Aurora Behavioral Healthcare-Santa Rosa, LLC

“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: 50121 Based on interviews and record reviews, the facility failed to protect patient rights to receive care in a safe setting when one assigned staff member (Mental Health Technician, MHT 1) working the night shift (11 p.m. until 7 a.m.) on one of seven units (unit 200) did not perform visual safety checks to ensure patients were mentally and physically safe as ordered by the physician. This failure had the potential to result in patients who were hospitalized for being at risk for self-harming behavior, harming themselves. Findings: During a concurrent interview and record review on 7/9/26 at 11:05 a.m. with Nurse Informaticist (NI), the facility’s video surveillance footage of hallway in unit 200, dated 7/8/26 at 1:37 a.m., was reviewed. NI stated the video showed facility staff “rounding on patients” (patient safety checks in which assigned staff visually looks at patients to confirm they are safe) and documenting observation in an “Observation Rounds” log. The surveillance footage showed MHT 1 sitting in her chair from 1: 37 a.m. until 2:01 a.m. NI confirmed MHT 1 did not stand up and perform patient safety checks when the physician had ordered that all patients on the unit be checked every five minutes. During a continuation of the same interview and record review with NI, the facility’s video surveillance footage, dated 7/8/26 at 4:27 a.m., was reviewed. NI confirmed MHT 1 stood up at 4:27 p.m., walked up to a partially closed door of a patient’s room, wrote an entry in the log binder, but did not open or walk into the patient’s room to make a direct observation of the patient. NI confirmed MHT 1 then walked to an adjacent patient’s door, did not push the door open or walk into that second room to make a direct observation of that patient, and then she wrote something on her log. During an interview on 7/8/26, at 3:30 p.m., the Risk Manager (RM) stated that when patients are sleeping, MHTs are expected to go into the room to make sure patients are safe and breathing. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment and Prevention,” dated 10/23/25, the P&P indicated staff members are to ensure that individual patients’ immediate safety needs are met by monitoring them at least every 15 minutes, or more frequently if ordered by a physician.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38088 Based on observation, administrative interviews, and administrative document reviews, the hospital did not ensure the Patient Rights, in a manner sufficient to ensure behavioral health quality and patient safety, when it did not: 1) Ensure clear expectations for safety was established for all facility staff and patients. (Cross Reference A-145); 2) Ensure the right for freedom from abuse was coordinated, responded to, investigated and reported by the facility for all patients. (Reference A-145); and, 3) Ensure patients’ right for Informed Consent and response to Grievances for all patients. (Reference A-123, A-131). The cumulative effect of these systemic problems resulted in a decrease in patient safety and the facility’s inability to ensure the provision of quality health care in a safe environment, when: Patient-to-Patient Assaults and Staff-Patient Assaults were not effectively reported, investigated, assessed and monitored to ensure patient safety; when Patient Rights for Informed Consent for administration of anti-psychotic medications were not completed; and, when Patient Grievances and Complaints were not responded to in time-dependent manner.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 40402 Based on observation, interviews and record reviews, the hospital failed to ensure a safe and appropriate Discharge Planning Process as evidenced by failure to: 1. Have in effect a Discharge Planning Process that focuses on the patient goals and treatment preferences (Cross Reference A-802; 2. Ensure an effective transition of the patient from the hospital to post-discharge care (Cross Reference 802); and, 3. Reduce the factors leading to a preventable hospital readmissions. (Cross Reference A-802) The cumulative effect of these systemic problems resulted in the inability of the hospital’s Discharge Planning process to safely discharge patients post-hospitalization.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 37427 Based on interview and record review, the facility failed to send written letters of grievance resolutions, according to the facility policy and procedure, to three patients: 1.) Patient I, one of 23 unsampled patients; 2.) Patient H, one of 23 unsampled patients; and, 3.) Patient 5, one of 12 sampled patients. This failure resulted in violation of patient rights and possible missed opportunities for improvement of patient care. Findings: 1. Patient I’s Face Sheet (demographic information), undated, indicated Patient I was admitted to the facility on 8/02/24, and was discharged from the facility on 8/04/24. During a review of the facility Grievance Log, it indicated the facility received a grievance from Patient I, dated 8/4/24, at 10:30 a.m. Patient I reported not getting the help needed to get around, sustaining a big bruise on the side of her leg from not getting help taking clothes off and taking a shower. During a review of the facility Grievance Log Follow-up form, dated 8/20/24 at 4 p.m., Patient I was contacted and reported the following: a. She had bruises from getting in and out of bed; b. She was told she would have 1:1 care; c. Her son talked to the doctor and was told Patient I was not med [medication] compliant and did not attend groups; and, d. Staff acted “snobby” as if they did not like their jobs. During an interview on 9/12/24 at 9:10 a.m. with Patient Ambassador (PA), the PA stated by the time she received Patient I’s grievance/complaint, Patient I had been discharged from the facility. The PA further stated she did not send a resolution letter to Patient I. During an interview on 9/12/24 at 10:34 a.m., with Risk Manager (RM), the RM stated she could provide no documentation of a follow-up resolution letter that addressed Patient I’s grievance, but the facility should have sent a letter with resolution to Patient I. During a review of the facility’s policy and procedure (P&P) titled, “Grievance and Complaints,” dated 5/26/22, the P&P indicated, “III. Definitions... Grievance: The written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights... Complaints that are not resolved prior to the patient’s discharge and all grievances will be acknowledged in writing... A resolution letter shall be sent within 30 calendar days and shall include: a. The name of the hospital contact person b. A description of the nature of the concern c. The actions taken to investigate the concern d. Results of actions taken e. Date of completion of the grievance process.” 49936 2. During a review of Patient H’s Facesheet (demographics), undated, the Facesheet indicated Patient H was admitted on 7/26/24, with admitting diagnosis of unspecified psychosis (a group of symptoms that causes a person to lose touch with reality, disrupting their thoughts and perceptions) and was discharged on 8/1/24. During a review of the Grievance Log entry for Patient H’s complaint, dated 8/1/24, the entry indicated Patient H submitted a written complaint alleging that Mental Health Technician (MHT), “[name] shaved my vagina in my sleep and injected me with something attached to syringe and needle and cut my hair and stuck something in my vagina.” The entry also indicated the complaint was resolved on 8/2/24. During a review of the Complaint / Grievance Summary, undated, the form indicated a follow-up call to Patient H was attempted on 8/6/24, but did not indicate a resolution letter was sent. During an interview on 9/12/24 at 3:25 p.m., with the Risk Manager (RM), the RM stated the facility was unable to find evidence that a resolution letter was sent after the grievance was resolved. During a review of the facility’s policy and procedure (P&P) titled, “Grievance and Complaints,” dated 5/26/22, the P&P indicated, “III. Definitions... Grievance: The written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights... Complaints that are not resolved prior to the patient’s discharge and all grievances will be acknowledged in writing... A resolution letter shall be sent within 30 calendar days and shall include: a. The name of the hospital contact person b. A description of the nature of the concern c. The actions taken to investigate the concern d. Results of actions taken e. Date of completion of the grievance process.” 34448 3. During a review of Patient 5’s Facesheet (demographics), [undated], the Facesheet indicated Patient 5 was admitted to the facility on 3/4/2024, and discharged on 3/11/2024. The Facesheet further indicated, Patient 5’s admitting diagnoses included major depressive disorder. In addition, the Facesheet indicated, Patient 5 had previously been admitted to the facility on, 11/3/2023 through 12/5/2023. During a review of Patient 5’s, “Psychiatric Progress Note,” dated 3/6/2024 at 8:24 a.m., the “Psychiatric Progress Note,” indicated Patient 5 reported she was raped during her last admission (11/30/2023 through 12/5/2023) and had not reported the incident when it happened. The progress note further indicated during the Psychiatrist’s assessment, “[Patient 5] saw the man who she says raped her... he just passed by.” During a review of Patient 5’s, “Interdisciplinary Progress Note (IDN),” dated 3/6/2024 at 12:14 p.m., completed by Licensed Clinical Social Worker (LCSW), the IDN indicated, “Pt (Patient 5) reported a sexual assault incident occurred last time she was admitted here.” The IDN indicated LCSW had notified the Department of Social Services and Risk Management (RM) of the incident. During an interview on 9/11/2024 at 2:20 p.m., with the RM, the RM stated a patient complaint that could be resolved during the hospitalization, such as lost personal belongings, would be considered a complaint. The further stated, “If we were unable to resolve the complaint, we would consider it a grievance... I think it’s our practice to follow up grievances with a letter.” The RM stated she was unable to find documented evidence that a grievance resolution letter had been sent to Patient 5 after discharge. During a review of the facility’s policy and procedure (P&P) titled, “GRIEVANCE AND COMPLAINTS,” dated 5/26/2022, the P&P indicated, “III. Definitions... Grievance: The written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights. Complaints that are not resolved prior to the patient’s discharge and all grievances will be acknowledged in writing. A resolution letter shall be sent within 30 calendar days and shall include: a. The name of the hospital contact person. b. A description of the nature of the concern. c. The actions taken to investigate the concern. d. Results of actions taken. e. Date of completion of the grievance process.””

“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: 49936 Based on interview and record review, the facility failed to ensure Informed Consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a medical treatment) regarding psychotropic medications (drugs that affect a person’s mental state) were obtained, per the facility’s policy and procedure, for four of 12 sampled patients (Patient 1, 6, 7, 8) and five of 25 unsampled patients (Patient A, B, C, D, E). 1. Sampled Patient 6 and Patient 7’s Informed Consent forms were incomplete. 2. Sampled Patient 1’s Informed Consent form was incomplete. 3. Unsampled Patient A, B, C, D, and E’s Informed Consent forms were incomplete. 4. Sampled Patient 8’s Informed Consent form was incomplete. These failures had the potential to violate patients’ rights to make informed decisions regarding their treatment based on a complete Informed Consent process. Findings: 1.a. During a review of the Patient 6’s Facesheet (demographics), undated, the Facesheet indicated Patient 6 was admitted on 8/30/24, with admitting diagnoses of major depressive disorder, and recurrent and severe psychotic symptoms. During a concurrent interview and record review on 9/10/24 at 2:28 p.m. with Nurse Manager EE, Patient 6’s Informed Consent form, dated 8/30/24, was reviewed. The psychotropic medication Informed Consent form for the administration of the following medications did not include a max (maximum) dosage and was not signed by a psychiatrist: Lithium, Seroquel, Klonopin. Nurse Manager EE stated all psychotropic medications needed to have a signed Informed Consent forms and max dosage for each psychotropic medication listed. Nurse Manager EE verified Patient 6’s Informed Consent form was not properly filled out. During an interview on 9/12/24 at 1:55 p.m., with the Psychiatrist, the Psychiatrist stated verbal and written Informed Consent forms needed to be completed before psychotropic medications were ordered and administered. During an interview on 9/12/24 at 2:13 p.m., with Psychiatrist BB, Psychiatrist BB stated Informed Consent forms for psychotropic medications should include the name of the medication, dosing, explanation of side effects, and signatures of patient and psychiatrist. During a review of Patient 6’s Medication Administration Record (MAR), dated 8/30/24 to 9/11/24, the MAR indicated Patient 6 was administered the first dose of the following medications on the corresponding dates: A. Clonazepam (Klonopin) on 8/30/24, for agitation; B. Lithium on 8/30/24, for mood; and, C. Quetiapine (Seroquel) 8/30/24, for psychosis (a group of symptoms that cause a person to lose touch with reality, disrupting their thoughts and perceptions). During a review of the facility’s policy and procedure (P&P) titled, “Consent for Medications, Treatments and Procedures,” dated 5/26/22, the P&P indicated, “The purpose of this policy is to provide a process for obtaining consent for patients in accordance with state law. [Name of facility] requires informed consent for psychotropic medication... the attending psychiatrist will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges ... This will be documented on the consent form prior to psychotropic meds being given.” 1.b. During a review of the Patient 7’s Facesheet (demographics), undated, the Facesheet indicated, Patient 7 was admitted on 9/3/24, with an admitting diagnosis of major depressive disorder and was discharged on 9/9/24. During a concurrent interview and record review on 9/10/24 at 2:28 p.m., with Nurse Manager EE, Patient 7’s Informed Consent form, dated 8/30/24, was reviewed. The psychotropic medication Informed Consent form for the administration of the following medications did not include a max dosage and was not signed by a psychiatrist: Lithium, Seroquel, Klonopin. Nurse Manager EE stated all psychotropic medications needed to have a signed Informed Consent form and max dosage for each psychotropic medication listed. Nurse Manager EE verified Patient 7’s Informed Consent form was not properly filled out. During an interview on 9/12/24 at 1:55 p.m., with the Psychiatrist, the Psychiatrist stated verbal and written Informed Consent forms needed to be completed before psychotropic medications were ordered and administered. During an interview on 9/12/24 at 2:13 p.m., with Psychiatrist BB, Psychiatrist BB stated Informed Consent forms for psychotropic medications should include the name of the medication, dosing, explanation of side effects, and signatures of patient and psychiatrist. During a review of Patient 7’s Medication Administration Record (MAR), dated 9/3/24 to 9/9/24, the MAR indicated Patient 7 was administered the first dose of the following medications on the corresponding dates: A. Aripiprazole on 9/3/24, for, “major depressive disorder, single episode, unspecified;” B. Benztropine on 9/3/24, for EPS (group of side effects that can result from taking antipsychotic drugs); C. Duloxetine on 9/3/24, for, “major depressive disorder, single episode, unspecified;” D. Gabapentin on 9/3/24, for Anxiety; E. Trazodone on 9/5/24, for insomnia; and, F. Hydroxyzine on 9/8/24, for mild anxiety. During a review of the facility’s policy and procedure (P&P) titled, “Consent for Medications, Treatments and Procedures,” dated 5/26/22, the P&P indicated, “The purpose of this policy is to provide a process for obtaining consent for patients in accordance with state law. [Name of facility] requires informed consent for psychotropic medication... the attending psychiatrist will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges ... This will be documented on the consent form prior to psychotropic meds being given.” 35030 2. During a review of Patient 1’s clinical record, indicated Patient 1 was admitted on 9/4/2024, for a diagnosis of Psychosis (a mental disorder that causes people lose contact with reality). During a review of Patient 1’s, “Informed Consent for the Administration of Psychotropic Medications,” dated, 9/4, indicated, “ ... 2. My physician is proposing the following medications (Medication Name, Max dose): Depakote (for the treatment of bipolar); Haldol (for severe aggression); and, Lithium (for the treatment of bipolar).” The psychiatrist signature was left blank, and there was no max dose documented. During an interview on 9/10/2024, at 2:35 PM with Psychiatrist CC, Psychiatrist CC stated she did not sign the Informed Consent for psychotropic medication for Patient 1. Psychiatrist CC further stated she had a face-to-face conversation with Patient 1 and received a verbal consent but did not document it in the clinical record. Psychiatrist CC stated she was not aware she had to complete the max dose on the Informed Consent. During a review of the facility’s policy and procedure titled, “Consent for Medications, Treatments and Procedures, dated, 5/26/2022, indicated, “ ... II Procedure: 1. Medication: a. The attending psychiatrist will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges. The consent procedure may be done in person with the patient or by a 3-way phone conversation between the patient, physician and nurse and parents/legal guardian for patients under 18 years of age ... This will be documented on the consent form prior to psychotropic meds being given.” 37427 3. Unsampled Patients A, B, C, D, E did not have completed Informed Consent forms in their medical records. During a review of Patient A’s Face Sheet, undated, it indicated Patient A was admitted on 9/04/24, with an admitting diagnosis of unspecified psychosis (a group of symptoms that cause a person to lose touch with reality and have difficulty distinguishing what is real and what is not). During a review of Patient A’s Medication Administration Record (MAR), the MAR indicated Patient A was administered the following medications: 1. Olanzapine DT tab, 5 mg (medication to prevent psychosis or antipsychotic) During a record review of Patient A’s medical record, there was no Informed Consent form located in Patient 5’s medical record. During a review of Patient B’s Face Sheet, undated, it indicated Patient B was admitted on 8/23/24, with an admitting diagnosis of major depressive disorder. During a review of Patient B’s MAR indicated Patient B was administered the following medications: 1. Fluoxetine capsule 80 mg (anti-depressive medication), on 8/29/24, and daily thereafter through 9/10/24; and, 2. Trazadone tablet 50 mg (anti-insomnia), on 8/26/24, and daily thereafter through 9/9/24. During a record review of Patient B’s medical record, Patient B’s Informed Consent form was not signed by the prescribing MD nor was the medication strength and dosage written on the form. During a review of Patient C’s Face Sheet, undated, it indicated Patient C was admitted on 8/23/24, with an admitting diagnosis of major depressive disorder. During a review of Patient C’s MAR, it indicated Patient C was administered the following medications: 1. Divalproex sodium ERT ER 500 mg (mood stabilizer), twice a day on 8/23/24, and twice daily thereafter through 9/10/24; 2. Trazadone tablet 50 mg, at bedtime (for insomnia) daily on 8/25/24, and daily thereafter through 9/5/24; and, 3. Hydroxyzine pamaote 50 mg (for anxiety) every six hours as needed for mild anxiety, on 8/26/24, 9/2/24, and 9/5/24. During a record review of Patient C’s medical record, Patient C’s Informed Consent form was not signed by the prescribing MD, nor was the medication strength and dosage written on the form. During a review of Patient D’s Face Sheet, undated, it indicated Patient D was admitted on 8/13/24, with an admitting diagnosis of unspecified psychosis. During a review of Patient D’s MAR, it indicated Patient D was administered the following medications: 1. Risperdone tablet 1 mg (for mood) twice a day, daily on 8/14/24 and 8/15/24; 2. Lorazepam tablet 2 mg (as needed for emergent [symptoms]), on 8/15/24; 3. Haloperidol solution 5 mg (for emergent [symptoms]), on 8/15/24; 4. Ativan solution 2 mg (for emergency [symptoms]), on 8/15/24; and, 5. Risperdone tablet 2 mg (for mood), twice a day, on 8/16/24, and twice daily thereafter through 8/20/24. During a record review of Patient D’s medical record, Patient D’s Informed Consent form was not signed by the prescribing MD, nor was the medication strength and dosage written on the form. During a review of Patient E’s Face Sheet, undated, it indicated Patient E was admitted on 9/09/24, with an admitting diagnosis of unspecified psychosis. During a review of Patient E’s MAR, it indicated Patient E was prescribed the following medications: 1. Haloperidol tablet 5 mg (as needed for severe aggression), start on 9/9/24, end on 10/8/24; 2. Hydroxyzine pamoate 50 mg (as needed for mild anxiety), start on 9/9/24, end on 10/8/24; and, 3. Trazadone tablet 50 mg (as needed for insomnia), start on 9/9/24, end on 10/8/24. During a record review of Patient E’s medical record, there was no Informed Consent form located in Patient E’s medical record. During an interview on 9/12/24 at 2:45 p.m. with the Nurse Educator (NE), the NE acknowledged the missing documents and appropriate signatures. The NE stated Informed Consents for psychotropic medications should be signed by the patient or Responsible Party, the nurse and the MD who prescribed the medication, and the medication strength and dosage should be noted on the form as well. During an interview on 9/12/24 at 3 p.m., with the Chief Nursing Officer (CNO), the CNO stated Informed Consent forms should be completed for each patient with medication strength, dosage and signatures by patient/Responsible Party, nurse and MD prescriber. During a review of the facility’s policy and procedure (P&P) titled, “Consent for Medications, Treatments and Procedures,” dated 5/26/2022, the P&P indicated, “The purpose of this policy is to provide a process for obtaining consent for patients in accordance with state law. [Name of facility] requires informed consent for psychotropic medication... the attending physician will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges...” 34448 4. During a review of Patient 8’s Facesheet (demographics), [undated], the Facesheet indicated Patient 8 was admitted to the facility on 8/6/2024. Patient 8’s admitting diagnosis was unspecified psychosis (a loss of grasp on reality). During a review of Patient 8’s, “Physician Medication Orders,” dated 8/6/2024 through 9/10/2024, the, “Physician Medication Orders,” indicated on 8/21/2024, Patient 8 was prescribed Risperdal (antipsychotic medication), 1 milligram (mg) by mouth daily, by Psychiatrist CC. In addition, the physician medication orders indicated the indication for Risperdal was, “psychosis.” During a review of Patient 8’s, “INFORMED CONSENT FORM FOR THE ADMINISTRATION OF PSYCHOTROPIC MEDICATION (S),” dated 8/21/2024, the Informed Consent form indicated, “2. My physician is proposing the following medications (Medication Name, Maximum dose): Risperdal.” Review of the Informed Consent form indicated, the medication Risperdal was handwritten in the designated space without a maximum dose. Review of the Informed Consent form indicated, “We discussed how the proposed medication(s) may be helpful in my treatment...We talked about the possible risks and benefits of my medication(s)... black box warnings... common side effects.” Further review of the Informed Consent form indicated the space at the bottom of the Informed Consent, where the Psychiatrist was to sign, date, and time the document, was left blank. During an interview on 9/10/2024 at 9:30 a.m., with Nurse Manager EE (NM EE), for Units 400 and 500, NM EE stated the Psychiatrist was supposed to sign the Informed Consent forms. During a concurrent interview and record review on 9/12/2024 at 9:40 a.m., with Pharmacist DD, Patient 8’s, “Medication Administration Record (MAR),” dated, 8/21/2024 through 9/12/2024, was reviewed. Pharmacist DD stated on 8/21/2024, Patient 8 was administered Risperdal 1 mg daily. On 8/24/2024, the Risperdal was increased, and Patient 8 was administered 2 mg. Pharmacist DD further stated on 8/26/2024, the Risperdal dosage was increased, and Patient 8 was administered 3 mg twice a day, which was the current dose Patient 8 was receiving. In addition, Pharmacist DD stated the maximum dosing range for Risperdal was up to 16 mg/day. During an interview on 9/12/2024 at 1:40 p.m., with Psychiatrist CC, Psychiatrist CC stated she would stop by Health Information Management and sign the Informed Consent forms after the patients were discharged. Psychiatrist CC stated, “The Informed Consent forms should be signed before starting treatment.” During a review of the facility’s policy and procedure (P&P) titled, “Consent for Medications, Treatments and Procedures,” dated 5/26/2022, the P&P indicated, “The purpose of this policy is to provide a process for obtaining consent for patients in accordance with state law. [Name of facility] requires informed consent for psychotropic medication... the attending physician will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges.””

