat, billing insurance and physician relationship with the hospital. The COA forms were given upon admission to the patient or the legal guardian if patient was a minor. If the COA forms were not signed upon admission, the admitting staff would obtain the signatures from the legal guardian upon discharge when the legal guardian or parent picked up the patient. Currently there was no process in place to make any attempts to deliver the COA information or obtain signature by admitting department during patient’s stay. PAS stated, “that is something we can work on.” During a concurrent interview and record review on 1/24/2025 at 9:10 a.m. with the Patient Admitting supervisor (PAS), Patient 14’s “Conditions of Admission (COA)” forms, dated 3/2/2024, was reviewed. The COA forms indicated, “General Admission Consent to Care ... Legal Relationship Between Hospital and Physician ... Release of Information ... Financial Agreement ... Assignment of Insurance Benefits ... Third Party Liability and Billing ... Personal Valuables ... Consent to Photograph ... Discharge ... Arbitration ... the undersigned certifies that he/she has read the foregoing conditions of admission, received a copy thereof, clarified any doubts as to its meaning and accepts its terms, and is the patient, the patients legal representatives, or duly authorized by the patient as the patient’s general; agent to execute the conditions of admissions.” The COA forms also indicated, “Parent unavailable” under the signature of patient/guardian/conservator section. During the same interview on 1/24/2025 at 9:10 a.m. with the Patient Admitting Supervisor (PAS), PAS stated there was no signature obtained from Patient 14’s parent upon admission and discharge. PAS also stated there was no attempt made to deliver the information and obtain the signature when Patient 14 was hospitalized. During a review of the facility’s policy and procedure (P&P) titled, “Patient Admitting Checklist of Legal Documentation,” dated 11/2023, the P&P indicated, “All patient admitting representatives are to ensure that any patient admitting to [the facility] receives and/ or signs for receipt of all legal documentation ... Upon admission, the following items must be given to the patient and/ or signature must be obtained: Conditions of Admission: This document outlines [the facility] general consent to care; legal relationship between hospital and physician; release of information; financial agreement; assignment of insurance benefits; third party liability and billing; personal valuables; consent to photograph; and discharge ... Adolescent or Adult Checklist: with every admission a checklist is generated to ensure that all of the above mentioned forms or handouts are properly delivered to a patient. The patient or parent acknowledge receipt of these items of signing the checklist. The patient admitting representative is required witnessing the patient’s or parent’s signature ... if minor patient arrives without parent/legal guardian, unit is to contact the Admitting Department when the parent/legal guardian is visiting or is picking patient up upon discharge.””

“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: 36206 Based on interview and record review, the facility failed to: 1. Inform family members of the use of restraints (chemical restraints, a medication that is not being used as a standard treatment for the patient’s medical or psychiatric condition and that results in restriction of the patient’s freedom of moment) for one of 30 sampled patients (Patient 18), in accordance with the facility’s policy and procedure regarding restraints. This deficient practice resulted in family members not being informed of the treatment provided at the facility including understanding the risks and benefits of the treatment (use of chemical restraint on Patient 18) and being able to help make informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). 2. Ensure the medication informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was completed prior to medication administration for one of 30 sampled patients (Patient 10), in accordance with the facility’s policy and procedure regarding medication consent, when the consent for prescribed Melatonin (medication that helps to regulate sleep and other bodily function) was missing the psychiatrist (physician who specializes in mental health) information. This deficient practice resulted in Patient 10 receiving Melatonin without a complete consent. It also had the potential to result in Patient 10’s parent not being fully informed of the risks and benefits, of Patient 10 taking Melatonin, before giving consent for the treatment. Findings: 1. During a concurrent interview and record review on 1/22/2025 at 9:38 a.m., with Nurse Managers (NM) 3 and 4. NM 3 and NM 4 stated the following: Patient 18 was admitted on 1/8/2024 on a 5150 hold (72-hour involuntary hold at a psychiatric [focuses on the diagnosis, treatment, and prevention of mental health disorders] facility for someone experiencing a mental health crisis) for being a danger to others. Patient 18 requested that his (Patient 18) mother be notified if Patient 18 was placed on restraints or seclusion (involuntary confinement of patient alone in a room or area from which the patient is physically prevented from leaving). Restraints, included chemical restraints (a medication that is not being used as a standard treatment for the patient’s medical or psychiatric condition and that results in restriction of the patient’s freedom of moment) or emergency medications. Patient 18 was given Thorazine (treats behavior disorders, reduces anxiety [excessive and persistent worry]) 50 milligrams (mg, a unit of measurement) IM (in the muscle) for agitation (a feeling of irritability or restlessness), paranoia (persistent and irrational feelings of suspicion, mistrust, and persecution), and provoking peers on 1/19/2024 at 1:40 p.m. NM 3 and NM 4 stated that Patient 18’s mother had not been notified of the chemical restraint (Thorazine medication), despite Patient 18’s request to inform Patient 18’s mother. During a review of Patient 18’s “Integrated Admission Assessment,” dated 1/08/2024, the assessment indicated Patient 18 wished for the facility to contact his (Patient 18) mother if the facility required the use of seclusion or restraints for Patient 18. During a review of Patient 18’s “Psychiatric and Mental Status Examination,” dated 4/16/2024, the Examination indicated the following: Patient 18 was admitted on 1/08/2024. According to the report, Patient 18 was running into traffic, stranger attempted to save him (Patient 18) from getting hurt. Patient 18 ended up fighting the individual ...subsequently placed on a 5150 hold. “Transferred to this facility for stabilization of behavior.” During a review of Patient 18’s physician’s order dated 1/19/2024 at 1:37 p.m., the order indicated to give chlorpromazine (Thorazine, treats behavior disorders, reduces anxiety) 50 mg IM (in the muscle), once for psychosis (a mental disorder characterized by a disconnection from reality). During a review of Patient 18’s flow sheet (a tool that clinicians use to document patient care) titled, “6793 Emergency Use of Medications Assessment Flowsheet,” dated 1/19/2024 at 1:40 p.m., the flow sheet indicated the results of Patient 18’s physical assessment, fall (an unintentional event that results in a person coming to rest on the ground or another lower level) risk, vital signs (blood pressure, pulse, respiratory rate and temperature) and mental status exam after the intervention (administration of Thorazine) dated 1/19/2024 at 1:40 p.m. The flow sheet did not include notification of Patient 18’s mother on the use of a chemical restraint. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated the following: Registered Nurse (RN)/designee notifies the patient’s legal guardian/parent, as applicable, as soon as possible and documents the notification in the patient’s chart. During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Rights/Philosophy,” dated 10/2023, the P&P indicated the following: “Each patient shall receive a reasonable response to his/her request for treatment and /or services within the hospital’s capacity, stated mission, and applicable law and regulations. The basic patient’s rights for voluntary and involuntary patients are as follows ...Patient, conservator, parent, and/or anyone designated by the patient shall be informed of the following as appropriate ...b. The plan of treatment while in the hospital and the staff providing care; c. The risk and side effects of medication and treatment procedures and any alternatives ...” 