Canyon Ridge Hospital

“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: 46917 Based on interview and record review, the facility failed to ensure patient observation rounds were documented in accordance with the facility’s policy and procedure (P&P) for five of 32 sampled patients (Patient 1, 3, 5, 10, and 13) when staff did not document patient observation every 15 minutes appropriately. This failure had the potential to delay identification of clinical deterioration, which could increase the risk of self-harm and compromised patients’ safety. Findings: 1a. During a review of Patient 1’s “Psychiatric Evaluation” (PE) dated June 18, 2026, the “PE” indicated, “ ... patient has a history of bipolar disorder [mental health condition that causes extreme shifts in mood, energy, and activity levels] ...the patient is tangential [wandering off-topic], grandiose [unrealistic, inflated sense of superiority] , paranoid [feelings of intense suspicion], hyper religious [extreme religious beliefs] with poor insight and judgement ...patient will be admitted to psychiatric inpatient adult unit ...” During a review of Patient 1’s “Patient Observation Rounds” (POR), dated June 18, 2026, the “POR” indicated missing staff initials at 5:15 AM and 5:30 AM. During a concurrent interview and record review on July 2, 2026, at 2:41 PM, with the Chief Nursing Officer (CNO), Patient 1’s POR dated June 18, 2026, was reviewed. The CNO verified that Patient 1’s POR was missing staff initials at 5:15 AM and 5:30AM. 1b. During a review of Patient 3’s “PE” dated June 28, 2026, the “PE” indicated, “ ...Patient is extremely disorganized, confused, and a poor historian. Stated she thought she was going to die ... Patient also has voices telling her to harm herself”. During a review of Patient 3’s “POR” dated June 28, 2026, and June 30, 2026, indicated the following: - June 28, 2026, at 7:15 PM, missing behavior, location and staff initials. - June 30, 2026, at 7:45 AM, missing staff initials. During a concurrent interview and record review on July 2, 2026, at 2:41 PM, with the CNO, Patient 3’s POR dated June 28, 2026, and June 30, 2026, were reviewed. The CNO verified that Patient 3’s POR were missing behavior, location, and staff initials. 1c. During a review of Patient 5’s “PE” dated June 26, 2026, the “PE” indicated, “ ...female with reported history of borderline personality disorder [mental health condition severe instability in emotions, struggle to regulate their feelings] ... she wanted to end her life and run on the freeway ... she had a bad day and was contemplating suicide while watching cars pass ...” During a review of Patient 5’s “POR” dated June 26, 2026, through June 27, 2026, indicated the following: - June 26, 2026, at 3:45 PM, missing staff initials. - June 27, 2026, missing staff initials at 9:45 AM and 3:15 PM. During a concurrent interview and record review on July 2, 2026, at 2:42 PM, with the CNO, Patient 5’s POR dated June 26, 2026, and June 27, 2026, were reviewed. The CNO verified that Patient 5’s POR were missing staff initials. 1d. During a review of Patient 10’s “PE” dated June 26, 2026, the “PE” indicated, “ ...female with reported history of depression [persistent feeling of sadness] and ADHD [attention-deficit/hyperactivity disorder, condition marked by persistent patterns of inattention, impulsivity] ... having a mental health episode as she is hearing voices and believes persons are after her ...” During a review of Patient 10’s “POR”, dated June 29, 2026, the “POR” indicated missing staff initials at 7:15 PM. During a concurrent interview and record review on July 2, 2026, at 2:42 PM, with the CNO, Patient 5’s POR dated June 29, 2026, was reviewed. The CNO verified that Patient 5’s POR was missing staff initials. 1e. During a review of Patient 13’s “PE” dated June 6, 2026, the “PE” indicated, “ ...female brought into [name of facility] on a 5150 [California law for involuntary 72-hour psychiatric hold of people who are a danger to self or others] hold for danger to self ... endorsed severe depressed mood with feeling of hopelessness, ...and suicidal ideations [thoughts with ending one’s own life] ...” During a review of Patient 13’s “POR” dated June 27, 2026, the “POR” indicated missing behavior, location, and staff initials at 11:45 PM. During a concurrent interview and record review on July 2, 2026, at 2:42 PM, with the CNO, Patient 13’s POR dated June 27, 2026, was reviewed. The CNO verified that Patient 13’s POR was missing behavior, location, and staff initials. During an interview on July 1, 2026, at 1:45 PM, with the Charge Nurse (CN), the CN stated patient “POR”s should be signed by the staff and by signing it shows the accuracy of the rounds. During an interview on July 2, 2026, at 8:39 AM, with the Mental Health Worker (MHW), the MHW stated they have to directly visualize the patients every 15 minutes to see the behavior and location of patients. The MHW further stated the “POR” needs to be signed and initialed. During a concurrent interview and record review on July 2, 2026, at 2:43 PM, with the CNO, the facility’s P&P titled, “Patient Observation” dated April 2011, was reviewed. The P&P indicated, “The purpose of patient observation is to ensure patient safety, as well as, to provide a process for observing and documenting patient location and behavior ... 4. Assigned staff will clearly print their name and initials in the appropriate section(s) of the patient observation form ...31. If a round was missed, the nursing staff should inform the Charge Nurse and circle the missed round ...nursing staff initials and Charge Nurse signs on the back of the form ...” The CNO stated the P&P was not followed. .”