“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: 38088 Based on observation, interview and record review, the facility failed to ensure three sampled patients (Sampled Patient 2, Sampled Patient 5, Sampled Patient 9), and 11 Unsampled Patients (Unsampled Patient R, Unsampled Patient AA, Unsampled Patient Q, Unsampled Patient N, Unsampled Patient O, Unsampled Patient P, Unsampled Patient G, Unsampled Patient T, Unsampled Patient U, Unsampled Patient V, Unsampled Patient H) received the right to be free from all forms of abuse, when: 1. Two Sampled Patients (Sampled Patient 5 and Sampled Patient 9) and three Unsampled Patients (Unsampled Patient O, Unsampled Patient R, Unsampled Patient T) were slapped, punched and had their heads slammed on a table on 2/24/24, 3/31/24, 4/5/24, 7/11/24. 2. Three Sampled Patients (Sampled Patient 2, Sampled Patient 5 and Sampled Patient 9), and 11 Unsampled Patients (Unsampled Patient R, Unsampled Patient AA, Unsampled Patient Q, Unsampled Patient N, Unsampled Patient O, Unsampled Patient P, Unsampled Patient T, Unsampled Patient U, Unsampled Patient V, Unsampled Patient G, and Unsampled Patient H), who lodged allegations of sexual and physical abuse, which were not thoroughly investigated, documented or reported to the California Department of Public Health within 24 hours. These incidents resulted in patients experiencing split lips, headaches, dizziness, pain, fear, and anger and had the potential to contribute to longer hospitalizations due to depression, increased assaultive behaviors, re-hospitalization, lack of trust, and the potential for additional psycho-social harm and suicide. Findings: 1. During a concurrent interview and video record review, on 9/11/24, at 1:15 p.m., with the Performance Improvement Analyst (PIA), the video indicated an assaultive incident on 3/31/24, at 3:55 p.m., in Unit 100 Day Room. The video indicated 12 adolescent patients were seated at tables and chairs. The video indicated at 3:55 p.m., a Mental Health Technician walked out of the room. The video indicated at 3:56 p.m., Unsampled Patient P walked to Unsampled Patient O, who was sitting at the table. The video indicated Unsampled Patient P punched Unsampled Patient O two times, from behind, with right- and left-handed closed fists. The video indicated Unsampled Patient O was punched on both sides of her head, ears and face. The video indicated Unsampled Patient O held her head, did not move, and sobbed. The PIA stated, “It looked like [Unsampled Patient O] was in shock. This was a significant event considering her vulnerable state.” She stated Unsampled Patient O looked, “Distraught,” and, “[Unsampled Patient P] looked menacing.” The video indicated staff entered the Day Room and removed Unsampled Patient P. The video indicated an observation of one staff who recreated the incident by demonstrating how Unsampled Patient P punched Unsampled Patient O with both closed fists. The video indicated an observation Patient O was sobbing uncontrollably, her shoulders were shaking, her face appeared with her mouth open, sobbing and crying with an expression of fear (Open mouth, with the lips tight, the mouth flattens into a sideways oval. The corners of the mouth pull back and the lips might cover the front teeth. A quivering mouth). During a concurrent interview with the PIA, and video record review, on 9/11/24, at 1:40 p.m., a video indicated Unit 500 Hallway on 7/10/24 at 7:39 a.m. The video indicated a Mental Health Technician seated on the left side of the hallway across from Unsampled Patient N’s doorway. The video indicated a second Mental Health Technician standing outside Unsampled Patient N’s doorway. The video indicated the positions of the Mental Health Technicians directly across from one another, reduced the walkway access distance of the hallway. The video indicated Sampled Patient 9, seated directly under the telephone, located three doors away from Unsampled Patient N’s doorway. The video indicated on 7/10/24 at 7:39 a.m., Unsampled Patient N was in the doorway of his room. At the same time, the seated Mental Health Technician on the left side of the hallway, was talking to a third patient, and the walkway past Unsampled Patient N’s doorway was constricted by three people, directly across from one another. The video indicated at 7:39.38 a.m., Unsampled Patient N walked out of his room into the hallway, when Sampled Patient 9 stood up and walked down the hallway, in an attempt to walk past the two Mental Health Technicians and Unsampled Patient N. The video indicated Sampled Patient 9 was forced to walk past Unsampled Patient N, within striking range, because of the placement of the two Mental Health Technicians on both sides of the hallway. The video indicated Unsampled Patient N walking towards Sampled Patient 9, and threw two punches with his right and left closed fists, to the right side of Sampled Patient 9’s face. The PIA stated no actions were noted to be taken until after Unsampled Patient N had thrown his first punch and made contact with Sampled Patient 9’s face. The video indicated at 7:40.58 a.m., the Mental Health Technician, behind Unsampled Patient N, had pulled him back into his room. The video indicated Sampled Patient 9 appeared upset and agitated, he checked his face and mouth with his fingers. The PIA stated, “He looked upset like he was checking for blood or an injury and ran back to his room.” She stated Unsampled Patient N had a reputation for assaultive and dangerous actions. She stated, “If I was a patient I would stay away from him.” During a concurrent interview, video record review, and record review on 9/11/24, at 1:50 p.m., with the PIA, the video indicated Unit 300’s Day Room on 2/24/24 at 11:09.32 a.m. The video showed only Unsampled Patient T’s legs, Unsampled Patient U and Unsampled Patient V, in the upper right side of the video. The video was not able to indicate the entire Unit 300 Day Room, which resulted in an observation of all the Unsampled Patients from the waist down only. The PIA stated the camera did not provide observation of the entire Day Room. She stated the video had been reviewed by Administration and had not been re-adjusted to provide a view of the entire room. A review of a document titled “CAMERA REVIEW of EVENTS - IR PE-24-53590,” indicated Unsampled Patient U wore, “plaid paints in wheelchair / knee brace.” Unsampled Patient V wore, “red shirt, gray pants, dark purple hair.” The PIA reviewed the video and stated, “You can see [Unsampled Patient U] get up and walk to where [Unsampled Patient T] was seated in the corner.” The video indicated on 2/24/24, at 11:09.32 a.m., Unsampled Patient V’s legs, seated in a wheelchair, wearing a leg brace. At 11:09.55 a.m., the video showed Unsampled Patient V stand up and walk in the direction of Unsampled Patient T, where she lunged in the direction of Unsampled Patient T. The video captured a disturbance occurred. The PIA stated, “There appears to be more than one assault occurring, but you can’t clearly see the actions as the bodies aren’t visible on video.” The video indicated at 11:10.29 a.m., seven facility staff members entered the Day Room, 34 seconds after the start of the assaultive incident. The PIA stated she remembered this incident, and there were three patients involved in the assault of Unsampled Patient T. She stated, “I spoke with her mother, and she was very upset and wanted [Unsampled Patient T] discharged.” The PIA stated Unsampled Patient T’s mother had, “Heard from her daughter that she was assaulted.” The PIA stated she did not know what the Policy and Procedure for reporting to parents, guardians, or the California Department of Public Health were. During an interview and concurrent record review with the RM on 9/12/24 at 2:15 p.m., she stated the facility investigation into the Facility-Reported Incident for Unsampled Patient Q’s allegations of being touched on her breasts by Unsampled Patient R, that occurred on 4/5/24 and 4/7/24, indicated the facility had concluded the allegation of inappropriate touching by Unsampled Patient R to Unsampled Patient Q, had not occurred. During the concurrent interview and medical record review with the RM, on 9/12/24, at 2:30 p.m., Unsampled Patient’s R medical record was reviewed, and she stated it indicated an additional witnessed patient-to-patient assault incident between Unsampled Patient AA and Unsampled Patient R, on 4/4/24, that resulted in Unsampled Patient R getting a bloody lip. The RM stated both incidents were not on the facility Occurrence List. She stated both of the incidents were not documented in the facility risk system titled, “Risk Connect,” (An email reporting system used by staff to report actual observations or allegations of abuse to the Risk Department). She stated there was no document found in the facility risk management system of how the assault on Unsampled Patient R on 4/5/24, was investigated or resolved. The RM stated there was no documentation that indicated this incident was reported to the facility risk management, or reported in the morning flash meeting, and she stated she could not find documentation that indicated he was assessed by nursing or the physician. She stated the current system was not effective at documenting, tracking or following-up with abuse allegations. She stated the facility should have filed reports to Children Protective Services and self-reported to California Department of Public Health. The RM stated she did not know what the definition of harm was, but stated the facility did not consider an assault, that did not require a trip to the Emergency Room, rising to the level of being reported to the California Department of Public Health. During the concurrent interview and medical record review with the RM, on 9/12/24, at 2:30 p.m., Unsampled Patient AA’s medical record was reviewed, and it indicated on a document titled, “General Progress Notes,” dated 4/5/24 at 4 p.m., “Patient was doing a group therapy in the day room when all of a sudden he punched one of the patient on the face and his lip was bleeding.” The RM stated there was no documentation of the incident in Unsampled Patient R’s medical record about being punched by Unsampled Patient AA on 4/4/24. She stated there was no documentation in the Unusual Reporting tool titled, “Risk Aware.” She stated she was unable to find any documentation this incident was investigated, and it was not reported to the California Department of Public Health or Child Protective Services. She stated there was no investigation file in the Risk Department files. She stated, “We only send reports for a patient injury level that get sent out to the Emergency Room for assessment.” She stated, “Only if an injury is sustained by a patient, like bloody nose, do we report it as an Unusual Occurrence.” She stated she did not know what the Center for Medicare Services’ (CMS) definition of harm or injury was. She stated Unsampled Patient R did have a bloody lip, and it should have been reported. A review of an investigation document for Unsampled Patient O, titled “California Healthcare Event and Reporting Tool,” indicated “Date of Incident: 3/31/24.....Reported Date: 4/4/2024.” The incident was not reported to the California Department of public health until four days after the incident occurred. A review of the facility document titled, “Occurrence Report Summary,” indicated “DATE OF INCIDENT: 3/31/24.....DATE Received: 4/1/24.....Summary of Event: Unsampled Patient P approached Unsampled Patient O from behind in the 100 Day Room and pushed her head against the table two times and then hits her two times as staff run over and intervene. Outcome: RN Assessment Data: Pt was hit on her head by another pt in an unprovoked attack. She was complaining of headache, dizziness & left arm pain.” A review of a document for Unsampled Patient O, titled, “FACESHEET,” indicated she was a 17 year-old female, admitted 3/27/24, discharged 4/1/24, with admitting diagnoses that included Major Depressive Disorder (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), recurrent severe without psychotic features, Suicidal Ideation’s, and Anxiety Disorder. A review of a document for Unsampled Patient O titled, “Psychiatric Progress Notes,” dated 3/31/24, indicated, “This afternoon, patient was struck unprovoked by peer. ...She was complaining of headache, dizziness & left arm pain. Medical Hospitalist notified and recommend transfer to ER for evaluation.” A review of a document for Unsampled Patient O, titled, “Psychiatric Progress Note,” dated 4/1/24, indicated, “Patient seen on rounds today and discussed with staff. Yesterday patient attacked peer unprovoked, including striking her head on the table in the dayroom.” A review of a document for Unsampled Patient O, titled, “Psychiatric Progress Note,” dated 4/2/24, indicated, “The patient is unable to care for physical or psychiatric needs. The patient is at risk for decompensation and readmission to the hospital ... Patient recently attacked peer unprovoked. “ A review of a document for Unsampled Patient O, titled, “General Progress Note,” dated 4/1/24, indicated, “Pt was hit on her head by another pt in an unprovoked attack. She was complaining of headache, dizziness & left arm pain.” A review of a document for Unsampled Patient P, titled, “Nursing Progress Notes,” dated 4/1/24, indicated, “Patient stated that she is having flashbacks to the assault on 3/31/24, when she closes her eyes. Patient stated that she still has a headache and that her body is sore.” A review of a document for Sampled Patient 9, titled, “Face Sheet,” indicated he was a 51 year-old male admitted 6/28/24, and discharged 7/18/24, with diagnoses that included Unspecified Psychosis (A severe mental condition in which thought and emotions are so affected that contact is lost with external reality), Suicidal Ideation’s, and Homelessness. A review of a facility investigation document for Sampled Patient 9, titled, “Occurrence Report Summary,” indicated, “DATE OF INCIDENT: 7/10/24, DATE RECEIVED 7/11/24, Summary of Event: Unsampled Patient N punched Sampled Patient 9 in face both sides approximately 4 times unprovoked in hallway.....Investigation: ...The hallway monitor, MHT, is seated across the hall from Unsampled Patient N’s room and the chair blocked part of the hallway forcing patients to walk closer to Unsampled Patient N’s door on their way to the day room. The 1:1 staff member was standing next to Unsampled Patient N in the hall when the peer, Sampled Patient 9, entered Unsampled Patient N’s strike zone.” A review of a document titled, “California Healthcare Event and Reporting Tool,” indicated “Date of Incident: 7/10/24, Time of Incident 7:44 AM....Reported Date: 7/11/24 Time of Incident 5:43 PM. (34 hours after the video taped assault on Sampled Patient 9). A review of a document for Sampled Patient 9 titled, “General Progress Note,” dated 7/10/24, indicated, “Patient was assaulted by peer....Tylenol administered for pain. Transferred to Unit 400 for safety.” A review of a document for Sampled Patient 9 titled, “Nursing Progress Note,” dated 7/11/24, indicated, “Pt reports he is still having some pain in his jaw after a peer assaulted him earlier in the day. Pt taking (medication) for pain.” A review of a document for Sampled Patient 9 titled, “General Progress Note,” dated 7/10/24, indicated, “Patient was assaulted by peer.” A review of a document for Sampled Patient 9 titled, “Interdisciplinary Progress Note,” dated 7/10/24, indicated, “Met with patient to follow up on patient’s request to press charges on another patient who assaulted him....Patient reported being ‘okay’ following the attack but complained of pain to his jaw. Nursing confirmed that patient would be receiving an x-ray on his jaw.” A review of a document for Unsampled Patient N titled, “Face Sheet,” indicated he was a 26 year-old male admitted 8/12/22, and discharged 8/26/24, with diagnoses that included Unspecified psychosis (Delusions that cannot be clearly determined or characterized) and Schizophrenia (A serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality). A review of a document for Unsampled Patient N, titled, “General Progress Note,” dated 7/10/24, indicated, “Patient came out of his room and punched a peer in the face four times that was walking by.....A manual hold was initiated to bring the patient to a quiet room, was administered Ativan, and was placed in seclusion.” A review of a facility document titled, “CAMERA REVIEW of EVENTS - IR PE-24-53590,” dated 3/14/24, indicated, “Date of event: 2/24/24, Time of event: 11:15:40.....Nature of event: Assaultive Episode, Manual Hold, Seclusion.” The document did not indicate if the incident was escalated, reported in Flash or Closed. A review of a investigation document for Unsampled Patient T, of an online Self-Reported Adverse Event Document, indicated the facility reported this assaultive event occurred on 2/24/24, and reported it to the California Department of Public Health on 2/29/24. The document indicated, “14-year-old female patient approached 17-year-old female peer and started to punch her. She was struck several times as staff intervened. Patient examined by Hospitalist for soft tissue injury, recommended oral analgesic and ice applied to site.” A review of a document for Unsampled Patient T, titled, “Facesheet,” indicated, “Admit date 2/23/24.....Discharge Date 2/24/24.” Unsampled Patient T was admitted with diagnoses that included Major Depressive Disorder.” Unsampled Patient T was admitted from an acute care hospital after a suicide attempt that included slicing her arms from her wrist to her elbow. A review of a document for Unsampled Patient T, titled General Progress Note,” dated 3/14/24, indicated, “Late Entry: Patient assaulted by several peers in the day room on the morning of 2/25/24. Patient reports she was feeling frustrated by the antagonistic activity and jeering by several peers. Patient reports she was making efforts to Ignore. Per patient, one of the peers walked over and stood beside the patient and started to bang the wall right next to the patient’s head. Patient reported that she was unable to, ‘take it anymore’ and yelled for them to stop. Peers began punching the patient......Hospitalist conducted a thorough neuro and physical examination, concluding that patient sustained minor soft tissue bruising behind her right ear.” A review of a document for Unsampled Patient T, titled. “Medical Consult,” dated 2/24/24, indicated, “Subjective: Patient complains of pain in back of head following being struck on back of head numerous times with fists by another patient. She was also stuck a few times in the face and had her hair pulled. This happened earlier this morning. Her only current complaint is about the pain in the back of her head on the right. Objective Head: There is mild skin redness behind the right ear and tenderness of the right mastoid (Behind the ear) process. Assessment: Soft tissue injury s/p (Status post) assault.” A review of a document for Unsampled Patient T, titled, “Discharge Summary,” dated 2/25/24, indicated, “Patient was attacked by other patients on the unit leading to patient’s mother wanting to remove her from the hospital AMA (Against Medical Advice.).” A review of a document for Unsampled Patient V, titled, “Facesheet,” indicated she was admitted 2/23/24 and discharged 3/1/24. Unsampled Patient V was admitted with diagnoses that included Major Depressive Disorder, Suicidal Ideation’s. A review of a document for Unsampled Patient V, titled, “General Progress Note,” dated 2/24/24, indicated, “Pt observed by staff threatening a peer and making statements such as, ‘I better not catch you slipping.’ Pt began to punch that peer multiple times in the head. Pt was escorted to the quiet room and placed in a manual hold at 1115 (11:15 a.m.). Pt placed in seclusion at 1117 (11:17 a.m.). Pt began punching the walls in the quiet room and making holes in the wall. Pt continued to have aggressive and assaultive behavior in seclusion. Emergent meds given ...” During a record review of Unsampled Patient Q’s medical record, a document titled, “Face Sheet,” indicated she had been admitted on 3/30/24, and discharged 4/10/24. It indicated she was a 14 year-old female, with diagnoses that included Major Depressive Disorder and Suicidal Ideation’s. A document titled, “General Progress Note,” dated 4/4/24, indicated, “Around 7:24 p.m., patient was attacked by another peer on the unit. No injuries noted to patient....She reported she was feeling very anxious and unsafe due to being on the same unit as the peer that attacked her. She also felt that there was so much chaos which was making her anxiety worse.” A document titled, “Nursing Shift Risk Assessment,” dated 4/5/24, indicated, “Patient reported having thoughts of wanting to harm self-due to feeling unsafe on unit.” During a record review of Unsampled R’s medical record, a document titled, “Face Sheet,” indicated he had been admitted on 2/12/24, and discharged 4/9/24. It indicated he was a 14 year-old male who had diagnoses that included bipolar disorder (A mental condition marked by alternating period of elation and depression) and Autistic Disorder (A developmental disorder that included characteristics of impaired development in social interaction communication, and behavior). Review of a document for Unsampled Patient R, titled, “General Progress Note,” dated 4/5/24 at 5:03 p.m., indicated, “Patient is in a group therapy doing some slimy thing when all of a sudden patient was punch [sic] in the face by another patient in front of him, both immediately got separated. No manual taken place. Patient calms down and was redirectable. Tried to contact his social worker (sic) but no answer VM (Voicemail) was left and a call back number.” A review of Unsampled R’s document titled, “General Progress Note,” dated 4/6/24 indicated, “Patient is in a group therapy doing some slimy thing when all of a sudden patient was punch [sic] in the face by another patient in front of him, both immediately got separated, no manual taken. Patient calms down and was redirectable. Tried to contact his social worker but no answer VM (Voicemail) was left and a call back number.....Was Parent / Guardian notified? Yes Date / Time of notification: 4/5/24 at 5 p.m.” RM reviewed the medical record for Unsampled Patient AA and stated a document titled, “General Progress Notes,” dated 4/5/24, indicated, “Patient (Unsampled Patient AA) was doing a group therapy in the day room when all of a sudden he punch [sic] one of the patient (Unsampled Patient R) on the face and his lip was bleeding.” During a record review of Unsampled Patient AA’s medical record, a document titled, “Face Sheet,” indicated he had been admitted on 3/26/24, and discharged 4/13/24. Patient AA had diagnoses that included Psychosis and Schizophrenia. A document titled, “Psychiatric Progress Note,” dated 4/7/24, indicated, “The patient reports he had an incident one day ago with a peer where he has been getting agitated with a peer and asked him to stop but he wouldn’t listen, so he proceeded to punch him in the face and pushed him afar from him.” 2. During an interview on 9/10/24 at 9:15 a.m., the DSS stated she, “Guessed that she was the abuse coordinator for the facility.” She stated her role as DSS was to oversee abuse training, and abuse workshops for reporting, for all facility staff. She stated all the incident reports were review by the RM, and she reported to Child Protective Services and Adult Protective Services. She stated staff should report abuse to the Supervisor who should then contact the Administrator on call. She stated the facility would never call the police unless the resident asked them to call the police. She stated Abuse Education was provided in computer classes, and the Mandated Reporter’s responsibilities were covered. She stated, “I am the abuse coordinator and work with other departments to ensure we are meeting the expectations of regulatory standards.” She stated abuse allegations or reports should be reported to Adult Protective Services and Children Protected Services in 24 hours or no later than 36 hours. She stated it was the RM’s role to make the reporting decision. She stated, for state of California, all suspected cases of abuse and / or neglect should be reported as soon as possible with a follow-up letter sent to California Department of Public Health. During an interview on 9/10/24 at 10:45 a.m., CNO and CEO stated the DSS was the Abuse Coordinator for the facility and responsible to understand the Mandated Reporting and training requirements for the facility. The CNO stated the DSS was responsible for reporting abuse incidents to Adult Protective Services or Children Protective Services, and the RM’s team was responsible for regulatory requirements to report to California Department of Public Health. The CEO stated the RM and DSS were required to report directly to her. The CNO stated the facility provided monitoring for Abuse Prevention and Reporting by providing oversight for all the abuse and incident reports. She stated she had re-written the Abuse Policy and Procedure for the facility. She was asked to provide the resources for the Abuse Policy and Procedure and stated she had reviewed all the regulatory requirements but could not find language about abuse reporting requirements to the California Department of Public Health and timelines for reporting. The CNO stated the process for staff, when an observation of abuse or allegation of abuse occurred, was to have staff stay with the victim while another staff called the House Supervisor, who called the Nurse Manager. She stated, if it was an allegation of staff-to-patient abuse, the Supervisor was to suspend the employee until investigation was completed. If the allegation was a patient-to-patient abuse, the Supervisor was to place one of the patients on 1:1 [supervision], and the Supervisor was to document the details in the Facility Risk Connect reporting system. The CNO stated the investigation was to start with the accusation. She stated if it was discovered overnight, the staff were to keep the patients safe, but begin to interview witnesses. The CNO stated the investigation began when a report was populated in the facility reporting system. The CNO stated the Nurse was to interview the victim and document in the Progress Notes, and they were required to enter the information into the incident reporting system by the end of their shift. She stated the police were to be called right away if it was an accusation of sexual assault. She stated the DSS and RM were the ones who determined the competencies for the Abuse Prevention Reporting program for the facility. She stated the DSS and RM’s role had changed recently, and they had not done a good job preparing them. She stated the expectation for the Abuse Program was not well understood for the DSS. The CEO stated, “We need to do more.” The CNO stated the DSS was to be the coordinator for the training and not doing any investigations. She stated there was no job description for Abuse Coordinator. The CNO stated the Abuse information and data was reported to the Governing Body, and the last meeting was in May or June. During an interview on 9/10/24 at 2:15 p.m., the RM stated she could not get the investigation packets for the Facility-Reported Incidents (FRI CA00893755, CA00887769, CA00909325, CA00893250) because the previous Risk Manager had a different process, and she could not find the documentation. She stated she had only recently functioned in the Risk Manager Role. She stated there was no facility abuse investigation packet for the incident that occurred on 2/24/24, that involved Unsampled Patient T’s allegation of being assaulted by Unsampled Patient U. She stated there was no documentation of what the facility had done as a result of the assaultive incident, if it was substantiated, what was done by the facility to ensure it never happened again. During an interview on 9/11/24 at 8:45 a.m., with Nurse Manager FF, he stated, if staff witnessed or heard about abuse, they reported it to the RM and documented in the online risk reporting program. He stated Nurses were supposed to interview the patients and report that information to the RM. He stated, if a patient expressed a complaint or grievance, the Patient Ambassador would come and start the grievance process. During an interview with the RM and CNO on 9/11/23, at 2:31 p.m., a request was made for all facility Policies and Procedures for Abuse investigations (How the facility protected patients during an abuse investigation, how the facility substantiated or not, abuse allegations, how the facility proceeded, once an abuse allegation was substantiated, how the facility ensured it complied with Federal, State and local laws for its Abuse Program, how the facility ensured its abuse prevention and reporting process was effective, and for any evidence that all allegations of abuse were thoroughly investigated). The CNO stated the only Abuse Policy and Procedure they had did not include all of this requested information. She stated she was unsure what the Federal and State requirements were for reporting abuse allegations. During a record review and interview on 9/12/24 at 12:20 p.m., RN BBB stated, during a review of Sampled Patient 9 and Unsampled Patient N’s medical records, indicated, “The Safety of victim was not provided when Unsampled Patient N struck Sampled Patient 9.” During a concurrent interview and medical record review with the RM, on 9/12/24 at 2:05 p.m., she stated Unsampled Patient Q’s medical record indicated documentation that mentioned Unsampled Patient Q had informed the Patient Ambassador of a patient-to-patient incident on 4/6/24. Unsampled Patient Q stated Unsampled Patient R had, “Touched her boobs,” on 4/5/24, during an activity in the gymnasium. The RM stated the medical record indicated the Patient Ambassador provided Unsampled Patient Q with a Grievance Form to fill and submit. The RM stated the Mental Health Technician, assigned to the gym on the date of the patient-to-patient incident, were interviewed, and they all stated they did not witness the incident on 4/5/24, between Unsampled patient Q and Unsampled Patient R. During an interview and concurrent record review with the RM on 9/12/24 at 2:15 p.m., the RM stated the facility reported an incident that involved Unsampled Patient R allegedly touching the breasts of Unsampled Patient Q on 4/5/24. She stated the facility had reported it to the California Department of Public Health on 4/8/24. She stated a facility document, titled, “Occurrence Report Summary,” indicated, “DATE OF INCIDENT: 4/5/24 & 4/7/24 DATE RECEIVED: 4/8/24.....Summary of Event: Unsampled Patient Q accused Unsampled Patient R of touching her breasts in the gym on 4/5/24, buttocks in the gym on 4/7/24.” She stated the document indicated the event was unwitnessed and investigated, but there was no indication if the facility determined whether the allegation was substantiated or not. During further concurrent interview and medical record review with the RM, on 9/12/24 at 2:30 p.m., the RM stated the patient-to-patient incident documentation indicated a Patient Ambassador spoke with Unsampled Resident Q on 4/8/24, at 11:30 a.m., to provide a patient grievance follow-up. The RM stated the incident documentation indicated during that follow-up, Unsampled Resident Q stated on 4/7/24, at 4 p.m., another incident of patient-to-patient touching of Unsampled Patient Q’s buttocks by Unsampled Patient R, in the Gymnasium. Review of the Unusual Occurrence Report indicated Mental Health Technicians were interviewed and indicated they did not witness any sexually acting out behavior by Unsampled Patient R. The documentation indicated that Unsampled Patient R was interviewed by two providers, who stated Unsampled Patient R had denied any allegations for the incidents on 4/7/24 and 4/8/24. During the concurrent interview and medical record review with the RM, on 9/12/24, at 2:30 p.m., “No documentation of what happened with the grievance,” was documented in the reporting system titled, “Risk Aware (The facility’s online Unusual Occurrence reporting system that was utilized to report all reports of abuse).” She stated she understood, “the only incidents that needed to be reported to an outside agency was if an occurrence resulted in a visit to the Emergency Room.” She stated there was no indication the Grievance paperwork, provided to Unsampled Patient Q, had not been completed or logged into the facility data base. She indicated there was no documentation by the facility if the investigation was substantiated or not by the Risk Department. Risk Manager RM stated the online reporting tool document titled, “CA.GOV California Healthcare Event and Reporting Tool,” indicated the facility reported to the California Department of Public Health on 4/8/24 at 6:44 p.m. She stated the incident was detected by the facility on 4/7/24 at 11 a.m., 31 hours and 44 minutes after the allegation was communicated to the facility staff by Unsampled Patient Q. The RM stated she was unsure of the reporting time requirements to report incidents of abuse to the California Department of Public Health. She stated she would have to review the facility’s Policy and Procedure for abuse to determine the time requirements. During an interview on 9/12/24 at 4:05 p.m., the CNO stated, “I have an Inconsistent understanding of what needs to be reported.” She stated if an assault required medical attention at the emergency room it should be reported to the California Department of Public Health. She could not state what the facility’s definition of harm was. 34448 2.A. During a review of Patient 5’s Facesheet (demographics), [undated], the Facesheet indicated Patient 5 was admitted to the facility on 3/4/2024, and discharged on 3/11/2024. Patient 5’s admitting diagnoses included major depressive disorder. In addition, the previous admission Facesheet indicated Patient 5 had also been admitted to the facility on 11/20/2023 through 12/5/2023. During a review of Patient 5’s, “General Progress Note,” dated 3/6/2024 at 5:48 a.m., completed by Registered Nurse (RN GG), the Progress Note indicated, “Monday night (3/4/2024) Patient 5 stated she was uncomfortable here as during her last stay (11/3/2023 through 12/5/2023), a “demon” sexually assaulted her.” Review of the Progress Note indicated Tuesday night (3/5/2024) Patient 5 was distressed and eventually stated she was actually assaulted by a, “skinny, curly haired guy” during the night, and she did not remember the exact night. Further review of the Progress Note indicated RN GG did not notify Patient 5’s Provider and Parents of the sexual assault allegation. During a review of Patient 5’s, “Psychiatric Progress Note,” dated 3/6/2024, the Psychiatric Progress Note indicated, “(Patient 5) reports that on her previous admission, a peer raped her in the middle of the night... (Patient 5) denies reporting the incident when it happened.” Further review of the Psychiatric Progress Note indicated, during the Psychiatrist’s assessment, Patient 5 stated she wanted to be transferred to another facility because she saw the man who had raped her pass by her room, wearing glasses and a black hat. During a review of Patient 5’s, “Interdisciplinary Progress Note (IDN),” dated 3/6/2024, completed by Licensed Clinical Social Worker (LCSW), the IDN indicated, “Pt (Patient 5) reported a sexual assault incident occurred last time she was admitted here and the Therapist notified DSS (Department of Social Services) and Risk Management (RM) of the incident.” During a review of Patient 5’s, “IDN,” dated 3/8/2024, completed by LCSW, the IDN indicated LCSW had spoken with Patient 5’s family member (FM). The IDN indicated, after Patient 5 was discharged from the facility on 12/5/2023, Patient 5 told the FM that during her admission a man came into her room and started touching her. In addition, the IDN further indicated Patient 5, “Told (FM) that it is a man that does cleaning... She told me she has seen him working.” During a concurrent interview and record review on 9/10/2024 at 10:11 a.m., with RN GG, the “General Progress Note,” dated 3/6/2024 at 5:48 a.m., completed by RN GG, was reviewed. RN GG stated she was the night shift RN on 3/4/2024 and 3/5/2024, when Patient 5 alleged she had been sexually assaulted during her previous admission to the facility. RN GG stated she did not notify Patient 5’s Provider and Parent of the allegation. RN GG stated, “I usually pass it on to the morning nurse, because it was after hours.” During an interview on 9/10/2024 at 9:50 a.m., with the RM, the RM stated, “If (Patient 5) had reported the incident when it happened, during the first admission, we would have been able to follow-up. We didn’t have anyone here with that description.” During an interview on 9/10/2024 at 10:40 a.m. with RM, RM was asked if Patient 5’s sexual assault allegation had been reported to CDPH, RM stated, “It doesn’t look like it was reported to CDPH.” During a follow-up interview on 9/11/2024 at 2:20 p.m. with the RM, the RM stated she was unable to find documented evidence that Patient 5’s sexual assault allegation had been thoroughly investigated. The RM stated she reviewed the former Director of Performance Improvement and Risk Management’s files and, “he didn’t document anything we could find.” During an interview on 9/11/2024 at 2:43 p.m. with RN HH, RN HH stated, “(Patient 5) said someone came in her room and raped her and said this person didn’t work here.” RN HH further stated Patient 5 would change who the person was, and Patient 5 saw Housekeeper (HK 1), and stated, “That’s him.” RN HH stated HK 1 wore a black baseball cap. RN HH further stated she immediately reported Patient 5’s allegations to, “leadership,” and HK 1 was immediately moved to a different unit. During a review of the facility’s policy and procedure titled, “Patient Rights: Abuse Prevention and Reporting,” revised 6/12/2024, the P&P indicated, “PROCEDURE: 3. If the patient reports an allegation of abuse or neglect occurring while in the hospital, the following procedures will be followed; a. The staff to whom the allegation is reported will immediately notify the RN, who will contact the House Charge. The House Charge will notify the AOC. Contact the attending or on call provider. Document the event, including current patient status and additional interventions in the medical record. Notify the Risk Manager and enter the event into RiskConnect so that the Risk Manager may follow up on the investigation. Notify parent / guardian of the minor patient of the event. 4. If the allegation is against a staff member immediately remove the staff member from the unit and relieve them of their patient care duties for the remainder of the shift.” The P&P also indicated under: 5. “The Risk Manager will report the allegation of abuse or neglect occurring during hospitalization to CDPH within 24 hours.” During a review of the facility’s policy and procedure (P&P) titled, “ABUSE REPORTING,” dated 5/26/2022, the P&P indicated, “All incidents of suspected abuse will be reported in accordance with California regulations. Reporting obligations apply regardless of where the alleged abuse/neglect occurred. This procedure applies to information staff acquire, either by patient report or by staff observation and assessment, regarding suspected abuse.” 35030 2.B. A review of Patient 2’s clinical record, indicated Patient 2 was admitted to the facility on 9/28/2023, and discharged on 3/26/2024. Patient 2’s admitting diagnosis included bipolar disorder (a mental health disorder that causes mood swings that can make it hard to function in life). During a concurrent interview and record review on 9/11/2024 at 3:44 PM with the Performance Improvement Analyst (PIA), a review of Patient 2’s Complaint form, dated 1/5/24, indicated sexual abuse. The PIA stated Patient 2’s sexual abuse allegation was investigated and unsubstantiated. During an interview on 9/12/2024 at 8:45 AM, with the Risk Manager (RM), the RM stated Patient’s 2 sexual abuse allegation was not reported to the California Department of Public Health (CDPH). The RM stated all abuse allegations should be reported to CDPH within 24 hours. The RM stated the policy and procedure for reporting abuse was not followed. 