2. During a review of Patient 10’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 2/24/2024, the Psych Eval indicated, Patient 10, a 14-year-old, was admitted to the facility with diagnosis of disruptive mood dysregulation disorder (a mental health condition characterized by persistent irritability, anger, and frequent intense temper outbursts). During a concurrent interview and record review on 1/24/2025 at 2:42 p.m. with the Nurse Manager (NM 1), Patient 10’s “General Medication Consent (medication consent form, a consent form indicating a psychiatrist had discussed the risk and benefits of the medications being prescribed and the patient or patient’s legal representative gave consent to take the medication),” dated 3/2/2024, was reviewed. The medication consent form indicated, Melatonin (medication that helps to regulate sleep and other bodily function) was listed on the consent form with verbal consent given by Patient 10’s parent and witnessed by Registered Nurse (RN) 3. The medication consent form also indicated, “Psychiatrist Signature” section that required the name of the psychiatrist, date and time of signature, were left blank. During the same interview on 1/24/2025 at 2:42 p.m. with Nurse Manager (NM) 1, NM 1 stated the following: Melatonin had hypnotic (produce drowsiness) effect and would require consent from Patient 10’s parent when it was prescribed to be taken daily. It was the psychiatrist’s responsibility to discuss the risks and benefits, dosage, alternatives of treatment and answer all questions when obtaining the medication consent. Without the psychiatrist’s name and signature, it was unknown of who had discussed the Melatonin use with Patient 10’s parent to make sure Patient 10’s parent was fully informed of the medication’s purpose, risk and benefits, and side effects before giving the consent. NM 1 also said that RN 3 should not sign as a witness the medication consent because it was incomplete. NM 1 further stated Melatonin should not be given to Patient 10 without a complete consent. During a review of Patient 10’s “Order Chronology (list of physician order [orders written by physicians to direct care and treatment]),” dated from 4/9/2024 to 5/7/2024, the “Order Chronology” indicated, Melatonin 3 milligrams (mg, a unit of measure) orally to start on 4/9/2024 and stop on 5/7/2024. The “Order Chronology” also indicated Patient 10 received Melatonin 3 mg daily from 4/9/2024 to 5/7/2024. During a review of the facility’s policy and procedure (P&P) titled, “Consent Procedures for Medications,” dated 11/2023, the P&P indicated, “To ensure that all patients (voluntary and involuntary) are fully informed regarding the risks, side effects, and benefits of certain psychotropic (medications that affect a person’s mental state, emotions, and behavior) medications and their rights to refuse medication ... if the patient is a minor, the parent or legal guardian will be informed prior to administration and asked to sign the consent form ... Patient (guardian, conservator) consent is required for medications prescribed to affect the central nervous system (CNS, the primary control center of the body, consisting of the brain and spinal cord) to treat psychiatric disorders (medical condition that significantly affects a person’s thinking, mood and behavior) or illness including, but not limited to anti-depressants (medications helps to relieve symptoms of depression [mood disorder that causes a persistent feeling of sadness and loss of interest in life] and anxiety [a group of mental disorders characterized by significant feelings of fear]), mood stabilizing (medications to regulate mood, reducing mood swings and stabilizing emotions) and antipsychotics (medications to treat mental health conditions) ... the physician will explain to the patient, parent or legal guardian: nature of the patient’s mental condition; reason for taking such medication ... the type of medication, range of frequency of administration and dosage amount ...probable side effects of the medication ... a licensed nursing staff member will witness, as appropriate, the signature of the patient, parent, or legal guardian. This applies to situations where the consent is obtained over the phone ... medication will not be ordered if the consent form has not been completed.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to: 1. Ensure its nursing staff obtained a complete seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving)/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) order for each seclusion/restraint use for each of three of 30 sampled patients (Patient 10, 14 and 15), in accordance with facility’s policy and procedure regarding seclusion and restraints when: 1.a. Patient 10 was placed in seclusion without a seclusion order for three hours and five minutes and was placed on 5-point restraints (restraints applied to patient’s bilateral wrists, ankles, and chest) without a renewal order for one hour and five minutes on 6/15/2024. 1.b. Patient 14 was placed in seclusion and restrained for three hours and fifty minutes without a physician order on 3/5/2024. 1.c. Nursing staff initiated seclusion for Patient 15 without a physician order on 4/19/2024 at 5:45 p.m. and the renewal seclusion/restraint order was incomplete on 4/20/2024 at 1:45 a.m. These deficient practices resulted in Patients 10, 14 and 15 being placed in seclusion and restrained without a proper physician order and had the potential of placing the patients (Patients 10, 14 and 15) at risk for unnecessary and inappropriate seclusion/restraint use and at risk for injury. 2. Ensure physician orders included the indication for 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) for one of 30 sampled patients (Patient 16), in accordance with the facility’s policy regarding restraints. This deficient practice had the potential for restraints to be applied unnecessarily, thus putting Patient 16 at risk for injury. Findings: 1.a. During a review of Patient 10’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 2/24/2024, the Psych Eval indicated, Patient 10, a 14-year-old, was admitted to the facility with diagnosis of disruptive mood dysregulation disorder (a mental health condition characterized by persistent irritability, anger, and frequent intense temper outbursts). During an interview on 1/22/2025 at 10:49 a.m. with the Shift Supervisor (QRN 2), QRN 2 stated a physician order was required for seclusion (any involuntary confinement of a patient alone in a room or area where he or she 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). QRN 2 also stated each seclusion/restraint order was good for two (2) hours for youth (9-17 years old) patients. During a concurrent interview and record review on 1/24/2025 at 1:46 p.m. with Nurse Manager (NM) 3, Patient 10’s “Seclusion and Restraints Assessment Packet (S&R Assessment),” dated 6/15/2024, was reviewed. The S&R Assessment indicated, Patient 10 was placed in seclusion and restraint on 6/15/2024 at 9:35 p.m. The S&R Assessment also indicated Patient 10 was released from restraint and seclusion on 6/16/2024 at 12:40 a.m. NM 3 stated Patient 10 was in seclusion and restraint for three (3) hours and five (5) minutes. NM 3 stated there should be physician order for seclusion and restraints during the start and another seclusion and restraint renewal order two (2) hours after the initiation of seclusion and restraint. During a concurrent interview and record review on 1/24/2025 at 2:10 p.m. with NM 3, Patient 10’s physician orders, dated on 6/15/2024, was reviewed. The physician orders indicated the following: -“On 6/15/2024 at 9:38 p.m.: initial order: time limited order 2 hours for age 9 - 17; initial order: the patient needs to be released from seclusion/restraints by 11:35 p.m. or a new order to be obtained; -type of seclusion/restraints: 5 points restraint (restraints applied to a patient’s both wrist, ankles, and chest); -describe the precipitating incident: patient (Patient 10) biting left forearm, pulling own teeth off own mouth. Not following any redirection from staff.” During the same interview on 1/24/2025 at 2:10 p.m., NM 3 stated the following: each restraint order should specify the type of restraint. There was no seclusion order when Patient 10 was placed in a seclusion room on 6/15/2024 at 9:35 p.m. It