49936 2.C. Patient G, a minor (younger than 18 years old), alleged sexual abuse was not reported to the parent, provider, and Child Protective Services. In addition, Patient H’s sexual abuse allegation was not investigated nor documented, per the facility’s policy and procedure. During a review of Patient G’s Facesheet (demographics), undated, the Facesheet indicated Patient G, a minor, was admitted on 3/20/24, with an admitting diagnosis of bipolar disorder and was discharged on 4/10/24. During a review of Patient G’s General Progress Note, dated 4/3/24, the note indicated, “patient, complained about having ‘rape’ last night by a person named [name].” The space on the form for documenting notifications listed, “No,” indicating the parent/guardian and the provider were never notified. During an interview on 9/11/24 at 11:22 a.m., with Risk Manager (RM), the RM stated, if a allegation needed to be reported to Child Protective Services (CPS), then she would complete the report if the floor staff did not. During an interview on 9/12/24 at 10:18 a.m. with Patient G’s Parent, the Parent stated the staff never notified them of their child alleging rape. During a concurrent interview and record review on 9/12/24 at 1:45 p.m., with the RM, the Grievance Log entry for Patient G’s complaint, dated 4/3/24, was reviewed. The entry contained no notes describing the nature of the complaint. The RM verified the facility was unable to find evidence notifications were made to the parent or provider. The RM verified the facility was unable to find evidence that a report to Child Protective Services was completed. During a review of Patient H’s Facesheet (demographics), undated, the Facesheet indicated Patient H was admitted on 7/26/24, with an admitting diagnosis of unspecified psychosis (a group of symptoms that causes a person to lose touch with reality, disrupting their thoughts and perceptions) and was discharged on 8/1/24. During a review of the Grievance Log entry for Patient H’s complaint, dated 8/1/24, the entry indicated Patient H submitted a written complaint alleging that Mental Health Technician (MHT) “[name] shaved my vagina in my sleep and injected me with something attached to syringe and needle and cut my hair and stuck something in my vagina.” The entry indicated Patient H was discharged before she could be interviewed. The entry also indicated MHT was interviewed and cleared for work, but with no date, time, or details documented. The entry indicated the incident was, “escalated/resolved,” on 8/2/24. During an interview on 9/11/24 at 2:40 p.m., with the Performance Improvement Analyst (PIA), the PIA stated camera footage was saved for incidents as evidence for investigations, but stated no video recording was saved regarding this incident. The PIA also stated no video report was documented regarding the incident. During an interview on 9/11/24 at 2:55 p.m., with the Risk Manager (RM), the RM stated the previous Performance Improvement Analyst investigated the incident and interviewed the alleged perpetrator but was unable to find the notes regarding the allegation. The RM was unable to find documented evidence Patient H or any witnesses were interviewed and that the Nurse Manager was notified to consider placing the alleged perpetrator on suspended leave. The RM was unable to find documented evidence Patient H was offered assistance to report incident to law enforcement. During an interview on 9/12/24 at 6:32 a.m., with the MHT, the MHT stated she was not interviewed by anyone, including the previous Performance Improvement Analyst, the RM, or law enforcement, regarding this incident. The MHT denied ever speaking to the previous Performance Improvement Analyst to be cleared back to work. During an interview on 9/12/24 9:09 a.m., with Nurse Manager FF, Nurse Manager FF stated he was not informed of this allegation. Nurse Manager FF stated, if a staff member in his unit was under investigation for abuse, it was his responsibility to place the staff member on suspended paid leave pending the investigation. Nurse Manager FF stated he was not notified about the MHT having to be cleared to go back to work. Nurse Manager FF stated he was unable to find documentation in Patient H’s chart documenting the allegation. A review of a facility document titled, “PATIENT’s BILL OF RIGHTS,” not dated, indicated, “Your Right To Make a Complaint. You have the right to make a complaint and be told how to contact people who can help you. These people and their addresses and phone numbers are listed below.” A review of the document did not indicate the contact information for the California Department of Public Health. The document also included: “5. You have the right to be from mistreatment, abuse, neglect, and exploitation.” A review of a facility document titled, “Patient Rights: Abuse Prevention and Reporting,” revised 6/12/24, the P&P indicated, “Purpose: To provide guidance on response and reporting requirements for allegations of abuse, neglect, exploitation.....All patients have the right to be treated in a safe environment, free of abuse, neglect, exploitation, or harassment.....If the patient reports an allegation of abuse or neglect occurring while in the hospital, the following procedures will be followed...”PROCEDURE... 3. If the patient reports an allegation of abuse or neglect occurring while in the hospital, the following procedures will be followed ...Document the event, including current patient status and additional interventions in the medical record... If the allegation is against a staff member... immediately remove the staff member from the unit and relieve them of their patient care duties for the remainder of the shift...” 5. The Risk Manager will report the allegation of abuse or neglect occurring during hospitalization to CDPH within 24 hours.” Review of the document did not include the contact information for the Licensing Agency. The P&P also indicated, “Cases involving children ... must be reported to Child Protective Services as appropriate ... notify the adult patient or parent, guardian of the minor patient of the event ...” A review of a facility training document titled, “Abuse & Mandated Reporting,” dated February 2021, indicated, “ANY SUSPECTED OR REPORTED ABUSE RELATED TO THESE POPULATIONS MUST BE REPORTED TO CPS OR APS.....Mandatory Reporting will occur through CPS or APS.....The facility shall self-report the event to the California Department of Public Health (CDPH). Review of the document did not include the contact information for the Licensing Agency.” A review of a facility training document titled, “PATIENT CARE / COMPLIANCE Patient Rights & Mandated Reporting,” not dated, indicated, “Mandated Reporting Timing Any protective concerns should be reported to protective services immediately via phone call: Adult Protective Services (APS) Require written report faxed within 2 working days of the phone call.....Child Protective Services (CPS) Require written report faxed within 36 hours of phone call.” Review of the document did not include the contact information for the Licensing Agency.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 40402 Based on observation, interview and record review, the facility failed to ensure safe and appropriate discharge for two out of 27 Unsampled Patients (Patient L and Patient M). 1. Patient L was driven twice by Public Transporter NN to a building with no available resources or shelter. Patient L was taken back to the facility the first time and the second time was sent to the Emergency Department. 2. Patient M was driven by Public Transporter NN, after hours, to a closed chained-up building with no available resources or shelter. Patient M’s family called the police and filed a Missing Person’s report on Patient M. Patient M was found five days later and readmitted to the hospital. These failures resulted in Patient L and Patient M both being immediately re-hospitalized after being discharged from the facility. Findings: 1. During an interview on 9/8/24 at 4 PM, Family Member OO stated she launched the complaint with the State due to the facility just, “dumping my daughter at a closed building after dark using public transportation.” Family Member OO stated she filed a police report because they could not find Patient M after they found out she was discharged from the facility. Family Member OO stated her daughter was finally found by the police down by the river. Family Member OO stated she was told by the police they took Patient M to the hospital, and the hospital assisted her in obtaining adequate resources and shelter after being discharged by the hospital. During a review of Patient M’s medical record, Facesheet with an admission date of 5/5/23, it indicated Patient M was admitted with a diagnosis of Schizophrenia (mental illness that causes one to be out of touch with reality). The Facesheet indicated a discharge date of 6/9/23 at 4:03 p.m. During a review of Patient M’s medical record, a Case Manager’s Progress Note, dated 5/18/23, authored by Case Manager JJ, indicated the case manager called Patient M’s sister who stated she could not allow Patient M to stay with her after discharge. During a review of Patient M’s medical record, a Case Manager’s Progress Note, dated 5/28/23, authored by Case Manager JJ, indicated the case manager called Patient M’s mother who stated she could not allow Patient M to stay with her after discharge. During a review of Patient M’s medical record, MD (Medical Doctor) KK’s Progress Note, dated 6/4/23, indicated, “The patient continues to be gravely disabled, unable to provide food, shelter and clothing.” Recommendation: “Continue discharge planning for psychiatric follow up as patient is homeless.” During a review of Patient M’s medical record, DO (Doctor of Osteopathic) MM’s Progress Note, dated 6/6/23, indicated, “estimated length of stay....dependent on placement.” During a review of Patient M’s medical record, Psychiatric Progress Note, dated 6/9/23, authored by NP (Nurse Practitioner) LL, indicated, “Patient states she would like to go to a shelter today and advised case manager to see if we can discharge today to a shelter.” During a review of Patient M’s medical record, Social Work Note, dated, “Late Entry: on 6/9/23,” Social Worker QQ, indicated she, “let Patient M know there are no shelters for women in Sacramento that Social Worker QQ is aware of, and the only place she can go is to Resource Center RR.....Social Worker confirmed with the doctor it would be an AMA (against medical advice) discharge.” After multiple requests for the AMA paperwork Patient M signed, no paperwork signed by facility staff, medical doctor, or Patient M agreeing to an AMA discharge was received. During a review of Patient M’s medical record, no AMA paperwork was noted. During a review of Patient M’s medical record, a DO order, authored by DO MM, dated 6/9/23, indicated, “Discharge Order: Date of Discharge: 6/9/23, diagnosis Schizophrenia, Discharge status Regular. No Notes.” During a review of Patient M’s medical record, a DO Discharge Summary, authored by DO MM, dated 6/9/23, indicated on 6/9/23, Patient M stated she would like to go to a shelter and at that time she was discharged against medical advice.” DO MM indicated, Aftercare Plan: “The patient is discharged to shelter.” No AMA paperwork was included in the Discharge Summary. During a review of the Patient M’s medical record, a Discharge/Aftercare Plan signed by Social Worker QQ, dated 6/9/23, indicated, “Discharged to Resource Center RR....call 211 for more county services.....Patient to be picked up [by Public Transporter NN] on 6/9/23 at 4 p.m. A request for Public Transport NN’s documentation of transport times for Patient M’s departure from the facility and arrival at Resource Center RR was made. A departure time for 6/9/23 at 4:03 p.m., was received. Resource Center RR was two hours and 45 minutes away from the facility, which would have been an arrival time of 6:45 p.m. During an interview with Patient Advocate SS at Resource Center RR on 9/17/24 at 10 a.m., Patient Advocate SS was queried what services Resource Center RR provided to the public. Patient Advocate SS responded, “We only supply meals and showers for the homeless from 7 a.m. to 2 p.m.” Patient Advocate SS stated she knew the Resource Center RR building was closed after 2 p.m. When queried, Patient Advocate SS, if there were any shelter services for men or women at Resource Center RR, and Patient Advocate SS responded, “We do not have any shelter services for men and very limited shelter services (16 Beds) for women at another location. There is a wait list to get into our women’s shelter and there needs to be screening and prior approval for the bed in the women’s shelter.” Patient Advocate SS stated, “We do not take walk-ins.” During an interview with Case Manager JJ on 9/10/24 at 2:35 p.m., Case Manager JJ was queried if she had spoken with anyone at Resource Center RR to make arrangements for Patient M to stay at the women’s shelter. Case Manager JJ stated she did not. Case Manager JJ was queried if she followed up with Resource Center RR to find out if Patient M had arrived at Resource Center RR. Case Manager JJ stated she did not, stated she just called Public Transporter NN to pick Patient M at 4 p.m. Case Manager JJ was queried if she was aware Patient M was dropped off at a closed building due to Resource Center RR having limited hours and closed at 2 p.m. Case Manager JJ stated she was not aware of the limited hours. During an interview with the DSS (Director of Social Services) on 9/10/24 at 9:10 a.m., the DSS was queried about the facilities’ resource list for their Homeless Patients. The DSS responded she utilized Resource Center RR and sometimes did send patients there. The DSS was queried if she knew what services Resource Center RR provided and stated she was aware patients could get meals and a shower but did not believe it was a shelter. The DSS was queried for some of the risks that a female with a diagnosis of schizophrenia faced if she was dropped off after dark at a closed building with no resources. The DSS stated she could get very cold, not have food, water, or shelter and that could affect her health. The DSS was queried whose responsible it was to keep her resources’ list up-to-date and inform the facilities’ Case Manager what resources were available at the Resource Centers. The DSS stated she tried to keep it up-to-date but admitted Resource RR escaped her, and she had not updated the Resource list in a while. The DSS was queried if she had oversight of her Case Manager’s Discharge Planning, the DSS indicated she was responsible for the oversite of the Case Manager as she was the Director of Social Services. 2. Two complaints, dated, 3/13/24 and 3/14/24, were received from Adult Protective Services (APS). One complaint was from an APS Representative (APS UU) and the second complaint was from APS VV, regarding Patient L being dropped off at Resource Center RR, but the Discharge paperwork indicated he was supposed to be discharged to a shelter. APS VV indicated Transportation Driver TT contacted Sonoma County APS (at the direction of Sacramento APS) to report concern about this frail elder (Patient L), stating he was not comfortable leaving Patient L at a dining facility (Resource Center RR), when Patient L was supposed to be at a shelter and may even need more care than a shelter could provide. Patient L reported to Transportation Driver TT he refused to sign his Discharge paperwork. APS VV advised Transportation Driver TT to take Patient L to the nearest hospital Emergency Department. During a review of Patient L’s medical record, the Facesheet indicated Patient L was an 83-year-old male who was admitted to the facility on 2/9/24, and had a discharge date of 3/13/24. During a review of Patient L’s medical record, NP orders signed by NP LL, dated 2/9/24, indicated Patient L was admitted on 2/9/24, with a legal hold status of 5150 (regulation that indicates a patient can be held as an inpatient due to being a danger to self or others). Notes indicated, “Danger to Self and Gravely Disabled” (a condition where someone is unable to provide for their basic needs due to a mental health disorder). During a review of Patient L’s medical record, DO XX signed an order, dated, 2/24/24, for Patient L to be placed on a 5270 (a regulation hold that can extend a psychiatric hold for an additional 30 days. It’s used to provide intensive treatment for people who are gravely disabled due to a mental disorder) legal hold status, Notes: “Danger to Self and Gravely Disabled.” During a review of Patient L’s medical record, History and Physical, dated, 2/11/24, authored by MD YY, indicated his living situation as: “Homeless.” During a review of Patient L’s Nursing Admission Assessment, dated, 2/9/24, authored by RN ZZ, indicated, “Limitations: Gravely Disabled, Lack of insight to illness, multiple medical concerns, poor judgement, housing issues, poor concentration and unable to meet basic needs, impaired gait, transfer difficulty, standing/balance and generalized weakness.” During a review of Patient L’s Psychiatric Progress Note, dated, 2/26/24, signed by DO XX, indicated, “Patient L is still incapable of providing his own food, shelter, and clothing due to his physical and mental limitations including memory issues. During a review of Patient L’s Psychiatric Progress Note, dated, 2/29/24, signed by DO XX, indicated, “Patient L is still incapable of providing his own food, shelter, and clothing due to his physical and mental limitations including memory issues.” During a review of Patient L’s Psychiatric Progress Note, dated, 3/6/24, signed by DO XX, indicated, “Patient L is still incapable of providing his own food, shelter, and clothing due to his physical and mental limitations including memory issues, but we have been unable to find any placement for him here.....We will plan to plan to discharge him to a shelter.” During a review of Patient L’s Discharge Summary, dated 3/6/24, signed by DO XX, indicated, “Housing may be an issue, so shelter has been arranged.” During a review of Patient L’s MD orders, signed by DO XX, indicated, Discharge Patient L to a shelter. During a review of Patient L’s Discharge Summary dated 3/6/24, signed by DO XX, it was noted to not match the IDT Notes for discharge planning. During a review of Patient L’s Interdisciplinary Progress Note (IDT), dated 3/7/24, authored by Case Manager JJ, it indicated, Case Manager JJ called Loaves and Fishes, there was no answer as the call went into multiple loops of voicemail’s, not allowing her to leave a message. During a review of Patient L’s Psychiatric Progress Note, dated, 3/7/24, signed by DO XX, indicated, “Patient reportedly discharged yesterday 3/6/24, and was taken by [Public Transporter NN], to the shelter in Sacramento, but they told him he could not stay there. Reportedly [Transporter NN] drove around to a bunch of different shelters without any luck and then took him to get pizza before driving him all the way back to the facility again. This was treated like he never left the hospital, and his hospitalization continues. [Patient L] reports the discharge needs to be delayed until he is feeling better. He reports we need to do better planning and find him a safe place to go.” During a review of Patient L’s Nurses Notes, dated 3/11/24, authored by RN AAA, indicated, “Patient is disheveled and irritable, becomes agitated and raises his voice. Patient remains in wheelchair, ADL’s (Activities of Daily Living), very poor.” During a review of Patient L’s Psychiatric Progress Note, dated 3/12/24, signed by DO XX, indicated, “Apparently, they were unprepared for him yesterday when we tried to discharge him, but we will try to make them aware of his situation today. Hopefully this can all be set up today or tomorrow at the latest. If not, we will consider lateral transfer to our Sister Facility in Sacramento so they can contact APS.” During an interview with Case Manager JJ on 9/10/24 at 10:10 a.m., Case Manager JJ was queried if she had spoken with anyone from Resource Center RR to let them know Patient L would be arriving and needed placement in a shelter. Case Manager JJ stated she could not because every time she called Resource Center RR, she only got a voice mail and could not leave a message. Case Manager JJ was queried, when she also discharged Patient M to the same location nine months earlier, and the family contacted the facility due to Family Member OO filing a missing persons report on Patient M, why she would send another patient (Patient L) to the same Resource Center RR. Case Manager JJ stated she could not get through to anyone at Resource Center RR to make arrangements for either Patient L or Patient M. Case Manager JJ was queried why she would send Patient L, who needed a shelter to the same building address (Resource Center RR), where she already knew a week prior [Transportation Driver TT] had arrived the first time at Resource Center RR with Patient L and then contacted APS due to it not having a men’s shelter, Case Manager JJ stated she was unaware of the extent of the resources at Resource Center RR and was merely following her DSS resource list for placement. Case Manager JJ asked if Patient L signed his Discharge paperwork and agreed to returning to the same place he was returned from a week ago, Case Manager JJ stated she could not remember the details. No further communication occurred with Case Manager JJ and no further documentation was offered for Patient L’s Discharge paperwork. During a review of the Patient L’s medical record indicated no signed Discharge paperwork was found. During an interview with the DSS on 9/10/24 at 10:45 a.m., the DSS was queried if the facility had filed an APS report on Patient L prior to sending him to Resource Center RR. The DSS stated, “Yes, there was an APS report filed by this facility on Patient L,” then later indicated APS would not take the report, “so there was no APS report filed on Patient L by our facility.” The DSS was queried what the risks were to discharging homeless patients to a building with no resources or shelter, the DSS responded, “They would probably be readmitted for health problems.” During an interview with the CNO (Chief Nursing Officer) on 9/10/24 at 11:45 a.m., the CNO was queried what a safe and appropriate discharge was for homeless patients (Patient L and Patient M). The CNO responded, “Contact the shelter ahead of time and make arrangements for placement.” During a review of the Case Manager’s Job Description, the Job Description indicated the Case Manager reported to Director of Social Services. “Job Description: Provides quality case management and discharge planning services to all patients and their families. Serves as a member of interdisciplinary team supporting the organization’s treatment program and philosophy, and assures the deliverance of quality treatment to patients and their families. Key Responsibilities: Ensures linkage to mental health/recovery services, and facilitates communication with the county. Completion of discharge aftercare plan, and provides daily placement and collateral documentation. Coordinates discharge packets and reviews them with patients and their families. Completes required documentation and progress notes on time and individualized per patient. Upholds the Organization’s ethics and customer service standards.” During a review of the Director of Social Services (DSS) Job Description, the Job Description indicated, “The DSS reports to the CEO. Duties: Oversight, development and coordination of individualized discharge plan for the patient by utilizing treatment team and written chart information to determine the patient’s aftercare needs. Access by phone or written correspondence family or community resources such as nursing homes, group homes, or private mental health practitioners to meet patient’s aftercare needs. Attends regular treatment team meetings to provide social work perspectives for total case management of the patient by discussing progress notes charts and communicating any state or local agency legal requirement for case management with the interdisciplinary team.” During a review of the facility’s policy and procedure titled, “Discharge Planning / Aftercare,” revised 3/11/24, indicated, “Purpose: To help prepare all patients for their return to the community by connecting the patient with available community resources, treatment, shelter, and other supportive services, as appropriate. This policy also serves to specify the discharge planning procedures to ensure that discharge planning begins at the time of admission and is updated through the duration of the patient’s hospitalization. After care planning facilitates the optimal transition for patients from the hospital to the community. Procedure: Discharge planning shall be initiated at the time of the psychosocial evaluation. The social services department shall discuss with the patient, family, guardian and / or outpatient provider, as appropriate, the tentative discharge plan, including resident, outpatient treatment, financial / vocational / situation evaluation) as well as any Social Services interventions that are needed. These recommendations include the various levels of care indicated to assure that patients are treated at the appropriate level of care. The clinicians shall assist in implementing appropriate clinical interventions including Assisting in coordinating necessarily follow up care. If any difficulties arise in coordinating appointments, then clinicians will reach out to outpatient providers to schedule and coordinate a meeting to discuss complex cases. In developing discharge/aftercare plans, the following is assessed, safety needs and planning, housing needs and placement issues. The social work staff shall assist in implementing appropriate Social Services interventions including Addressing any need for placement or appropriate living arrangements. A homeless patient is determined by Senate Bill 1152, as an individual who: Lacks a fixed and regular nighttime, residence. The patient will be offered transportation to his or her chose [sic] discharge destination. The Social Services department will coordinate a transportation plan and review it with the patient prior to discharge.” During a review of the facility’s policy and procedure titled, “Against Medical Advice Intervention,” dated, 5/26/22, indicated, “Purpose: To address patients requesting Against Medical Advice (AMA) discharges. Patient will sign AMA form. The attending will be contacted to see and evaluate the patient and provide an AMA discharge order, Patient will be encouraged to contact his/her family, significant other to inform them of the intent to leave. Complete the AMA request for Discharge information from. An AMA discharge is considered a treatment failure. Complete an incident report and attach copy of Request for AMA form. The RN House Supervisor will report AMA status of discharged patient at shift handoff-to provide data regarding the discharge. Indicate on 24-hour DON report by Nurse Manager/Supervisor. Notify DON/AOC prior to AMA discharge.””

“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: 38335 Based on observation, administrative interviews, and administrative document reviews, the Hospital, failed to ensure the Governing Body §482.12, functioned effectively and demonstrated consistent oversight of the Hospital’s operations, in a manner sufficient to ensure behavioral health quality and patient safety, when it DID NOT: 1) Ensure clear expectations for safety was established for all facility staff and patients. (Cross Reference A-144, A-145) 2) Ensure Nursing Services and Hospital Management were evaluated to ensure care was provided in a safe and effective manner. 3) Ensure the hospital-wide quality assurance program was successfully implemented, monitored, and reflected provision of services provided to patients. 4) Ensure consistent and effective staffing in Leadership an Nursing services. 5) Ensure oversight and monitoring of Social Services to provide patients with a professional standard of care. The cumulative effect of these systemic problems resulted in an increase of Patient-to-Patient Assaults, essential therapies and modalities being withheld from patients treatment, harmful patient treatment millieu, and the facility’s inability to ensure the provision of quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 38335 The hospital failed to ensure an effective performance improvement program, for identified hospital services, which accurately reflected the depth and scope of departmental operations, to ensure services provided were evaluated on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. (Cross Reference A-0283) The cumulative effect of these systemic problems resulted in the hospital’s failure to meet statutorily mandated compliance with the Condition of Participation for Quality Assurance Performance Improvement.”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 38335 The hospital failed to ensure there was adequate qualified mental health professionals and supportive staff to carry out an intensive and comprehensive active treatment program and to protect and promote the physical and mental health of the patients. The cumulative effects of these systemic problems resulted in the hospital’s failure to meet statutorily mandated compliance with the Condition of Participation for Special Staff Requirements for Psychiatric Hospitals. (Cross Reference A-1615, A-1704)”

“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: 38088 Based on interview and record review, the facility did not ensure patient safety and protect vulnerable patients when: 1. Multiple sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 11) were not provided a safe setting which resulted in patient-to-patient physical harm. This included head lacerations, witnessed physical assaults (Punching with closed fists), pulling hair, patient manual holds (A method of restraint in which a patient’s freedom of movement or normal access to his or her body was restricted by means of staff physically holding the patient for safety reasons), patient seclusion (Involuntary confinement of a patient in a room alone, for any period of time, from which the patient was physically prevented from leaving) and emergent involuntary medication administration (The administration of any psychiatric medication or drug to a patient by the use of force, discipline, or restraint, including administration upon a patient who lacks capacity to accept or refuse medication) to patients; and, 2. The facility failed to follow the Abuse Prevention Policy, Competency Training Policy, Level of Observation Policy, Hallway Monitor Policy, Sexual Acting Out and Vulnerable Patient Policy, for six out of nine sampled residents (Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, and Patient 21). This failure resulted in an unsafe environment, allowing for sexual acting out behavior which injured vulnerable Patients. These failures resulted in an unsafe environment which allowed for patients and staff to experience physical harm and sexual acting out behavior. Findings: (Cross Reference A-263, A-1680, A-1704, A-1725, A-1726) During an observation on 3/18/24, in Unit 500 (High Acuity, all Male unit for patients with behaviors that required more observation than other floors, for resident and staff safety), on 3/18/24, at 11:35 a.m., the community room (a room for patients to listen to music, watch movies or participate in therapy) was closed and locked. One Unlicensed Staff was monitoring patients in their bedrooms by rounding on each room with an ipad. The other Unlicensed Staff was standing outside of Room 501 for a 1:1 observation (A process where a staff watches a patient constantly for safety, for themselves or others). There were no activities or therapists in the unit interacting with patients. Eight other patients were in their darkened rooms, covered by sheets or blankets. There was no music. The walls had multiple areas of unpainted plaster patches that were in various states of repair. During an interview with the Director of Quality Management and Patient Risk and the Director of Clinical Services, on 3/18/24, at 9:35 a.m., the Director of Clinical Services stated Unit 500 was a high acuity and for violent male patients. He stated the unit had a restricted daily census of ten for patient and staff safety. During an observation and interview on 3/18/24 at 10 a.m., a Mock (Practice) Code Green (An escalating psychiatric event or emergency that presented a potential need for staff to physically restrain a patient) was observed. The facility was a locked facility with restricted access into and out of each unit. During a Code Green, staff were supposed to arrive to provide support. The Director of Quality Management and Patient Risk and the Director of Clinical Services stated, “The Director of Nursing and the House Supervisor were supposed to show up but did not, because the House Supervisor called in sick and the Director of Nursing was doing direct patient care, and there is no Chief Nursing Officer.” During an interview on 3/18/24, at 10:48 a.m., the Director of Nursing stated, “There is immense pressure from the Chief Executive Officer to get more patients to increase the census. There is so much pressure to get more patients, heads in beds.” He stated I was never consulted before patient admissions if we had enough staffing to provide safe care for patients. The Director of Nursing stated the Chief Executive Officer was under huge pressure to get the census up because she talked about it all the time at leadership meetings. During an interview on 3/18/24, at 3:45 p.m., the Director of Plant Operations and Safety stated he was not aware of any staff injuries in the inpatient units. He stated a patient had kicked a fire extinguisher off the wall, and when the fire extinguisher engaged, patients and staff were breathing the fumes from the extinguisher. He stated it went everywhere, and it was not good for anyone to breath. He stated he remembered staff who went to urgent care for treatment because it affected their breathing. He was not aware if any patients had breathing issues associated with the extinguisher fumes. During an interview on 3/18/24 at 11:50 a.m., Unlicensed Staff Z stated, “In December it started to get really unsafe in the facility. We worked out of ratio (Number of staff to number of patients) consistently on the weekends and nights.” She stated there had been an increase in Code Greens, and without enough staff, there was no one to respond. She stated the facility had admitted patients they cannot safely take care of, violent, assaultive patients. She stated the patients got out of control and could not be de-escalated, and then patients and staff got hurt. Unlicensed Staff Z stated she has been hit and punched multiple times until she was sore. She stated she told the Director of Nursing and Administrators, and she was afraid and there was not enough staff. During an interview on 3/18/24 at 12 p.m., Licensed Staff AA stated they were frequently without enough staff to monitor patients. She stated the last Chief Nursing Officer and the Chief Executive Officer terminated a lot of staff, and it created a bad staffing shortage, and now people were afraid to speak up about safety and staffing. She stated they did not want to lose their jobs. She stated it was unsafe for patients and staff to work out of ratio. She stated if they did not have staff, they could not consistently and safely assess and monitor patients for any escalating agitated behaviors. She stated the patient units were frequently short staffed and out of ratio, so patients would not be taken to the cafeteria for meals. Licensed Staff AA stated patients could not even eat in the unit community room because, without enough staff, staff could not monitor the patients who ate in the community room and the patients who stayed in their rooms. She stated the patients all had to eat in their rooms like, “Caged animals.” She stated, “It is unsafe and worse on weekends.” During an interview on 3/19/24, at 9:45 a.m., Unlicensed Staff Y stated Patient 1 was a 1:1 patient. He stated he was on the 1:1 because he consistently engaged in assaultive behaviors against patients and staff. He stated patients and staff were not safe because of the staffing. Unlicensed Staff Y stated, on night shift there were only two Mental Health Workers (MHW). He stated one MHW was assigned to the 1:1 patient, and the other MHW observed the other patients every five to 15 minutes. He stated, if a patient began to escalate his behaviors and attacked either another patient or staff, there would not be enough staff available to keep the other patients safe. He stated it was a dangerous situation. He stated they worked out of ratio all the time. Unlicensed Staff Y stated Patient 1 had been here a couple of years, and because of his behavior he was stuck in his room. He was confined to his room to keep him and other patients safe. He stated Patient 1 had punched and kicked him and other patients. During an interview on 3/19/24, at 10:20 a.m., Unlicensed Staff BB stated there had been a lot of patient-to-patient assaults in the facility. He stated recently the patients started a riot that was so bad the police were called and came into the facility with their guns drawn. He stated a lot of patients and staff were hurt. He stated another time a patient stood up in the dining room and walked over to another patient and, “just checked him, I mean really punched him,” and then walked over to the wall and started banging his head and screaming he needed help. “I tried to de-escalate, but he was so agitated I had to use a physical hold and put him into a seclusion room, where he was emergently medicated. The lack of staffing contributed to the assaults because there are not enough staff to assess and monitor all the patients and respond to an escalation of behaviors.” During an interview on 3/19/24, at 10:40 a.m., Unlicensed Staff CC stated it was really dangerous for patients when it was short-staffed. Patient 1 was so aggressive and assaultive on other patients that at one point the doctor ordered him to be on a 2:1 observation (Two staff to watch one patient). He stated the facility took him off 2:1 because it was too many staff [watching him]. He stated Patient 1 did not have any quality of life because he was stuck in his room, could not be around other patients for safety, he could not participate in activities or have leisure time outside. Patient 1’s stay was like being in jail. Patient 1 was so difficult staff could not get him to cooperate with anything without endangering him or other patients or staff. Unlicensed Staff CC stated everyone had told administration that it was not safe for patients or staff when they are so short-staffed. He stated nothing changed. He stated, when a situation escalated and patients observed it, they got agitated too and it was dangerous. He stated patients just sat in their rooms and listen to the voices in their heads and it was dangerous. During an interview on 3/20/24, at 2 p.m., Physician DD stated Patient 1 needed to be moved to a more appropriate facility for his assaultive behaviors. He stated Patient 1 had assaulted other patients and staff and even, “Popped me,” a couple of times. He stated Patient 1 remained on 1:1 observation because of his behaviors and assaults on other patients. He stated Patient 1 would remain in a