would be considered as restraining patient without a physician order. Nursing staff should contact physician to obtain restraints renewal order by 11:35 p.m. because each restraint order was only good for two (2) hours for youth patients. Patient 10 was restrained without renewal order for one (1) hour and five (5) minutes (from 11:35 p.m. to 12:40 a.m.). During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “The physician or Registered Nurse (RN) can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the seclusion/restraints (S/R), and document on the Seclusion/Restraint Order form as follows: A. Time Limits: 1) Adults 18 and older up to four (4) hours; 2) Youth 9 - 17 up to two (2) hours ... B. The physician’s orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration. The S/R can be ordered for less than above stated maximum. The length of the S/R is limited by the continued need for the intervention rather than the length of the order ... In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained Registered Nurse may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes.” 1.b. During a review of Patient 14’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 3/3/2024, the Psych Eval indicated, Patient 14, a 17-year-old, was admitted to the facility with diagnosis of psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). During an interview on 1/22/2025 at 10:49 a.m. with the Shift Supervisor (QRN 2), QRN 2 stated a physician order was required for seclusion (any involuntary confinement of a patient alone in a room or area where he or she 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). QRN 2 also stated each seclusion/restraint order was good for two hours for youth (9-17 years old) patients. During a concurrent interview and record review on 1/23/2025 at 11:40 a.m. with the Nurse Manager (NM 2), Patient 14’s “Seclusion and Restraints Assessment Packet (S&R Assessment),” dated 3/5/2024, was reviewed. The S&R Assessment indicated, Patient 14 was placed on 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) and seclusion on 3/5/2024 at 6:22 p.m. and restrained on 3/5/2024 at 7:35 p.m. Patient 14 was released from seclusion and restraint on 3/5/2024 at 10:10 p.m. During the same interview on 1/23/2025 at 11:40 a.m. with the Nurse Manager (NM) 2, NM 2 stated Patient 14 was on seclusion and was restrained for three (3) hours and fifty (50) minutes. During a concurrent interview and record review on 1/23/2025 at 11:50 a.m. with NM 3, Patient 14’s physician orders, dated 3/5/2024 was reviewed. The physician order indicated the following: -On 3/5/2024 at 6:25 p.m.: Physical Hold ordered: yes; To prevent imminent (about to happen) physical or emotional harm to others because of threats, attempts, or other acts the patient overly or continually makes or commits. -On 3/5/2024 at 8:22 p.m.: Renewal Order #1: time limited ordered: 2 hours for ages 9 - 17; specific behavior or requiring restraints/seclusion: danger to others, patient continues to scream, cursing at staff, unable to make a safety plan for when patient (Patient 14) is released. During the same interview on 1/23/2025, at 11:50 a.m. with Nurse Manager (NM) 2, NM 2 stated that there was no physician order when seclusion and a restraint were initiated at 6:22 p.m. and at 7:35 p.m., respectively. NM 2 also stated there was the renewal order at 8:22 p.m. but it did not indicate what type of restraints to be continued. NM 2 stated Patient 14 was on seclusion and restrained from 6:22 p.m. to 10:10 p.m. (3hour 50 min) without a physician order. NM 2 stated nursing staff could not restrain without physician orders. NM 2 stated physician orders should be obtained within minutes upon seclusion and restraint initiation. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “The physician or Registered Nurse (RN) can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the seclusion/restraints (S/R), and document on the Seclusion/Restraint Order form as follows: A. Time Limits: 1) Adults 18 and older up to four (4) hours; 2) Youth 9 - 17 up to two (2) hours ... B. The physician’s orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration. The S/R can be ordered for less than above stated maximum. The length of the S/R is limited by the continued need for the intervention rather than the length of the order ... In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained Registered Nurse may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes.” 1.c. During a review of Patient 15’s Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 4/17/2024, the Psych Eval indicated, Patient 15 was admitted to the facility with diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), mixed with psychotic (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality) features. During an interview on 1/21/2025 at 1:52 p.m. with the Nurse Manager (NM 1), NM 1 stated a physician order was required for any seclusion (any involuntary confinement of a patient alone in a room or area where he or she 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). NM 1 also stated each restraint order was good for four (4) hours for adult patients (18 and older). During a concurrent interview and record review on 1/23/2025 at 3:22 p.m. with Nurse Manger (NM) 3, Patient 15’s “Seclusion and Restraints Assessment Packet (S&R Assessment),” dated 4/19/2024, was reviewed. The S&R Assessment indicated, Patient 15 was placed in physical hold, seclusion and restraints on 4/19/2024 at 5:45 p.m., released from restraints on 4/20/2024 at 2:45 a.m. and seclusion on 4/20/2024 at 3:45 a.m. NM 3 stated Patient 15 was in restraints for nine (9) hours and seclusion for ten (10) hours. During a concurrent interview and record review on 1/24/2025 at 2:56 p.m. with NM 3, Patient 15’s physician orders, dated 4/19/2024, was reviewed. The physician orders indicated the following: -“On 4/19/2024 at 5:45 p.m.: initial order: time limited order: 4 hours for age 18 or older; type of seclusion/restraint: therapeutic/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); type of seclusion/restraint: 5 points restraints (restraints applied to a patient’s both wrist, ankles, and chest); specific behavior or requiring restraints/seclusion: danger to others, Patient (Patient 15) attacked 1:1 staff and continued to attack staff that arrived at the code grey (hospital emergency response when someone is acting violently, aggressively or threateningly), patient (Patient 15) continued made threats throughout whole interaction.” -“On 4/19/2024 at 9:45 p.m.: renewal order #1: time limited order: 4 hours for age 18 or older; type of seclusion/restraint: 5 points restraints; type of seclusion/restraint: seclusion; specific behavior or requiring restraint/seclusion: danger to others ...” -“On 4/20/2024 at 1:45 a.m.: renewal order #2: time limited order: 4 hours for age 18 or older; specific behavior or requiring restraint/seclusion: danger to others ...” During the same interview on 1/24/2025 at 2:56 p.m. with Nurse Manager (NM) 3, NM 3 stated the following: there was no seclusion order when Patient 15 was placed in seclusion on 4/19/2024 at 5:45 p.m. Also, the renewal order #2 on 4/20/2024 at 1:45 a.m. was missing the type of restraint/seclusion. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “The physician or Registered Nurse (RN) can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the seclusion/restraints (S/R), and document on the Seclusion/Restraint Order form as follows: A. Time Limits: 1) Adults 18 and older up to four (4) hours; 2) Youth 9 - 17 up to two (2) hours ... B. The physician’s orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration. The S/R can be ordered for less than above stated maximum. The length of the S/R is limited by the continued need for the intervention rather than the length of the order ... In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained Registered Nurse may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes.” 2. During a concurrent observation and interview on 1/21/2025 at 2:54 p.m., in the DDMI Youth Unit (unit for minors who are developmentally delayed with mental illness), Patient 16 walked into the unit wearing restraints to both ankles. Nurse Manager (NM) 3 stated Patient 16 returned from a doctor’s appointment and had been placed on restraints due to Patient 16’s high AWOL (absent without leave, a mental health patient leaves a facility without permission) risk. During an interview on 1/22/2025 at 4:10 p.m. with the Chief Nursing Officer (CNO), the CNO stated that restraint orders should include the type of restraints to be used and the indications or reasons for the restraints. Each restraint order should stand alone. During a concurrent interview and record review on 1/22/2025 at 4:18 p.m. with Nurse Managers (NM) 3 and 4. NM 3 and NM 4 stated the following: Patient 16 was 17 years old. Patient 16 was placed in ankle restraints on 1/21/2025 from 9:30 a.m. to 2:45 p.m. during transportation to a clinic appointment because Patient 16 was an AWOL (absent without leave, a mental health patient leaves a facility without permission) risk. Restraint orders for minors (ages 9 - 17) expire in 2 hours and require a new physician’s order. The physician ordered restraints on 1/21/2025 at 9:13 a.m., 11:23 a.m., and 1:12 p.m. NM 3 and NM 4 verified that orders written at 9:13 a.m. and 11:12 a.m. did not have an indication or reason for the ankle restraints. During a review of Patient 16’s “Psychiatric and Mental Status Examination,” dated 11/29/2023, the Examination indicated the following: Patient 16 was admitted on involuntary status (against ones will) for danger to self, danger to others, and gravely disabled (a person is unable to meet their basic needs) on 11/27/2023. Patient 16 was 15 years old (in 2023). During a review of Patient 16’s physician’s order dated 1/21/2025 at 9:13 am, the physician’s order indicated the following: Type of Seclusion/Restraint: Walking Restraints/ -Transport. Associated problems: Blank (no documentation of problems). During a review of Patient 16’s physician’s order dated 1/21/2025 at 11:23 a.m., the physician’s order indicated the following: Type of Seclusion/Restraint: Walking Restraints/Transport. Associated problems: Blank (no documentation of problems). During a review of Patient 16’s physician’s order dated 1/21/2025 at 1:53 p.m., the physician’s order indicated the following: Type of Seclusion/Restraint: Walking Restraints/Transport. High AWOL risk. During a review of Patient 16’s “Seclusion & Restraints Flow Sheet,” dated 1/21/2025, the Flow Sheet indicated Patient 16 was placed on ankle (walking) restraints from 9:12 a.m. to 2:42 p.m., during transport. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated the following: The Hospital considers a patient a high risk for AWOL during transportation outside of the facility to be an imminent risk for harm to self or others (community). In this situation, with a physician’s order, the patient may be placed in transport restraints while outside the facility ...The same procedure ...will be used for transport restraints including but not limited to: obtaining MD (physician) order ...The physician or Registered Nurse can initiate the need for restrictive intervention, obtain a written or telephonic order for the restraints / Seclusion (S/R). Time Limits: ...Youth 9 - 17 (years of age) up to two (2) hours. The physician’s orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration ...Reassessment / Continuation Protocol. Physician / Qualified Registered Nurse (RN) reassesses patients for continuation of S/R ...as followings ... Youth 9 - 17 (of age) at two (2) hours ...Ensures a new order is written on the Seclusion Restraint Continuation Order justifying continuation of S/R.”

“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: 48212 Based on interview and record review, the facility failed to ensure its nursing staff assessed and monitored three of 30 sampled patients (Patient 11, 13, and 16) for behavior, circulation (flow of fluid, blood in the body), sensation (seeing, hearing, or smelling), movement, or were offered range of motion (movement of a joint), toileting, fluids, food, or hygiene, while placed on restraints (a device attached to the patient’s body that restricts freedom of movement), in accordance with the facility’s policy and procedures regarding seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) and 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), when the assigned Registered Nurse for each respective patient: 1. did not perform hourly assessment for Patient 11, who was placed in walking restraints (restraint applied to patient’s ankles to prevent patient from AWOL [absent without official leave, leaving the hospital without discharge order from physician]), on 2/13/2024 from 4:30 p.m. to 10:55 p.m. (10 hours 25 mins). 2. did not perform hourly assessment for Patient 13, who was placed in walking restraints on 2/28/2024, from 12:15 a.m. to 8:49 a.m. (8 hours 34 mins). 3. did not perform assessment for Patient 16, who was placed in ankle restraints, from 9:30 a.m. to 2:45 p.m., on 1/21/2025 (5 hours and 15 minutes). These deficient practices had the potential for the inability of staff to identify complications of restraints use for Patients 11, 13 and 16, and placed the patients (Patients 11, 13, and 16) at risk for injury such as loss of circulation or sensation to limbs, skin breakdown, and needs including hydration, toileting and hygiene not being met as needed. Findings: 1. During a review of Patient 11’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 1/22/2024, the psych eval indicated Patient 11 was admitted to the facility with diagnoses including but not limited to major depression (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) with psychotic features (delusions [a false or fixed belief that persists despite overwhelming evidence to the contrary] and hallucinations [a false perception of objects or events]), anxiety disorder (a group of mental disorders characterized by significant feelings of fear) and autistic spectrum disorders (a developmental disability caused by differences in the brain). During a review of Patient 11’s physician order, dated 2/13/2024, the physician order indicated, “transport/ transfer via ambulance to emergency room in walking restraints (restraint applied to patient’s ankles to prevent patient from AWOL [absent without official leave, leaving the hospital without discharge order from physician]) with a Registered Nurse (RN).” During a concurrent interview and record review on 1/23/2025 at 2:39 p.m. with the Nurse Manager (NM 2), Patient 11’s “Seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) and 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) Assessment Packet (S&R Assessment),” dated 2/13/2024, was reviewed. The S&R Assessment indicated, Patient 11 was placed in walking restraint on 2/13/2024 at 4: 30 p.m. and released from restraint on 2/13/2024 at 10:55 p.m. (10 hours 25 mins). During the same interview on 1/23/2025 at 2:39 p.m. with Nurse Manager (NM) 2, NM 2 stated the following: Patient 11 was sent to an emergency room for a medical evaluation and was placed in walking restraints due to high AWOL (absent without official leave, leaving the hospital without discharge order from physician) risk. A Registered Nurse (RN 4) was assigned to accompany Patient 11 and was responsible to perform assessment and monitoring every hour to check for range of motion (movement of a joint), hydration, hygiene and toileting to make sure Patient 11 was safe and Patient 11’s needs were met while in restraint. During a concurrent interview and record review on 1/23/2024 at 2:45 p.m. with NM 2, Patient 11’s “Seclusion & Restraints Flow Sheet,” dated 2/13/2024, was reviewed. The S/R flowsheet indicated, the section for checking range of motion, toileting, fluids, food and hygiene from 4:30 p.m. to 11p.m., was blank. NM 2 stated RN 4 did not document any assessment and monitoring every hour on 2/13/2024 from 4:30 p.m. to 10:55 p.m. (10 hours 25 mins). During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “Use of mechanical restraint during transport: [the facility] consider a patient at high risk for AWOL [absent without official leave, leaving the hospital without discharge order from physician] during transportation outside of the facility to be at imminent (about to happen) risk of harm to self and others (community). This is situation, with a physician’s order, the patient may be placed in transport restraints while outside the facility ... Patient placed in transport restraints outside the facility will be sent with a Registered Nurse (RN) to ensure the patient is continuously monitored and assessed ... The same procedure listed below will be used for transport restraints including but not limited to face to face assessment, monitoring, debriefing, etc ... Assigned staff conducts 15-minute patient observation on the Seclusion & Restraint Flow Sheet that includes the following: A. Review for signs of injury related to restraint application; B. evaluate patient behavior, staff interventions and patient responses; C. evaluate for breathing; D. monitor for circulation and skin integrity; E. perform range of motion exercise ... F. offer food during meal times using paper products; G. Offers fluid or upon request; H. assist with toileting; I. assists with personal hygiene ... RN assesses the patient’s medical and psychological status and readiness for discontinuation every hour and documents ...” 