solitary confinement situation for the duration of his stay due to his behaviors. He was having a deterioration of physical condition because of his behaviors and being uncooperative. He stated, “His teeth are terrible, and we cannot get him to go to a dentist. He was uncooperative. He has lost muscle mass as a result of being confined to his room and not getting any exercise. This if far from a therapeutic environment. His life is really quite terrible. You won’t find any documentation of his teeth because he won’t allow an exam.” He stated, “If they had more staff they could monitor him closely, develop a better relationship and perhaps allow for some cooperation, but staffing doesn’t allow that. He is really resource intensive.” He stated, “Patient 1 is in danger from other patients who respond to his behaviors by either protecting themselves or striking out against him out of fear.” During an interview on 3/21/24 at 9 a.m., the Interim Medical Director stated she was the Medical Director and also sat on the Governing Board. She stated her role was to address issues and resolve them. She stated the Governing Board had reviewed facility reported incidents that involved patient-to-patient assaults. She stated she did not recall if there were any recommendations by the Governing Body to address those concerns. She stated she thought staff could use more training on how to de-escalate agitated patients. The Interim Medical Director stated she was unaware of any patient safety, social services or staffing issues that have impacted the therapeutic milieu (Therapy provided to patients in the form of 1:1 counseling, group meetings, group therapy, and activities) for patient treatment at the facility. During an interview on 3/21/24 at 1:40 p.m., the House Supervisor stated the Admission process for this facility was to get heads in beds. She stated they never turned down a patient admission. She stated, “The problem was we do not have the appropriate staff with the appropriate training.” The House Supervisor stated the facility Administration was not interested in hearing about the staffing issues and any patient safety issues. She stated the danger to patients was there was not enough staff to detect increased agitation of patients and to mitigate the circumstances. She stated the more trained staff they had, the safer it was for patients and staff. During an interview on 3/22/24, at 10:30 a.m., the Director of Nursing stated, “Everyday at the morning daily meeting I hear about patient-to-patient assaults.” He stated they were supposed to have enough staff to help reduce the number of patient assaults, but they could not hire enough nurses and staff. He stated, without proper staffing, more patient-to-patient assaults would occur. The Director of Nursing stated, “The facility’s priority of admitting patients without considering if we had enough staff to safely care for them has contributed to an unsafe environment for patients and staff.” He stated staff have had to work with a 1:24 ratio, and it was unsafe. He stated the facility admitted all patients without consulting him if there was enough staff to provide care, and it was unsafe.The Director of Nursing stated one staff member was so traumatized by the patient riot and assaults that they had to move her to a different low acuity unit to get her to come back to work. Patients in this unit had attacked the nurses, and the nurses were afraid to come into work. During an interview on 3/22/24 at 11:45 a.m., Unlicensed Staff B stated she observed a patient-to-patient assault, and there was blood everywhere. She stated a patient slammed a chair down so loudly it frightened everyone. She stated blood splattered everywhere. During a record review and concurrent interview on 3/22/24,at 12:50 p.m., Licensed Nurse EE stated Patient 1 was admitted 8/12/22, and was on precautions for assaultive and violent behavior and Sexually Acting Out Behavior. He stated he was on 1:1 precautions, and they did not see a Psychosocial Note for Patient 1 completed in the last 72 hours. They stated, “In fact I don’t see any Psychosocial Notes in his medical record. The importance of the note is that it the basis of therapy. It documents the assessments of strengths and weaknesses of patients. Without it the therapy is inaccurate and inappropriate. You end up with a completely useless treatment plan.” They stated they could not find communication with his Conservator or any General Progress Notes for 12/12/23, about an incident that result in Patient 1 having a head laceration because of a patient-to-patient assault. They stated, “Patient 1 experienced harm and there was no indication if another patient experienced harm either because of the patient-to-patient assault.” Licensed Staff EE stated, “I would have expected a Progress Note describing the incident and investigation with interviews with the MHW and other patients who observed or had been involved.” They stated there should be a note about communicating with the Physician and Conservator, in addition to notifying the House Supervisor and Administrator, but there was no documentation of a head laceration, no pain assessment, and only notes about neuro checks ordered by a physician on 12/12/23 at 10:52 a.m. Unlicensed Staff EE stated the neuro checks were ordered every 15 minutes but only one was ever completed, and the rest were refused by patient 1. They stated, “It is like his behaviors and the injuries associated with him are normal.” During a concurrent interview with Licensed Staff EE and a record review on 3/22/24, at 12:55 p.m. for Patient 2, no Progress Notes about being assaulted on 12/11/23, were located in the medical record. Unlicensed Staff EE stated he could not find any documentation that Patient 2 was assaulted by another patient. They stated there was a pain assessment on 12/11/23, for left eye pain with administration of Tylenol, but there was no reassessment of the pain level after administration. They stated there should be documentation of the incident and assessment of Patient 2 to determine if he was harmed. During a concurrent interview with Licensed Staff EE and a record review on 3/22/24, at 12:55 p.m., for Patient 3, they stated there was no documentation on the assault by Patient 1 on 12/12/23, no assessment for injuries, no notifications to the physician. During a concurrent interview with Licensed Staff EE and a record review on 3/22/24, at 12:55 p.m., for Patient 5, they stated there was no documentation in the medical record that Patient 5 punched Patient 6 multiple times on two different attempts on two different days, except for two attempts to notify Patient 5’s father. During a concurrent interview with Licensed Staff EE and a record review on 3/22/24, at 12:55 p.m., for Patient 7, they stated Patient 7 assaulted Patient 11 on 12/8/23, but the medical record did not have any documentation about notification to Patient 7’s parents or physician, and no documentation of a second assault on Patient 11 on the same day. They stated the lack of documentation makes it seem like patient-to-patient assaults, “are normal.” During a concurrent document review and interview on 3/22/24 at 1:15 p.m., the Director of Quality Management Patient Risk was asked what was the P&P (Policy & Procedure) for investigating Abuse. He provided a document titled, “ABUSE PREVENTION,” revised 5/13/21, and he stated this was the only document the facility had. He stated there was no P&P for how to investigate an allegation or observation of abuse. He stated he did not know who the facility Abuse Coordinator, responsible for investigation and reporting abuse, was. He stated he did not know about reporting to the California Department of Public Health Licensing and Certification (CDPH L&C) for abuse allegations by patients or observations of patient-to-patient abuse. He stated he did not know what the regulatory requirements were for investigating and reporting to CDPH. The Director of Quality Management Patient Risk stated he thought the Department wanted the facility to wait until there were several Occurrence Report Incidents and just send in a summary to the CDPH. During a concurrent document review and interview on 3/22/24 at 1:15 p.m., with the Director of Quality Management Patient Risk, a review of a document titled, “Occurrence Report Summary, not dated, about the Entity-Reported Incidents: CA00875640, CA00875645, CA00875656, indicated, “TIME OF INCIDENT 12/11 17:50 (5:50 p.m.) Summary of Event: Incident 1 : Patient (1) was in the day room, when he stood up and assaulted another client (Patient 2) unprovoked. Staff member immediately intervened. Staff escorted pt to the quiet room. Manual hold initiated from 1750 - 1751 to administer emergent meds.....Investigation: Video Review: Incident 1: MHT (Mental Health Technician) was present within 5 ft of patient (1). Patient 1 stand [sic] up casually and walk past another patient (Patient 2) with no signs of aggression before turning towards the peer and punching several times. MHT immediately separates patients. Other staff enter room and escort Patient 1 out of room.” He stated there was no indication that a review of the situation was conducted to determine what caused the incident and how to prevent it from happening again. He stated that information might be in Patient 1 and Patient 2’s medical records. A review of the Complaint Intake information indicated incident one was reported to the Department 12/15/23 at 4:53, four days after the incident occurred. Further review of the document indicated, “TIME OF INCIDENT 12/11 9:30 Incident 2: Pt (1) was walking down the hallway when he suddenly went into peers’ (Patient 3) room and attacked peer unprovoked. Staff responded immediately and manually separated patient (1) from peer (Patient 3). Using manual hold, patient (1) was escorted to the quiet room where he was given emergent meds IMs (Intramuscular Injection) ... after which he was put in seclusion. Investigation: Incident 2: Patient (1) enters room and remains for 6 seconds before staff enter and remains in room for total of 22 seconds before being escorted out by MHTs. ...The patient (3) was hit on his upper left arm as he tried to block punches.” The Director of Quality Management Patient Risk, stated the investigation notes were not clear. A review of the Complaint Intake information indicated incident two was reported to the Department 12/18/23 at 8 a.m., seven days after the incident occurred. Further review of the document indicated, “TIME OF INCIDENT 12/12 9:30 a.m. Incident 3: Patient (1) unprovoked walked into another patient’s room (Patient 4) and punched him multiple times. Manual hold initiated to bring patient into the quiet room. Seclusion then initiated for safety. Patient(1) received laceration on head during the encounter....Investigation: Incident 3: One MHT present in hallway at time of incident. Patient 1 crosses the hall and enters room (Patient 4) for 52 seconds. Both patients then exit room, Patient 1 returns to his room while Patient 4 goes to RN station and reports incident.” A review of the Complaint Intake information indicated incident three was reported to the Department 12/15/2023 at 4:58 p.m., three days after the incident occurred. During a concurrent document review and interview on 3/22/24 at 1:15 p.m., the Director of Quality Management Patient Risk, reviewed a document titled, “Occurrence Report Summary,” not dated, about Entity-Reported Incident CA00878894, reported to the Department by the facility on 12/18/23 at 8 a.m. Review of the intake information indicated Patient 1 sustained a head laceration after an assault on Patient 4. Review of Patient 1’s medical record, a document titled, “General Progress Note,” dated 12/11/23 at 4:50 p.m., indicated, “Pt slapped buttocks of female staff member while conversing in the day room. 12/11/23 at 7:25 p.m., Client was in the day room and assaulted another client unprovoked. Staff escorted pt to quiet room. Manual hold initiated.....to administer emergent meds. Pt in seclusion for threatening and assaultive behavior as he is an immediate danger to others. 12/12/23 at 12:03 a.m., Pt (1) was walking down the hallway when he suddenly went into peers’ (4) room and attacked peer unprovoked. ...Via manual hold patient was escorted to the quiet where he was given emergent meds (IMs) ...after which he was put in seclusion. Pt (1)remained in seclusion until he was calm and not a threat to anyone. This was patients (Patient 1) second assault incident of the day....12/12/23 at 2:38 p.m. Pt (1) entered another patient’s (4) room and punched him as he laid in bed. 2nd pt got up and hit Patient 1. Patient 1 left 2nd pt’s room and returned to his own room, at this point, staff entered Patient 1’s room and escorted him to quiet room. In the quiet room, this nurse noticed that pt was bleeding from the head.” A review of the Complaint Intake information indicated incident two was reported to the Department 1/9/24 at 12:57 p.m., five days after the incident occurred. During a concurrent document review and interview on 3/22/24 at 1:15 p.m., the Director of Quality Management Patient Risk, reviewed a document titled, “Occurrence Report Summary,” not dated, about Entity-Reported Incident CA00875638, reported to the Department by the facility on 12/15/23, at 4:46 p.m., which indicated, on 12/8/23 at 8:42 a.m. and 2:02 p.m., Patient 7 punched Patient 8 multiple times in two separate incidents. The document indicated, “Summary of Event: Patient 7 came after the other pt (Patient 8) who backed up into her room and hit her 3 times, in the left cheek, left temporal area, and upper right of the chest. Staff intervened and Patient 7 was escorted to seclusion room at 8:42 a.m. ... Pt agreed to IM without manual restraint.....At approximately 2:02 Patient 7 went into the unit day room and went directly to the same patient (Patient 8) that she previously assaulted. She grabbed the patient’s hair and began punching her multiple times....Investigation: ...Video review confirms events as document by RN. One staff was monitoring hallway and one was conducting rounds in hall during assault. Staff member in day room during 2nd incident.” During an interview on 3/22/24, at 2:05 p.m., the Director of Quality Management Patient Risk stated he did not know the details about each incident. He stated the nurses wrote the details in the medical record. He stated all the incidents were tracked and presented to leadership at the morning meetings and at the Quality Committee Meeting. He was unable to answer what the facility had implemented to prevent future patient-to-patient assaults. During an interview on 3/22/24, at 2:10 p.m., Consultant U stated, “I could not find documentation of an abuse prevention program. It was mostly done by word of mouth.” She stated, without a P&P on the facility Abuse Prevention, it could potentially lead to confusion by staff and contribute to more abuse incidents. During an interview and document review on 3/22/24 at 3:25 p.m., the Director of Quality Management Patient Risk stated the data collected by the Quality Department indicated patient safety was worse at this time than in the last five years. He stated patient safety was not getting better if one looked at the number of patient assault incidents. During an interview on 3/22/24, at 3:40 p.m., the Chief Executive Officer stated she heard about patient abuse at the daily flash meetings and incident reports that were reviewed. She was unable to state who in leadership was responsible for the coordination of the Abuse Prevention Program at the facility. She was unable to state what the facility engaged in for abuse prevention or response and whether the Governing Body had any oversight of the facility Abuse Prevention Program. Review of a document titled, “Face sheet,” indicated Patient 1 was a 26-year-old male, admitted on 8/12/22, with diagnoses including Unspecified psychosis not due to a substance or known, physiological defect. He had a diagnosis of Schizophrenia and was conserved by a contracted professional who was responsible for finding long-term placement. He had medication orders for Thorazine, Lamotrigine, and PRN orders for Thorazine, Ativan and Tenex. The Rationale for inpatient stay was documented as, “For grave disability and danger to others.” Review of a document titled, “[GACH Facility Name] Progress/Visit Notes ED Physician Notes ...Reason for Hold A danger to others.” Review of a record for Patient 1 titled, “Seclusion and Manual Hold Audit,” indicated between 2/11/24 and 3/19/24, Patient 1 had been placed in a manual hold eight times, placed in seclusion five times, and had been emergently medicated three times, for punching a MHT, punching a Psychiatrist, Sexually Acting Out Behaviors with staff, spitting on staff. Patient 2 was a 26-year-old male, admitted 11/28/23, for Unspecified psychosis not due to a substance or known psychological defect. Comments from admission indicated, “26 yo Male. PT is paranoid and delusional, assaulted another cell mate while in jail due to believing they were trying to control him.” Patient 4 was a 30-year-old male, admitted 10/18/23, for Schizophrenia, unspecified. Comments from admission indicated, “30 yo male currently detained at Sonoma Co. Jail. PT was arrested and declared incompetent to stand trials. Attempts to restore competency at jail have failed.” Patient 5 was a 17-year-old male, admitted 1/2/24, from Inpatient Psych Juvenile Services. Admitted with Diagnoses of Major depressive disorder, single episode, unspecified. Comments from admission indicated, “17 yo Male. PT endorses SI with plan to cut self with a knife, says he is depressed for a friendship he ruined over the summer.” Patient 6 was a 17-year-old male, admitted 1/3/24, from inpatient Psych Juvenile Services for diagnoses that included bipolar disorder, unspecified. Comments from admission indicated, “Pt has been in the ED for 82 hours, still agitated, psychotic and assaultive, requiring chemical and physical restraints.” Patient 7 was a 16-year-old female, admitted 12/2/23, from inpatient Psych Juvenile Services for diagnoses of Major Depressive Disorder, single episode unspecified. Comments from admission indicated, “Pt is a 16-year-old female who ... made threat to kill herself by OD.” Patient 11 was a 14-year-old female, admitted 12/7/23, from inpatient Psych Juvenile Services for diagnoses that included Major depressive disorder, single episode, unspecified. Comments from admission indicated, “Pt’s SI (Suicidal Ideation) has been increasing over the past week and were in the ED a week ago for SI and safety plan that has been working till today. Pt has history of suicide attempt, history of mental illness.” During a review of the facility Policy and Procedure titled, “INCIDENT REPORTING & INVESTIGATION Policy Number: LD 110.01,” revised 8/5/19, indicated, “[Psych GACH Facility Name] will provide an effective mechanism for the reporting, investigation, and / or prevention of all incidents and injuries to patients ... Incidents may include: ...Confrontations between patients or involving staff.” During a review of the facility Policy and Procedure titled, “ABUSE REPORTING Policy Number RI 800.14 a,” reviewed 5/13/21, indicated, “Each patient receives care in a safe environment....This includes protection for patient’s emotional health and safety, as well as his/her physical safety. Respect, dignity and comfort would be components of an emotionally safe environment....Definition: Abuse: is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another.” During a review of the facility P&P titled, “CODE GREEN,” dated 12/7/23, it indicated, “a. Nursing Leadership (Chief Nursing Officer, Director of Nursing, House Nursing Supervisor, or designee) will monitor code response and delegate tasks to staff responding to the Code Green to ensure the following objectives are met. i. Hospital Safety: Ensure the safety and security of patients and staff across all units.””