2. During a review of Patient 13’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 8/23/2024, the Psych Eval indicated, Patient 13 was admitted to the facility with diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought), and autism (a developmental disorder that affects a person’s communication, behavior, and social interaction). The Psych Eval also indicated, Patient 13 had episodes of attempting to AWOL (absent without official leave, leaving the hospital without discharge order from physician). During a review of Patient 13’s physician orders, dated 2/27/2024, the physician order indicated, “transport/ transfer with ambulance to [an acute care facility] emergency room with walking restraint (restraint applied to patient’s ankles to prevent patient from AWOL) with Registered Nurse staff and 1:1 (a type of care where a patient is under constant observation by a single staff member) Mental Health Worker.” During a review of Patient 13’s “Seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) and 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) Assessment Packet (S&R Assessment),” dated 2/28/2024, the S&R Assessment indicated, Patient 13 was placed in walking restraint on 2/28/2024 at 12:15 a.m. and released from restraint on 2/28/2024 at 8:49 a.m. (8 hours and 34 mins). During an interview on 1/24/2025 at 3:55 p.m. with the Nurse Manager (NM) 1, NM 1 stated there was no Registered Nurse hourly assessment found in Patient 13’s medical record for the restraint episode on 2/28/2024 from 12:15 am to 8:49 a.m. NM 1 stated, “It was not done.” During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “Use of mechanical restraint during transport: [the facility] consider a patient at high risk for AWOL [absent without official leave, leaving the hospital without discharge order from physician] during transportation outside of the facility to be at imminent (about to happen) risk of harm to self and others (community). This is situation, with a physician’s order, the patient may be placed in transport restraints while outside the facility ... Patient placed in transport restraints outside the facility will be sent with a Registered Nurse (RN) to ensure the patient is continuously monitored and assessed ... The same procedure listed below will be used for transport restraints including but not limited to face to face assessment, monitoring, debriefing, etc ... Assigned staff conducts 15-minute patient observation on the Seclusion & Restraint Flow Sheet that includes the following: A. Review for signs of injury related to restraint application; B. evaluate patient behavior, staff interventions and patient responses; C. evaluate for breathing; D. monitor for circulation and skin integrity; E. perform range of motion exercise ... F. offer food during meal times using paper products; G. Offers fluid or upon request; H. assist with toileting; I. assists with personal hygiene ... RN assesses the patient’s medical and psychological status and readiness for discontinuation every hour and documents ...” 3. During a concurrent interview and record review on 1/22/2025 at 4:18 p.m. with Nurse Managers (NM) 3 & 4. NM 3 and NM 4 stated the following: Patient 16 was placed in ankle restraints on 1/21/2025 from 9:30 a.m. to 2:45 p.m. during transportation to a clinic appointment because Patient 16 was an AWOL (absent without leave, a mental health patient leaves a facility without permission) risk. While a patient was placed on restraints, the patient’s behavior, circulation (flow of fluid, blood in the body), sensation (seeing, hearing, or smelling), and movement should be assessed every 15 minutes. In addition, patients should be offered range of motion (movement of a joint), toileting, fluids, food, and hygiene every 2 hours. The assessment should be documented in the “Seclusion & Restraint Flow Sheet.” During the same interview with Nurse Managers 3 and 4 (NM 3 and NM 4) on 1/22/2025 at 4:18 p.m., NM 3 and NM 4 verified that these assessments or interventions (such as toileting and offering fluids) were not done for Patient 16 while Patient 16 was placed on restraints. NM 3 and NM 4 stated these assessments and interventions should be done to avoid patient injury due to restraint use or prevent patient from being hungry or thirsty. During a review of Patient 16’s “Psychiatric and Mental Status Examination,” dated 11/29/2023, the Examination indicated the following: Patient 16 was admitted on involuntary status (against one’s will) for danger to self, danger to others, and gravely disabled (a person is unable to meet their basic needs) on 11/27/2023. During a review of Patient 16’s physician’s order dated 1/21/2025 at 9:13 a.m., the physician’s order indicated the following: Type of Seclusion/Restraint: Walking Restraints/Transport. Associated problems: Blank During a review of Patient 16’s physician’s order dated 1/21/2025 at 11:23 a.m., the physician’s order indicated the following: Type of Seclusion/Restraint: Walking Restraints/Transport. Associated problems: Blank. During a review of Patient 16’s physician’s order dated 1/21/2025 at 1:53 p.m., the physician’s order indicated the following: Type of Seclusion/Restraint: Walking Restraints/Transport. High AWOL risk. During a review of Patient 16’s “Seclusion & Restraints Flow Sheet,” dated 1/21/2025, the Flow Sheet indicated Patient 16 was placed on ankle (walking) restraints from 9:12 a.m. to 2:42 p.m., during transport. During a review of Patient 16’s “Seclusion & Restraint Flow Sheet,” dated 1/21/2025, the flow sheet indicated the following: -Section: Behavior/Observation Key, Document Q (every) 15 minutes. The section was blank. Patient 16’s behaviors, such as hostile, agitated, quiet were not documented. - Section: Circulation/Sensation/Movement: Document Q 15 minutes when in restraints. The section was blank. Patient 16’s circulation whether normal, pale (loss of color from normal skin tone, indicating circulation problems), cyanotic (bluish skin color due to lack of blood flow) ..., sensation, good or diminishing ..., or the ability to move affected limbs were not documented. - Section: General Key: Document at least every two (2) hours. The section was blank. There was no documentation indicating the following was either, done, offered, refused, or not applicable: ROM (range of motion), BRP (restroom privileges), fluids, food, hygiene. During a concurrent interview and review of Patient 16’s “Seclusion & Restraint Flow Sheet,” on 1/23/2025 at 9:38 am, with Nurse Managers (NM) 3 & 4. NM 3 and NM 4 verified that the Flow sheet was incomplete and missing the following documentation. Patient 16’s behaviors, such as hostile, agitated, quiet were not documented. Patient 16’s circulation whether normal, pale (loss of color from normal skin tone, indicating circulation problems), cyanotic (bluish skin color due to lack of blood flow) ..., sensation, good or diminishing ..., or the ability to move affected limbs was not documented. There was no documentation indicating the following was either, done, offered, refused, or not applicable: ROM (range of motion), BRP (restroom privileges), fluids, food, hygiene. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated the following: Patient placed in transport restraints outside the facility will be sent with a Registered Nurse to ensure the patient is continuously monitored and assessed. Assigned staff conducts 15-minute patient observation on the “Seclusion & Restraint Flow Sheet,” that includes the following: A. Review for signs of injury related to restraint application B. Evaluates patient behavior, staff interventions, and patient responses C. Evaluates for breathing D. Monitors for circulation and skin integrity E. Performs range of motion exercises... F. Offers food during mealtimes using paper products G. Offers fluids or upon request H. Assist with toileting I. Assist with personal hygiene J. Obtain vital signs ...”

“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 two of two sampled Qualified Registered Nurse (QRN, trained Registered Nurse) completed the face-to-face assessment (an in person assessment completed by a physician, qualified Registered Nurse or other Licensed Independent Practitioner [LIP] of patient in seclusion [any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving ]/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], within one hour of initiation to evaluate patient’s medical condition and response to intervention) within an hour after the initiation of seclusion/restraint for two of 30 sampled patients (Patients 1 and 13), in accordance with the facility’s policy and procedure regarding seclusion and restraint when: 1. The QRN (QRN 3) did not take vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) during the face-to-face assessment of Patient 1 on 5/13/2023. This deficient practice had the potential for QRN not accurately identifying Patient 1’s response to the treatment (chemical restraint, a medication that is not being used as a standard treatment for the patient’s medical or psychiatric condition and that results in restriction of the patient’s freedom of moment) and put Patient 1 at risk for respiratory distress (difficulty breathing) and/or other complications. 2. The QRN did not perform face-to-face assessment for Patient 13 when Patient 13 was placed in walking restraint (restraint applied to patient’s ankles to prevent patient from AWOL [absent without official leave, leaving the hospital without discharge order from physician]) on 2/28/2024. This deficient practice had the potential for Patient 13 not being properly assessed if the restraint (walking restraint/ankle restraint) was applied appropriately or if there is a need for the restraint use, which may put Patient 13 at risk for injury such as skin breakdown, compromised circulation (the flow of blood in the body), etc. Findings: 1. During a review of Patient 1’s “Medical Doctor Progress Notes,” dated 5/12/2023, the MD Progress Notes indicated, Patient 1 was admitted to the facility with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), manic (a state of abnormally elevated mood), autism spectrum disorders (ASD, a developmental disability caused by differences in the brain), medication non-compliance, random violence and gravely disabled (unable to care for self). During an interview on 1/22/2025 at 10:14 a.m. with the Registered Nurse (RN 2), RN 2 stated, a face-to-face assessment (an in person assessment completed by a physician, qualified Registered Nurse or other Licensed Independent Practitioner [LIP] of patient in seclusion [any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving ]/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] within one hour of initiation to evaluate a patient’s medical condition and response to intervention) was required to check the patient’s response to medication and vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) to make sure patient was stable and not in distress within an hour after an emergency medication (medications used to treat acute [new onset] agitation [a state of restlessness, unease, and excessive activity]) was administered. During an interview on 1/22/2025 at 10:49 a.m. with the Shift Supervisor (QRN 2), QRN 2 stated the following: only the Qualified Registered Nurse (QRN) could perform the face-to-face assessment. All shift supervisors and nurse managers were trained to be the QRN. Face-to-face assessment was required within an hour after seclusion/restraint initiation. The face-to-face assessment included a head-to-toe assessment, mental assessment, vital signs, and assess patient’s behavior and response to seclusion/restraint. It was done to determine the need to continue or terminate seclusion/restraint. The QRN had to communicate with the physician after face-to-face assessment to report patient’s response to intervention and for further order as needed. During a concurrent interview and record review on 1/23/2025 at 3:37 p.m. with the Nurse Manager (NM) 3, Patient 1’s “Seclusion and Restraints Assessment Packet (S&R Assessment),” dated 5/13/2023, was reviewed. The S&R Assessment indicated the following: Patient 1 was placed in seclusion and restraint on 5/13/2023 at 10 a.m. and released from seclusion and restraint on 5/13/2023 at 1:50 p.m. Patient 1 received an emergency medication of Zyprexa (medication to treat severe mental health condition)10 milligrams (mg, a unit of measure) intramuscularly (IM, injection given directly into a muscle) at 10:05 a.m. The face-to-face assessment was performed on 5/13/2023 at 10:40 a.m. There were no vital signs recorded in the face-to-face assessment. During the same interview on 1/23/2025 at 3:37 p.m. with the Nurse Manager (NM) 3, NM 3 stated vital signs should be part of the face-to-face assessment to make sure Patient 1 was responding well and not having adverse effect such as respiratory distress (difficulty breathing) or overly sedated (excessive drowsiness, loss of response, and inappropriate movement) from the intervention (administration of Zyprexa medication) especially when the emergency medication was given. NM 3 confirmed that the face-to-face assessment was incomplete. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “A Physician, Qualified Registered Nurse (QRN), or other Licensed Independent Practitioner (LIP) as allowed by law and scope of practice conducts an in-person, face-to-face assessment of the patient in seclusion/restraint (S/R) within one (1) hour of initiation and documents findings ... The purpose of this evaluation is to determine if the use of these measures is justified to prevent the patient from causing harm to self or others. It is also completed to ensure that the use of S/R poses no undue risk to the patient’s medical or psychological well-being ... The evaluation incorporates the following: B. Reviews, with the staff, the physical and psychological status of the patient; C. Evaluates the patient’s immediate situation, the patient’s reaction to the intervention, the patient’s behavioral condition, and the need to continue or terminate the S/R ... E. Evaluate the patient’s medical condition including a complete review of systems assessment, behavioral assessment ... F. Ensures that the use of S/R poses no undue risk to the patient’s medical or psychosocial well-being ... H. Assesses the safety of patients in S/R, including the appropriate implementation/application of S/R interventions and their physical and emotional status.” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medications,” dated 10/2023, the P&P indicated, “Patient receiving emergency medications are to be monitored and assessed for medication efficacy and possible side effects ... the Qualified Registered Nurse (QRN)/ Licensed Independent Physician (LIP) will conduct a face-to-face assessment or the patient within one hour of administration of emergency medication to assess physical and psychological status, including the effectiveness of the medication ... vital signs will be taken immediately following administration of the emergency mediation and monitored every thirty (30) minutes until evaluation of QRN/LIP.” 2. During a review of Patient 13’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 8/23/2024, the Psych Eval indicated, Patient 13 was admitted to the facility with diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought), and autism (a developmental disorder that affects a person’s communication, behavior, and social interaction). The Psych Eval also indicated, Patient 13 had episodes of attempting to AWOL (absent without official leave, leaving the hospital without discharge order from physician). During a review of Patient 13’s physician orders, dated 2/27/2024, the physician order indicated, “transport/transfer with ambulance to [an acute care facility] emergency room with walking restraint (restraint applied to patient’s ankles to prevent patient from AWOL [absent without official leave, leaving the hospital without discharge order from physician]) with Registered Nurse staff and 1:1 (a type of care where a patient is under constant observation by a single staff member) Mental Health Worker.” During an interview on 1/22/2025 at 10:49 a.m. with the Shift Supervisor (QRN 2), QRN 2 stated the following: only the Qualified Registered Nurse (QRN) could perform the face-to-face assessment (an in person assessment completed by a physician, qualified Registered