“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: 40402 Based on observation, interview and record review, the facility failed to follow the Abuse Prevention Policy, Competency Training Policy, Level of Observation Policy, Hallway Monitor Policy, Sexual Acting Out and Vulnerable Patient Policy, for 14 out of 17 sampled residents (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 11, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, and Patient 21). This failure resulted in an unsafe environment that allowed for: 1. Sexual acting out behavior (multiple incidences of sexual abuse and sexual intercourse with physical bruising, which resulted in a patient being sent out for a rape kit). 2. Physical harm (Head Lacerations, Punches, Pulling Hair) resulting in patient manual holds (A method of restraint in which a patient’s freedom of movement or normal access to his or her body was restricted by means of staff physically holding the patient for safety reasons), patient seclusion (Involuntary confinement of a patient in a room alone, for any period of time, from which the patient was physically prevented from leaving) and emergent involuntary medication administration (The administration of any psychiatric medication or drug to a patient by the use of force, discipline, or restraint, including administration upon a patient who lacks capacity to accept or refuse medication). This resulted in sexual and physical abuse that injured vulnerable Patients. Findings: 1. During an interview with the DON (Director of Nursing), on 3/22/24 at 10:25 a.m., the DON was queried as to who assessed the patient’s acuity and did the room assignments for new admissions. The DON responded he assigned that to the House Supervisor and Charge Nurse. The DON was queried if the House Supervisor and Charge Nurses had been trained and had competencies to perform this role. The DON responded, training at the facility was basically non-existent due to the constant low staffing they have had for two years. The DON stated he had been at the facility for two years and had never properly been trained. The DON was queried as to his awareness of Sexual Acting Out Patients being roomed with Vulnerable Patients. The DON stated he knew it has happened in the past but they tried their best not to room Sexual Acting Out Patients with Vulnerable Patients. The DON was queried as to the risks of patient safety when Sexual Acting Out Patients were roomed with Vulnerable Patients. The DON stated he was aware the Vulnerable Patients had sustained injury when this inappropriate room assignment had occurred. The DON was queried about his expectations for his staff when they performed Observation Rounds for Vulnerable patients and Sexual Acting Out patients who were on Precautions. The DON stated he expected his staff to monitor patients per the MD order for each patient. The DON was queried as to what his quality assurance method was for monitoring staff compliance for Observation Rounds with each patient’s MD order. The DON stated they were supposed to be spot-checking their Observation Sheets with the Surveillance video to see if they matched, but they were so short staffed they did not have time to spot-check the video with their charting. The only time they spot-checked the Observation Sheets with the video was sometimes when there was an Unusual Occurrence that happened and then they tried to watch the surveillance video at that time and verify the Observation Sheets. The DON was queried as to the risk to patient safety when Observation Rounding was not occurring as it should for Vulnerable and Sexual Acting Out patients. The DON stated he thought the outcome would not be good due to the risk of patient injury which had happened. The DON stated there was no leadership structure at the facility and due to this, the only time anything ever changed in the facility was when CDPH did a survey and then mandated the facility to come up with a Plan of Correction. The DON stated the CNO (Chief Nursing Officer) of the facility was let go a few weeks ago. The DON stated he, too, would be emailing his resignation this day to the Chief Executive Officer. The DON stated the CEO had never been supported of his requests for adequate resources to run the facility safely. Patients 18 and 19 During an observation and review of the facility’s surveillance video on 12/13/23, and confirmed on 3/19/24, the surveillance video from 8/14/23, at 10:26 p.m., revealed Patient 18 exited his room and then entered Patient 19’s room. Patient 18 was then observed, 53 minutes later, exiting Patient 19’s room, at 11:19 p.m. There was no hall monitor, monitoring the hallway at this time. During a review of Patient 18’s medical record, Intake Assessment, dated 8/3/23, Licensed Staff I indicated, Patient 18 had a Sexual Acting Out Risk score of 5, an Unpredictable Behavior score of 5 and a Danger to Others score of 15. The Intake form indicated a score, “15 and above score = High Risk - Vigilant monitoring of aggressive/dangerous behavior, intervene quickly at first sign of escalation.” During a review of Patient 18’s Observation Sheet, dated 8/14/23, between the times of 10:15 p.m. to 11:30 p.m., Patient 18 was checked off by MHT (Mental Health Technician) G and MHT H as being in her room when she was not. During a review of Patient 19’s Observation Sheet, dated 8/14/23, between the time of 10:15 p.m. to 11:30 p.m., Patient 19 was checked off by MHT G and MHT H as being in his room as a normal observation. During a review of MHT G’s HR File on 12/13/23, a Corrective Action Report, dated 12/17/23, indicated, MHT G, “was performing safety rounds on 8/14/23, MHT G marked a patient in their room when they were not there.....At this time, the patient was with another patient in that patient’s room.” MHT G’s Corrective Action Report revealed he was counseled over a Patient Safety Violation. Training competencies from the HR Director for MHT G were requested but none were received. Upon a request to view MHT H’s HR File on 12/13/23, the Director of HR did not produce an HR File but did produce a termination email, dated 8/17/23, addressed to MHT H’s contracting company, indicating MHT H’s contract was terminated immediately. The HR Director stated he was aware that the surveillance video from 8/14/23, revealed MHT H had falsified the Observation Rounding Sheet, dated 8/14/23, on Patient 18 and Patient 19 between the hours of 10:15 and 11:30 p.m. The training competencies from the HR Director for MHT H were requested but none were received. During an interview with the DON on 12/13/23 at 1:45 p.m., the DON was queried as to the follow-up on the 8/14/23, falsified Observation Rounding Sheets from the MHT G and MHT H on both Patient 18 and Patient 19. The DON stated they terminated MHT H and counseled MHT G for the falsification of those documents. The DON was queried about the 8/14/23, Sexual Acting Out incident that occurred between Patient 18 and Patient 19 between 10:15 p.m. and 11:30 p.m. The DON stated he was aware Patient 18 had told Juvenile Hall post-discharge from the facility that she had sexual intercourse with Patient 19 on 8/14/23, the night before she left the facility. Patient 19 had also admitted to having sex with penetration, with Patient 18 on 8/14/23, between the hours of 10:15 p.m. and 11:30 p.m. The DON was queried if Patient 19 had any history of Sexually Acting Out before the 8/14/23, incident. The DON stated he remembered Patient 19’s Admission intake had no history of Sexually Acting Out. The DON stated he noticed Patient 19 was re-scored as a Vulnerable risk after the 8/14/23, incident. Review of Patient 18’s medical record, revealed a Discharge Summary, dated 8/15/23, authored by Psychiatrist E, indicating, “Condition stable, patient was discharged back to juvenile hall in Placerville with transportation provided by probation officer and aftercare provided by juvenile hall.” During a review of Patient 18’s medical record, a General Progress Note, dated 8/16/23, authored by the Director of Social Services, indicated, “CPS (Child Protective Services) reports filed on 8/16/23 for an incident that occurred on 8/14/23.” Review of Patient 19’s medical record, revealed a Psychiatric Progress Note, dated 8/17/23, authored by Psychiatrist J, which indicated, “Patient 19 was able to talk about the sexual encounter he had with female patient. He stated that he wished it didn’t happen but did not make any objections while it was happening. He also tells me that he did not ejaculate and stopped the process at some point but then woke up more and realized that what he was doing was wrong and didn’t want to get caught. He acknowledges that he did not say anything to stop the process before that time.” Patient 20 and Patient 21 During a review of Patient 20’s medical record, a Generalized Progress Note, dated 7/7/23, authored by Licensed Staff K, indicated, “It has been reported that the patient had bruises/bruise-like marks inflicted to their neck caused by sucking skin. At the time of the incident, the patient was asleep. The patient reported the incident after waking up to the roommate’s (Patient 21) actions. Physician notified. Patient claims that peer was touching their body, rubbing against them, and kissing them, yet the patient claims that they have been asleep during the occurrence.....Patient decided to press charges against the peer (Patient 21) who inflicted bruises/bruise-like marks on the patient’s neck.” During a review of Patient 20’s medical record, Psychiatric Evaluation, authored by Psychiatrist E, dated, 7/7/23, indicated, “Patient 20, was admitted on the evening of 7/6/23, and sustained bruises bruise-like marks inflicted to her neck caused by sucking skin.” At the time of the incident, the patient was asleep in their room. During a review of Patient 20’s medical record, Admission Intake Assessment, dated 7/6/23, authored by Licensed Staff L, indicated, Vulnerability Score of 20. A Vulnerable Score of 15 = High Risk - Patient should be roomed close to the nurses’ station in a private room or with a roommate who is not on Danger to Self or Sexually Acting Out precautions. During a review of Patient 21’s medical record, the Admission Intake Assessment, dated 7/7/23, authored by Licensed Staff M, indicated a Sexual Acting Out Risk score of 20. A score of 15 = High Risk: RN to consult MD for Sexual Acting Out precaution and MD will order at least one of the following: blocked room / “no roommate” status “distance rule” from peers, observation level changes. During a review of Patient 20’s medical record, Risk Assessment Re-Score Form, dated 7/7/23, authored by Licensed Staff M, indicated, a lower Vulnerability Risk Score of 15 after Patient 21 was accused of assaulting Patient 20. During a review of Patient 20’s medical record, Patient Observation Sheet, dated 7/6/23, indicated, no issues for 7/6/2023. During a review of Patient 21’s medical record, Patient Observation Sheet dated, 7/6/23, indicated, Switched to SAO at 10:45 p.m. During a review of Patient 20’s medical record, a General Progress Note, dated 7/7/23, authored by Licensed Staff K, indicated, “Patient left the facility for a rape kit accompanied by MHT and Police officer going to Family Justice Center for a rape kit.” During a review of Patient 21’s medical record, Admission intake Assessment, dated, 7/5/23, authored by Licensed Staff I, indicated, “Patient 21 was charged in Idaho with assault for holding a knife and waving it around. Patient 21 reports there is an open CPS case against the facility in Idaho due to the assault that occurred.” Special Instructions: Prefers not to room with a, “super hetero white girl.” During a review of Patient 21’s medical record, a Generalized Progress Note, dated, 7/20/23, authored by Unlicensed Staff N, indicated, “Case Manager received a message from residential treatment center indicating that the reason Patient 21 was denied was due to him having an active assault charge against him. Patient 21 assaulted staff at his previous placement. He was able to get a hold of a knife and tried to hurt someone.” During an interview with the CNO, on 12/13/23, at 2 p.m., the CNO was queried as to the policy for the placement of Vulnerable residents. The CNO stated his belief was the facility’s policy indicated, Vulnerable patients with a High Vulnerable Risk score should be roomed close to the nurses’ station in a private room or with a roommate who is not a Danger to Self / Danger to Others or a patient who is on Sexual Acting Out precautions. The CNO was queried as to why Patient 20 was roomed with Patient 21 who was a danger to himself and also had a history of assault at his previous residential treatment center. The CNO stated, “sounds like it was a training issue.” Competencies for Unlicensed Staff M and Unlicensed Staff N were requested but never receive them. During a review of the staffing schedule for 7/6/23, the Census was documented as 16. Per the Unit Base Staffing Policy, a census of 16 would mandate two RN’s, one Hall Monitor and two Mental Health Technicians to safely care for that acuity. The Staffing Sheet for 7/6/23, revealed there was one RN and two Mental Health Technicians scheduled. Patient 16 and Patient 17 During a review of Patient 16’s medical records, a Suspected Child Abuse Report, dated 11/6/23, authored by Unlicensed Staff O, indicated, “Date of incidences: 11/3/23 and 11/4/23 at the facility.” The form listed Patient 16 as victim and Patient 17 as Suspect. The Incident information, indicated, “Patient 17 entered Patient 16’s room three times in two days having consensual sexual intercourse with the male peer at 6:45 p.m. on Friday, November 3, and at 2:45 p.m. on November 4. [Patient 16’s name] reported he was pressured by [Patient 17’s name] into having sex with her two days in a row.” During a review of Patient 16’s medical record, an Admission Intake Assessment, dated, 10/19/23, authored by Licensed Staff I, indicated, Patient 16 was scored on the Vulnerable Risk Scale as a 20. A Vulnerable Score of 15 = High Risk - Patient should be roomed close to the nurses’ station in a private room or with a roommate who is not on Danger to Self or Sexually Acting Out precautions. During a review of the Census on 3/18/24, Patient 16 was rooming with Patient 22 on 11/4/23. During a review of Patient 16’s medical record, a Nursing Progress Note, dated, 11/5/23, authored by Licensed Staff P, indicated Patient 16 was on 1:1 for additional SAO observation. During a review of Patient 16’s medical record, Progress Note, dated 11/6/23, authored by Psychiatrist F, indicated, “I spoke with nursing staff. Nursing staff report over the weekend, the patient was involved in a sexual act.....We will likely need to contact appropriate authorities after.” During a review of the Surveillance Video and Camera Review of Events Form, dated, 11/3/23 - 11/4/23, Camera viewing from 200 B, time of events 6:03 p.m., 6:41 p.m., and 2:44 p.m., the Nature of Event was Sexual Acting Out from Patient 17 toward Patient 16. Events Described: Friday 11/3/23 at 6:03 p.m., Patient 17 entered Patient 16’s room at 6:04 p.m. Unlicensed Staff Q entered Patient 16’s room, handing out lunch tickets and did not discover Patient 17 in there. At 6:05 p.m., Patient 17 left Patient 16’s room, re-entered at 6:41 p.m., and left a second time at 6:45 p.m. On Saturday 11/4/23, at 2:39 p.m., during Patient Safety observation rounds, the MHT did not enter rooms. At 2:44 p.m., Patient 17 entered Patient 16’s room. At 2:48 p.m., the MHT entered Patient 16’s room and did not discover Patient 16 in the room. At 2:50 p.m., Patient 16’s roommate (Patient 22) walked out of their room. At 2:51 p.m., Patient 22 re-entered their room. At 2:54 p.m., Patient 17 left Patient 16’s room, returning to her room. Patient 17 was in Patient 16’s room unattended and unnoticed by staff approximately 16 minutes. During a review of MD orders, authored by the Interim Medical Director, Patient 17 was on Sexual Acting Out Precautions from 11/2/23 - 11/7/23. During a review of Patient 17’s medical record, Historical Profile, dated 11/2/23, from previous admissions, indicated Patient 17 had a score of 15 for Sexual Acting Out on previous admissions. A score of 15 = High Risk: “RN to consult MD for Sexual Acting Out precaution and MD will order at least one of the following: blocked room /“no roommate” status, “distance rule” from peers, observation level changes.” During a review of Patient 17’s medical record, Nursing Progress Note, dated 11/3/23, authored by Licensed Staff V, indicated, SAO (Sexual Acting Out), Patient 17 making inappropriate sexual comments with her peers. During a review of Patient 17’s medical record, a General Progress Note, dated, 11/4/23, authored by Licensed Staff K, indicated, “Patient reported to the MHT that she had sex twice with another patient on the unit.” Patient 17 stated, “she went into another patient’s room last night and today in the afternoon and says that she had sex twice with the same patient.” During a review of Patient 17’s medical record, a Psychiatric Progress Note, dated 11/6/23, authored by the Interim Medical Director, indicated, “Patient 17 reports that she had sex with a male peer, consented, and states that it happened twice....She then reports that it hurt her emotionally since it reminded her of the past.” During a review of Patient 17’s medical record, an Admission Intake Assessment, dated 11/2/23, authored by Licensed Staff I, indicated Patient 17 was scored as a 15 for Danger to Others. “Score of 15 Requires vigilant monitoring of aggressive/dangerous behavior, intervene quickly at first sign of escalation. Do not room with Vulnerable patient.” During a review of Patient 16’s medical record, Observation sheets, dated, 11/3/23, during the times of 5:57 p.m. to 6:49 p.m., indicated Patient 16 was listed as being in the Day room, Hallway, and Cafeteria. No Hall Monitor was visible at the time of the incident. During a review of Patient 16’s medical record, Observation sheets, dated 11/4/23, authored by Unlicensed Staff T, during the time of 2:39 p.m. to 3:09 p.m., indicated Patient 16 was listed as being Awake and Sleeping. No Hall Monitor was visible at the time of the incident. During a review of Patient 17’s medical record, Observation Sheets, dated 11/3/23, authored by Unlicensed Staff Q, Unlicensed Staff W and Unlicensed Staff X, charted from 5:56 p.m. to 6:49 p.m., indicated Patient 17 was charted as being in the Day room and the Nurses Station. During a review of Patient 17’s medical record, Observation Sheets, dated 11/4/23, authored by Unlicensed Staff Unlicensed Staff T, Unlicensed Staff X, charted from 2:39 p.m. to 3:09 p.m., indicated Patient 17 was awake, lying, sitting and sleeping. During a review of Unlicensed Staff T’s HR File on 12/13/23, indicated Unlicensed Staff T was terminated from the facility. During an interview with the Director of HR, the Director of HR was queried for the reason Unlicensed Staff T was terminated and responded he terminated her for multiple disciplinary issues, including falsifying Observation Sheets. During a review of the staffing on 3/19/24, the Census for Unit 200 was 16 patients for both 11/3/23 and 11/4/23. The staffing consisted of two RN’s and four MHT’s. The staffing was sufficient pertaining to staff / patient ratio, but the Observation Sheets were not an accurate reflection of patient activity as they did not match the patient activity seen on the surveillance video. During a review of the facility’s policy and procedure titled, “Precautions” dated 5/26/22, the Policy indicated, “Precautions process: Prior to admission, the Assessment and Referral RN will review the patient’s case with the admitting psychiatrist and consider the type of precautions necessary to maintain the safety of the patient. Upon admission the physician may order precautions if indicated and identify one of the following observation levels: Q15 (every 15 minutes) check, Q 5 min (every 5 minutes) checks, 1:1 constant visual observation with close enough proximity to the patient to address a safety concern.....Precautions that providers can order may include but are not limited to: ...Assault/ Violence Precautions, Sexual Acting Out, and Vulnerability Precautions.....Sexual/Sexual Acting out (SAO) Precautions: No patient shall participate in any sexual acts while undergoing treatment at the facility, regardless of age or perceived consent. Sexual activity among patients can negatively impact progress towards treatment goals and / or cause harm to both the patient and others. Intervention for patients on SAO precautions may include but not limited to: Observation for inappropriate sexual behavior with staff or peers. Redirection of sexual statements or suggestive comments, monitor patient for attempts to expose themselves, attempt to elude staff observation sneaking into other patient’s rooms, and collusion with peers to distract staff, Staff will redirect all inappropriate sexual behavior and set clear and supportive limits, Provider may order, ‘No roommate status’ or ‘private room’......Vulnerability Precautions: patients admitted to the facility may particularly be vulnerable to exploitation for others. Patients admitted to the facility are screened for vulnerability risk and those identified are placed on Vulnerability Precautions. Precaution Interventions for vulnerability risk may include (but not limited to): place the patient in a room within close proximity of the nursing station, the patient should not be placed in a room with a patient on assault or sexual precautions. Staff will maintain vigilance and enforce strict boundaries between this patient and patients on violence precautions, Comprehensive hand off communication including risk of exploitation to all staff assuming care for this patient.....In the event of exploitation, staff will follow the actions outlined in the violence precaution section of this policy......Assault/Violence Precautions interventions for a patient with potential for harming others include (but not limited to): Avoidance of loud or harsh tones when speaking, offer redirection to task at hand, use de-escalation techniques and non-violent interventions, setting supportive limits and offer choices to patient, remove the patient from peer audience, ensure safety of vulnerable patients, encourage voluntary therapeutic time out, monitor the environment closely for contraband that can be used as weapons, Do not room patient on violence precautions with patients who are on vulnerability precautions. Place low demands on patient to participate in activities if participation escalates the patient or puts the patients at risk.” During a review of the facility’s policy and procedure titled, “Sexual Acting Out,” dated 5/26/22, the Policy indicated, “In accordance with our philosophy and mission, all Facility patients shall receive humane and compassionate psychiatric care in a safe setting. Any patient alleging to be a victim of sexual assault will be treated with dignity and in accordance with this policy. No patient shall participate in any sexual acts while undergoing treatment at the facility regardless of age or perceived consent. The facility will protect all patients from sexual advances, intimidation, or abuse, will be promptly investigated and treatment will be adjusted, as necessary. The facility is a mandated reporter. By extension, any facility employee who has received report from a patient or family member involving sexual abuse or neglect, or otherwise believes an act of sexual abuse, intimidation, or aggression has taken place against a patient (whether potentially occurring prior to or during a patient’s stay at the facility), that employee must report to the facility administration within 24 hours. Any patient assessed as potentially harmful to other patients (via sexual abuse, harassment, or intimidation) must be placed on SAO (Sexual Acting Out) Precautions. Any patients assessed as vulnerable to sexual intimidations, unflattering attention, or abusive behaviors must be placed on Vulnerability Precautions and counseled to approach staff at any time they feel threatened. ....Scoring frequency must be done: At the initial assessment in the Assessment and Referral Department, every 24 hours by the RN within the Daily Nursing Flow Sheet, after every incident indicative of an SAO risk factor (i.e., disrobing, boundary violations, aggressive behavior), after any new risk factors are found during the patient’s stay (whether through psychological assessment, physician visits, or other daily interactions)....The House supervisor will notify the Director of Quality & Risk Management, the Director of Nursing, the Director of Clinical Services and / or assigned social services staff, the attending Psychiatrist of patient involved, the Medical Director, and the Chief Executive Officer....The identified House Supervisor and/or social services staff will follow-up with the treatment planning accordingly....A patient alleging or believed to be a victim of alleged or actual coerced sexual behavior will be taken to a hospital of choice based on the desire of patient, their family, or the Attending Physician. A physician order is necessary to take the patient to an emergency room. If the Attending Physician cannot be reached, call the physician on-call or the Medical Director....To the fullest extent possible prior to the patient being taken to a hospital or emergency room for examination: contact the local police department to document an official report of the alleged coerced sexual behavior. Document this in the patient medical record. If the patient is a minor, the parent/guardian are also informed that the police department will be notified. Discourage the patient from bathing, showering, or washing their genital area, discourage the patient from changing clothes, female patients should not void. If necessary, to void, save specimen in a clean catch container and transfer it to the emergency room with the patient.....If the police officer wants to interview the alleged sexual offender, the following procedure applies....If known, any patient who has been discharged after sexually abusing or intimidating a