Nurse or other Licensed Independent Practitioner [LIP] of patient in seclusion [any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving ]/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] within one hour of initiation to evaluate patient’s medical condition and response to intervention). During the same interview on 1/22/2025 at 10:49 a.m. with the Shift Supervisor (QRN 2), QRN 2 stated that all shift supervisors and nurse managers were trained to be the QRN. Face-to-face assessment was required within an hour after seclusion/restraint initiation. The face-to-face assessment included a head-to-toe assessment, mental assessment, vital signs, and assess patient’s behavior and response to seclusion/restraint. It was done to determine the need to continue or terminate seclusion/restraint. The QRN had to communicate with the physician after face-to-face assessment to report patient’s response to intervention and for further order as needed. During a concurrent interview and record review on 1/24/2025 at 3:50 p.m. with the Chief Nursing Officer (CNO), Patient 13’s “Seclusion and Restraints Assessment Packet (S&R Assessment),” dated 2/28/2024, was reviewed. The S&R Assessment indicated, Patient 13 was placed in walking restraint on 2/28/2024 at 12:15 a.m. and released from restraint on 2/28/2024 at 8:49 a.m. (8 hours and 34 mins). The S&R Assessment Packet also indicated the face-to-face assessment section was blank. CNO stated the face-to-face assessment was not done on 2/28/2024 when Patient 13 was placed in walking restraint. CNO stated face-to-face assessment was required when Patient 13 was placed in walking restraint. CNO stated the QRN needed to check Patient 13’s restraint to make sure it was applied appropriately, not too loose or not too tight. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “A Physician, Qualified Registered Nurse (QRN), or other Licensed Independent Practitioner (LIP) as allowed by law and scope of practice conducts an in-person, face-to-face assessment of the patient in seclusion/restraint (S/R) within one (1) hour of initiation and documents findings ... The purpose of this evaluation is to determine if the use of these measures is justified to prevent the patient from causing harm to self or others. It is also completed to ensure that the use of S/R poses no undue risk to the patient’s medical or psychological well-being ... The evaluation incorporates the following: B. Reviews, with the staff, the physical and psychological status of the patient; C. Evaluates the patient’s immediate situation, the patient’s reaction to the intervention, the patient’s behavioral condition, and the need to continue or terminate the S/R ... E. Evaluate the patient’s medical condition including a complete review of systems assessment, behavioral assessment ... F. Ensures that the use of S/R poses no undue risk to the patient’s medical or psychosocial well-being ... H. Assesses the safety of patients in S/R, including the appropriate implementation/application of S/R interventions and their physical and emotional status.””

“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: 48212 Based on interview and record review, the facility failed to ensure two of two qualified Registered Nurses (QRN, trained Registered Nurse- QRN 2 and QRN 5)) communicated with/notified the physician after face-to-face assessment (an in person assessment completed by a physician, qualified Registered Nurse or other Licensed Independent Practitioner [LIP] of patient in seclusion [any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving ]/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] within one hour of initiation to evaluation patient’s medical condition and response to intervention) was completed for two of 30 sampled patients (Patients 14 and 15), in accordance with the facility’s policy and procedure regarding seclusion and restraint. This deficient practice had the potential to put Patients 14 and 15 at risk for unnecessary seclusion and restraint as well as delay of care when the physicians are not informed by the QRN regarding the outcome of the face-to-face evaluation of Patients 14 and Patient 15’s appropriateness for seclusion/restraint and need for other treatment or intervention. Findings: 1. During a review of Patient 14’s “Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 3/3/2024, the Psych Eval indicated, Patient 14 was admitted to the facility with diagnosis of psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). During an interview on 1/22/2025 at 10:49 a.m. with the Qualified Registered Nurse/Shift Supervisor (QRN 2), QRN 2 stated the following: only the Qualified Registered Nurse (QRN) could perform the face-to-face assessment (an in person assessment completed by a physician, qualified Registered Nurse or other Licensed Independent Practitioner [LIP] of a patient in seclusion [any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving ]/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] within one hour of initiation to evaluate a patient’s medical condition and response to intervention). During the same interview on 1/22/2025 at 10:49 a.m. with the Qualified Registered Nurse/Shift Supervisor (QRN 2), QRN 2 said all shift supervisors and nurse managers were trained to be the QRN. Face-to-face assessment was required within an hour after a seclusion/restraint initiation. The face-to-face assessment included a head-to-toe assessment, mental assessment, vital signs, and assess patient’s behavior and response to seclusion/restraint. It was done to determine the need to continue or terminate seclusion/restraint. The QRN had to communicate with the physician after a face-to-face assessment to report patient’s response to intervention and for further order as needed. During a concurrent interview and record review on 1/23/2025 at 11 a.m. with the Nurse Manager (NM 2), Patient 14’s “Seclusion and Restraints Assessment Packet (S&R Assessment),” dated 3/5/2024, was reviewed. The S&R Assessment indicated, Patient 14 was placed in seclusion and restraint on 3/5/2024 at 9 a.m. and released from seclusion and restraint on 3/5/2024 at 12:20 p.m. The S/R Assessment also indicated a face-to-face assessment was completed by QRN 2 on 3/5/2024 at 9:45 a.m. with the comment of “No further orders” under “MD (medical doctor) Notified/ Comments” section. During the same interview on 1/23/2025 at 11 a.m. with the Nurse Manager (NM) 2, NM 2 stated QRN 2 did not specify which physician was notified. NM2 stated QRN 2 should have documented the name of the physician QRN 2 contacted after the face-to-face assessment was done on Patient 14. NM 2 stated, usually, the QRN should contact the ordering physician to give report. During an interview on 1/23/2025 at 3:22 p.m. with the Nurse Manager (NM 3), NM 3 stated the purpose of MD notification after face-to-face assessment was to give update to the physician regarding patient’s condition and response to intervention, and to ask for further order as needed. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “A Physician, Qualified Registered Nurse (QRN), or other Licensed Independent Practitioner (LIP) as allowed by law and scope of practice conducts an in-person, face-to-face assessment of the patient in seclusion/restraint (S/R) within one (1) hour of initiation and documents findings ... The purpose of this evaluation is to determine if the use of these measures is justified to prevent the patient from causing harm to self or others. It is also completed to ensure that the use of S/R poses no undue risk to the patient’s medical or psychological well-being ... The LIP/QRN contacts the attending physician or designee to discuss the evaluation of the patient, the need for other interventions or treatments, and the need to continue or discontinue the S/R. This needs to be done as soon as possible after completing the S&R Assessment Packet 1 Hour Face-to-Face Evaluation but no longer than thirty (30) minutes after the evaluation is completed.” 2. During a review of Patient 15’s Psychiatric and Mental Status Examination (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 4/17/2024, the Psych Eval indicated, Patient 15 was admitted to the facility with diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), mixed, with psychotic (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality) features. During an interview on 1/22/2025 at 10:14 a.m. with the Registered Nurse (RN 2), RN 2 stated, a face-to-face assessment (an in person assessment completed by a physician, qualified Registered Nurse or other Licensed Independent Practitioner [LIP] of patient in seclusion [any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving ]/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] within one hour of initiation to evaluation patient’s medical condition and response to intervention) was required to check the patient’s response to medication and vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) to make sure patient was stable and not in distress within an hour after an emergency medication (medications used to treat acute [new onset] agitation [a state of restlessness, unease, and excessive activity]) was administered. During an interview on 1/22/2025 at 10:49 a.m. with the Shift Supervisor (QRN 2), QRN 2 stated the following: only the Qualified Registered Nurse (QRN) could perform the face-to-face assessment. QRN 2 also said all shift supervisors and nurse managers were trained to be the QRN. Face-to-face assessment was required within an hour after seclusion/ restraint initiation. The face-to-face assessment included a head-to-toe assessment, mental assessment, vital signs, and assess patient’s behavior and response to seclusion/restraint. It was done to determine the need to continue or terminate seclusion/restraint. The QRN had to communicate with the physician after face-to-face assessment to report patient’s response to intervention and for further order as needed. During a concurrent interview and record review on 1/23/2025 at 3:22 p.m. with the Nurse Manager (NM) 3, Patient 15’s “Seclusion and Restraints Assessment Packet (S&R Assessment),” dated 4/19/2024, was reviewed. The S&R Assessment indicated the following: Patient 15 was placed in seclusion on 4/19/2024 at 9:10 a.m. and released from seclusion on 4/19/2024 at 11:07 a.m. with emergency medication of Haldol (medication used to treat nervous, emotional, and mental condition) 10 milligram (mg, a unit of measure) and Ativan (medication helps to reduce anxiety symptoms, produces a calming effect on the brain and nerves) 2 mg given intramuscularly (IM, injection given directly into a muscle) at 9:10 a.m. The face-to-face assessment was completed by Qualified Registered Nurse/ Shift Supervisor (QRN 5) on 4/19/2024 at 9:34 a.m. with “MD (medical doctor) Notified/ Comments” section that was blank. During the same interview on 1/23/2025 at 3:22 p.m. with the Nurse Manager (NM) 3, NM 3 stated there was no documentation of MD notification that was done after the face-to-face assessment on 4/19/2024 at 9:34 a.m. NM 3 also stated the purpose of MD notification after face-to-face assessment was to give update to the physician regarding patient’s condition and response to intervention, and to ask for further order as needed. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated, “A Physician, Qualified Registered Nurse (QRN), or other Licensed Independent Practitioner (LIP) as allowed by law and scope of practice conducts an in-person, face-to-face assessment of the patient in seclusion/restraint (S/R) within one (1) hour of initiation and documents findings ... The purpose of this evaluation is to determine if the use of these measures is justified to prevent the patient from causing harm to self or others. It is also completed to ensure that the use of S/R poses no undue risk to the patient’s medical or psychological well-being ... The LIP/QRN contacts the attending physician or designee to discuss the evaluation of the patient, the need for other interventions or treatments, and the need to continue or discontinue the S/R. This needs to be done as soon as possible after completing the S&R Assessment Packet 1 Hour Face-to-Face Evaluation but no longer than thirty (30) minutes after the evaluation is completed.” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medications,” dated 10/2023, the P&P indicated, “Patient receiving emergency medications are to be monitored and assessed for medication efficacy and possible side effects ... the Qualified Registered Nurse (QRN)/ Licensed Independent Physician (LIP) will conduct a face-to-face assessment for the patient within one hour of administration of emergency medication to assess physical and psychological status, including the effectiveness of the medication ... vital signs will be taken immediately following administration of the emergency medication and monitored every thirty (30) minutes until evaluation of QRN/LIP.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure one of three sampled Qualified Registered Nurses (QRN 3) was currently certified to perform face-to face-evaluations (determines if use of restraints is justified to prevent the patient from causing harm to self or others) for patients who were placed on restraints (a device attached to the patient’s body that restricts freedom of movement), in accordance with the facility’s “Seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) and Restraint Physical Hold Policy,” and the policy and procedure regarding “Qualified Registered Nurse Training for Seclusion & Restraint.” This deficient practice had the potential for inaccurate face-to-face evaluations performed, which may result in harm committed by patients to themselves or to others. Findings: During a concurrent interview and personnel file review on 1/24/2025 at 1:34 p.m. with the Human Resources Director (HRD), the HRD stated the following: Qualified Registered Nurse (QRN) 3, who was also a Shift Supervisor, was hired on 9/22/2014. Registered nurses, including all shift supervisors who have completed the training regarding performing face-to-face evaluations (determines if use of restraints is justified to prevent the patient from causing harm to self or others), when patients were placed on restraints, were called QRN. During the same interview on 1/24/2025 at 1:34 p.m. with the Human Resources Director (HRD), the HRD said all shift supervisors were required to be certified and competent in performing face-to- face evaluations for patients after being placed on restraints, and therefore, were required to complete an annual re-certification training and competency to ensure they were competent in performing the assessment. The training should be completed annually. During a concurrent interview and personnel file review on 1/24/2025 at 2:09 p.m. with the Education Coordinator (EDC), the EDC stated Shift Supervisors were required to complete annual training to ensure they are certified in conducting face-to-face evaluations. The EDC verified that QRN 3’s last training/competency was completed on 7/8/2023 and was valid until 7/2024. The EDC verified that QRN 3 should have completed the re-certification training in 7/2024, however, training had not been completed. During a review of QRN 3’s personnel file, the personnel file indicated QRN 3’s last training titled, “QRN One Hour Face-To-Face Certification Package,” was completed on 7/8/2023. During a review of the facility’s policy and procedure (P&P) titled, “Qualified Registered Nurse Training for Seclusion & Restraint,” dated 10/2023, the P&P indicated the following: The Qualified Registered Nurse (QRN) provides timely and quality review of patients in seclusion/restraint (S/R) and effective guidance to staff. There is special training provided to the staff designated to be a Qualified Registered Nurse...The designated QRN can provide One-Hour Face-To-Face Medical and Behavioral evaluation. All training for the QRN role is documented including the dates of training and demonstration of competency. The QRN is required to have annual refresher training for the One-Hour Face-To-Face Evaluation. During a review of the facility’s policy and procedure (P&P) titled, “Seclusion and Restraint Physical Hold Policy,” dated 10/2023, the P&P indicated the following: A Physician, Qualified RN (QRN), or other Licensed Independent Practitioner (LIP) as allowed by law and scope of practice conducts an in-person face-to-face assessment of the patient in Seclusion/Restraint (S/R) within one (1) hour of initiation and documents the findings ...The purpose of this evaluation is to determine if the use of these measures is justified to prevent the patient from causing harm to self or others ....Special training ...is required for Registered Nurses prior to conducting the one-hour face-to-face evaluation ... A. Certification of competency is required to successfully complete training. B. Competency reassessment is to be renewed annually ...”