patient will be carefully evaluated before subsequent admission. The patient’s attending physician will be notified prior to admitting the patient and appropriate level of care and precautions will be discussed to determine if the patient’s needs can be adequately met at the facility.” During a review of the facility’s policy and procedure titled, “Level of Observation,” dated, 5/26/22, the Policy indicated, “Purpose: To establish guidelines for the definition, use, and implementation of patient observation within the Hospital. In addition to recording the whereabouts of patients, the purpose is to provide a system of observation to provide safety and oversight based on patient acuity, severity/type of symptoms and overall needs. Policy: Each patient will be routinely observed in compliance with provider orders and prescribed protocols. Procedure: The provider shall order an observation level/status at time of admission.....The degrees of observation in the facility are: Safety: specified and dedicated staff member is assigned to the patient. Direct and continuous staff observation at a safe distance no more than 5 feet from patient at all times while the patient is awake. While the patient is asleep, the 1:1 staff member is to be in the doorway of the patient room, ensuring the patient is safe, while maintaining visual from the hallway. This level of observation is maintained even in the event of personal hygiene, toileting, and other self-care needs. Arrangements should be made for same sex staff or RN to accompany the patient during these times.......Routine 15-minute observations: Minimum level of observation for all patients, staff will observe and document patient’s location and behavior every 15 minutes, patient may attend all off-unit meals and program activities without restriction. Staff will check in with patient periodically during waking hours to ascertain safety and well-being. Observations may not be made in a doorway or at a distance. It is expected that staff conducting 15-minute observations approach the patient and engage the patient verbally during waking hours. When sleeping, staff will visually check the patient’s identity, observe respirations, and check that they are not in distress......Increased or heightened observation level (Q-5 Minute Checks): An RN or the Provider can order heightened or increased observation levels from Q-15 to Q-5 depending on the needs of a patient. Staff will observe and document patient’s location behaviors every 5 minutes, depending on the increased observation level order....A provider’s order is needed to institute a decreased observation level....Staff will complete the patient observation record as rounds are completed for each of their assigned patients, using the coding system describe on the record. Staff will note patient location and behavior at each required interval.....Observation Rounds are to be completed by the assigned staff every 15 minutes on every patient around the clock. This form includes every level of observation (i.e., 1:1). It is the responsibility of all assigned staff to notify the Charge Nurse in the event they are unable to complete their Observation Rounds in a timely manner.....Observation Rounds are never to be done in advance and are to be completed in a timely manner. All documentation on Observation Rounds sheet is to be the original and must not be modified or obscured.....Falsification of Observation Rounds is grounds for termination.” During a review of the facility’s policy and procedure titled, “Hallway Monitor,” dated, 10/23/23, the Policy indicated, “Purpose: to ensure safety of the unit milieu through hallway monitoring. Policy: The adolescent units will have a Hallway Monitor present on the unit at all times. The staff member assigned to the role must be in the hallway at all times when there are two or more patients on the unit. They must be vigilant of the hallway and therefore, can never be assigned patient observation rounding, higher levels of observation on any other task. The Hallway Monitor is to help ensure that the hallway is safe, that patients are going into their assigned rooms only and must position themselves, so they have a clear view of the hallway. The Hallway Monitor is to be continually surveilling the hallways and patient bed areas. The Hallway Monitor must not engage in social conversations with others in order to prevent distraction and to ensure patient safety.” During a review of the facility’s policy and procedure titled, “Patient Rights: Abuse Prevention” Revised 5/13/21, the Policy indicated, “Purpose: To ensure patients’ rights and patient safety. Policy: Abuse prevention related to patients receiving care in a safe setting and to be free from all forms of abuse or harassment. Definition of care in a safe setting: Each patient receives care in a safe environment. This includes standards of practice for patient environmental safety, infection control, and security. This includes protection for patient’s emotional health and safety, as well as his/her physical safety. Respect, dignity, and comfort would be components of an emotionally safe environment. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimation of one patient by another. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental, anguish, or mental illness. We report abuse occurring to any of our patients: Child abuse is defined as any act or failure to act those results in death, serious physical or emotional harm to those under 18. For Children, sexual abuse is a separate category of abuse, and includes incest, intercourse, rape, sodomy, fondling, exhibitionism, and commercial exploitation in prostitution or production of pornographic materials. Procedure: Prevention: The hospital ensures that the number and types of qualified, trained and experienced staff at the hospital and available to meet the care needs to every patient. Screening: The hospital ensures that person with a record of abuse or neglect are not hired or retained as employees. Identify: The hospital maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. Train: The hospital during its orientation program, and through an ongoing training program, provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection. Protect: hospital protects patients from abuse during investigation of any allegations of abuse or neglect or harassment. Investigate: The hospital investigates in a thorough and timely manner all allegations of abuse, neglect, and mistreatment. Report/respond: Any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State and Federal law. Document pertinent issues and interventions when dealing with abuse occurring in the hospital, such as patient sexual contact. Include direct statements by the patient and discussion of all therapeutic approaches taken, do not draw any conclusion or make subjective statements. Notify the charge nurse who will inform the doctor if necessary. Document your actions in the chart and include copies of any forms or faxes, and any identification numbers given to you. If appropriate, advise patient of the report and let the patient know that you are a mandated reporter.” During a review of the facility’s policy and procedure titled, “Orientation and Competency Training,” dated, 5/13/21, the Policy indicated, “Purpose: Introduce new employees to company history, organizational structure, employee benefits, and employment policies. The orientation includes competency training and assessment specific to the employee’s position. Competency training and assessments are completed to confirm staff understanding of policies, procedures, and work processes established to support quality care and customer service. Policy: Orientation and competency training programs are provided to help new employees become familiar with work environment, benefit program, and position responsibilities including scope of practice. Procedure: The education Department, working with the Human Resources Department, is to conduct a hospital orientation program for all new employees to acquaint them with the Hospital’s policies and procedures. Employees are paid for attending this program. Departments conduct individual orientation and in-service programs to further acquaint new employees with the individual work areas. These programs are the responsibility of department directors. New employees will have training and any applicable competency assessments for their assigned position at time of hire or transfer to a new or additional position. Applicable assessments for job competencies are to be completed during the first few weeks of assignment to a new position. These assessments are specific to the scope and responsibilities of duties as outlined in the job description. Competency assessments are evaluated to validate Knowledge (quiz), skill (a return demonstration) and critical thinking (discussion or review of scenario). Training is conducted and verification of competency is verified by an individual with expertise in content of topic and at an equivalent or higher level of licensure or experience. Expertise in content and ability to assess skill competency is based on education, experience, and current licensure. The Director of Education and the Director of Human Resources are responsible for monitoring compliance with competency assessment.....Skills day is conducted quarterly, and scheduled on the month hired for those who work directly with patient and (regularly) works in patient care areas.” During a review of the DON (Director of Nursing) job description, “Description of Position,” indicated, “organizes and administers areas of Nursing Services to attain the facility’s objectives established by the governing authority. Key responsibilities: Organizes programs, policies and procedures that are developed to assess, evaluate, and meet the needs of patient’s inpatient psychiatric services ...Plans supervises, and coordinates care given by Registered Nurse, Licensed Vocational Nurse, Licensed Psychiatric technician, and other mental health workers ...Plans and assigns staffing ratios based on patient needs, acuity, staff competency and regulatory requirements. Implements standards of nursing practice in the behavioral healthcare setting, annually reviewing the nursing practice ...Ensure clear, concise and current written policies and procedures are available to assist the staff and minimize risk factors ...Supports and maintains a culture of safety and quality ...Recommends modifications, additions or deletion personnel policies to ensure reasonable hours and acceptable working condition to provide patient care coverage ...Implements an effective, ongoing program to measure assess and improve the quality of nursing care delivered to psychiatric patients ...Assures that nursing leaders review monthly performance improvement compliance with established indicators and sees that corrective action are taken when negative outcomes are identified. Collaborates with facility leaders in developing, implementing, reviewing, revising, and monitoring facility-wide performance improvement activities ...Facilitates the patient’s access to the appropriate level of care and setting ...Upholds the Organization’s ethics and customer service standards.” During a review of the MHT (Mental Health Technician (I-III) job description, the MHT reports directly to the DON. The Mental Health Worker provides direct patient care to all patients with emotional or psychiatric disorder, supports, therapeutic milieu, ensures safety and well-being of patients and carries out general nursing assistance necessary to treatment of adolescents, adults or older adult patient as assigned. The Mental Health Worker is the primary person responsible for the safety of the unit milieu. Environmental safety rounds are required each shift and on-going safety assessments including secure contraband found within the milieu will be completed by the Mental Health Worker. Safety Observation are required to be documented and recorded in the patient’s medical record as ordered by the psychiatric provider or under the direction of the Registered Nurse. Key Responsibilities: Participate in treatment planning, Suggests modifications to treatment plan based on observations of patient behavior, Participate in implementing patients’ treatment plans by monitoring patients’ progress, Communicating information regarding patients’ behavior to other members of the treatment team, Co-facilitates didactic, educational, and community groups within the context of the adolescent treatment program, Encourages and facilitates patients’ participation in therapeutic activities, Supervises patients to ensure their safety and their involvement in treatment. Maintains a safe, orderly, and therapeutic physical environment for patients. Participates in maintaining the therapeutic milieu on the unit, enforces the level system or other methods of behavior management, Maintain patient, program, department, and related documentation. Complete orientation and competency assessments as required for position. Upholds the Organization’s ethics and customer service standards. Performs related duties, as requested. Demonstrates the ability to set limits for clients and uses de-escalation techniques appropriately. Follows all safety procedures; is alert to changing situations and contributes to preventing opportunities for danger to develop. Conducts and documents 15-minute (or more frequent including 1:1) rounds on patients in a timely manner. Works with nursing team to ensure that the unit maintains safe and therapeutic including appropriate use of a hall monitor. Good judgement, problem solving, and decision-making skills. 38088 (Cross Reference A-263, A-1680, A-1704, A-1725, A-1726) 2. During an observation on 3/18/24, in Unit 500 (High Acuity, all Male unit for patients with behaviors that required more observation than other floors, for resident and staff safety), on 3/18/24, at 11:35 a.m., the community room (a room for patients to listen to music, watch movies or participate in therapy) was closed and locked. One Unlicensed Staff was monitoring patients in their bedrooms by rounding on each room with an ipad. The other Unlicensed Staff was standing outside of Room 501 for a 1:1 observation (A process where a staff watches a patient constantly for safety, for themselves or others). There were no activities or therapists in the unit interacting with patients. Eight other patients were in their darkened rooms, covered by sheets or blankets. There was no music. The walls had multiple areas of unpainted plaster patches that were in various states of repair. During an interview with the Director of Quality Management and Patient Risk and the Director of Clinical Services, on 3/18/24, at 9:35 a.m., the Director of Clinical Services stated Unit 500 was a high acuity and for violent male patients. He stated the unit had a restricted daily census of ten for patient and staff safety. During an observation and interview on 3/18/24 at 10 a.m., a Mock (Practice) Code Green (An escalating psychiatric event or emergency that presented a potential need for staff to physically restrain a patient) was observed. The facility was a locked facility with restricted access into and out of each unit. During a Code Green, staff were supposed to arrive to provide support. The Director of Quality Management and Patient Risk and the Director of Clinical Services stated, “The Director of Nursing and the House Supervisor were supposed to show up but did not, because the House Supervisor called in sick and the Director of Nursing was doing direct patient care, and there is no Chief Nursing Officer.” During an interview on 3/18/24, at 10:48 a.m., the Director of Nursing stated, “There is immense pressure from the Chief Executive Officer to get more patients to increase the census. There is so much pressure to get more patients, heads in beds.” He stated I was never consulted before patient admissions if we had enough staffing to provide safe care for patients. The Director of Nursing stated the Chief Executive Officer was under huge pressure to get the census up because she talked about it all the time at leadership meetings. During an interview on 3/18/24 at 11:50 a.m., Unlicensed Staff Z stated, “In December it started to get really unsafe in the facility. We worked out of ratio (Number of staff to number of patients) consistently on the weekends and nights.” She stated there had been an increase in Code Greens, and without enough staff, there was no one to respond. She stated the facility had admitted patients they cannot safely take care of, violent, assaultive patients. She stated the patients got out of control and could not be de-escalated, and then patients and staff got hurt. Unlicensed Staff Z stated she has been hit and punched multiple times until she was sore. She stated she told the Director of Nursing and Administrators, and she was afraid and there was not enough staff. During an interview on 3/18/24 at 12 p.m., Licensed Staff AA stated they were frequently without enough staff to monitor patients. She stated the last Chief Nursing Officer and the Chief Executive Officer terminated a lot of staff, and it created a bad staffing shortage, and now people were afraid to speak up about safety and staffing. She stated they did not want to lose their jobs. She stated it was unsafe for patients and staff to work out of ratio. She stated if they did not have staff, they could not consistently and safely assess and monitor patients for any escalating agitated behaviors. She stated the patient units were frequently short staffed and out of ratio, so patients would not be taken to the cafeteria for meals. Licensed Staff AA stated patients could not even eat in the unit community room because, without enough staff, staff could not monitor the patients who ate in the community room and the patients who stayed in their rooms. She stated the patients all had to eat in their rooms like, “Caged animals.” She stated, “It is unsafe and worse on weekends.” During an interview on 3/18/24, at 3:45 p.m., the Director of Plant Operations and Safety stated he was not aware of any staff injuries in the inpatient units. He stated a patient had kicked a fire extinguisher off the wall, and when the fire extinguisher engaged, patients and staff were breathing the fumes from the extinguisher. He stated it went everywhere, and it was not good for anyone to breath. He stated he remembered staff who went to urgent care for treatment because it affected their breathing. He was not aware if any patients had breathing issues associated with the extinguisher fumes. During an interview on 3/19/24, at 9:45 a.m., Unlicensed Staff Y stated Patient 1 was a 1:1 patient. He stated he was on the 1:1 because he consistently engaged in assaultive behaviors against patients and staff. He stated patients and staff were not safe because of the staffing. Unlicensed Staff Y stated, on night shift there were only two Mental Health Workers (MHW). He stated one MHW was assigned to the 1:1 patient, and the other MHW observed the other patients every five to 15 minutes. He stated, if a patient began to escalate his behaviors and attacked either another patient or staff, there would not be enough staff available to keep the other patients safe. He stated it was a dangerous situation. He stated they worked out of ratio all the time. Unlicensed Staff Y stated Patient 1 had been here a couple of years, and because of his behavior he was stuck in his room. He was confined to his room to keep him and other patients safe. He stated Patient 1 had punched and kicked him and other patients. During an interview on 3/19/24, at 10:20 a.m., Unlicensed Staff BB stated there had been a lot of patient-to-patient assaults in the facility. He stated recently the patients started a riot that was so bad the police were called and came into the facility with their guns drawn. He stated a lot of patients and staff were hurt. He stated another time a patient stood up in the dining room and walked over to another patient and, “just checked him, I mean really punched him,” and then walked over to the wall and started banging his head and screaming he needed help. “I tried to de-escalate, but he was so agitated I had to use a physical hold and put him into a seclusion room, where he was emergently medicated. The lack of staffing contributed to the assaults because there are not enough staff to assess and monitor all the patients and respond to an escalation of behaviors.” During an interview on 3/19/24, at 10:40 a.m., Unlicensed Staff CC stated it was really dangerous for patients when it was short-staffed. Patient 1 was so aggressive and assaultive on other patients that at one point the doctor ordered him to be on a 2:1 observation (Two staff to watch one patient). He stated the facility took him off 2:1 because it was too many staff [watching him]. He stated Patient 1 did not have any quality of life because he was stuck in his room, could not be around other patients for safety, he could not participate in activities or have leisure time outside. Patient 1’s stay was like being in jail. Patient 1 was so difficult staff could not get him to cooperate with anything without endangering him or other patients or staff. Unlicensed Staff CC stated everyone had told administration that it was not safe for patients or staff when they are so short-staffed. He stated nothing changed. He stated, when a situation escalated and patients observed it, they got agitated too and it was dangerous. He stated patients just sat in their rooms and listen to the voices in their heads and it was dangerous. During an interview on 3/20/24, at 2 p.m., Physician DD stated Patient 1 needed to be moved to a more appropriate facility for his assaultive behaviors. He stated Patient 1 had assaulted other patients and staff and even, “Popped me,” a couple of times. He stated Patient 1 remained on 1:1 observation because of his behaviors and assaults on other patients. He stated Patient 1 would remain in a solitary confinement situation for the duration of his stay due to his behaviors. He was having a deterioration of physical condition because of his behaviors and being uncooperative. He stated, “His teeth are terrible, and we cannot get him to go to a dentist. He was uncooperative. He has lost muscle mass as a result of being confined to his room and not getting any exercise. This if far from a therapeutic environment. His life is really quite terrible. You won’t find any documentation of his teeth because he won’t allow an exam.” He stated, “If they had more staff they could monitor him closely, develop a better relationship and perhaps allow for some cooperation, but staffing doesn’t allow that. He is really resource intensive.” He stated, “Patient 1 is in danger from other patients who respond to his behaviors by either protecting themselves or striking out against him out of fear.” During an interview on 3/21/24 at 9 a.m., the Interim Medical Director stated she was the Medical Director and also sat on the Governing Board. She stated her role was to address issues and resolve them. She stated the Governing Board had reviewed facility reported incidents that involved patient-to-patient assaults. She stated she did not recall if there were any recommendations by the Governing Body to address those concerns. She stated she thought staff could use more training on how to de-escalate agitated patients. The Interim Medical Director stated she was unaware of any patient safety, social services or staffing issues that have impacted the therapeutic milieu (Therapy provided to patients in the form of 1:1 counseling, group meetings, group therapy, and activities) for patient treatment at the facility. During an interview on 3/21/24 at 1:40 p.m., the House Supervisor stated the Admission process for this facility was to get heads in beds. She stated they never turned down a patient admission. She stated, “The problem was we do not have the appropriate staff with the appropriate training.” The House Supervisor stated the facility Administration was not interested in hearing about the staffing issues and any patient safety issues. She stated the danger to patients was there was not enough staff to detect increased agitation of patients and to mitigate the circumstances. She stated the more trained staff they had, the safer it was for patients and staff. During an interview on 3/22/24, at 10:30 a.m., the Director of Nursing stated, “Everyday at the morning daily meeting I hear about patient-to-patient assaults.” He stated they were supposed to have enough staff to help reduce the number of patient assaults, but they could not hire enough nurses and staff. He stated, without proper staffing, more patient-to-patient assaults would occur. The Director of Nursing stated, “The facility’s priority of admitting patients without considering if we had enough staff to safely care for them has contributed to an unsafe environment for patients and staff.” He stated staff have had to work with a 1:24 ratio, and it was unsafe. He stated the facility admitted all patients without consulting him if there was enough staff to provide care, and it was unsafe.The Director of Nursing stated one staff member was so traumatized by the patient riot and assaults that they had to move her to a different low acuity unit to get her to come back to work. Patients in this unit had attacked the nurses, and the nurses were afraid to come into work. During an interview on 3/22/24 at 11:45 a.m., Unlicensed Staff B stated she observed a patient-to-patient assault, and there was blood everywhere. She stated a patient slammed a chair down so loudly it frightened everyone. She stated blood splattered everywhere. During a record review and concurrent interview on 3/22/24,at 12:50 p.m., Licensed Nurse EE stated Patient 1 was admitted 8/12/22, and was on precautions for assaultive and violent behavior and Sexually Acting Out Behavior. He stated he was on 1:1 precautions, and they did not see a Psychosocial Note for Patient 1 completed in the last 72 hours. They stated, “In fact I don’t see any Psychosocial Notes in his medical record. The importance of the note is that it the basis of therapy. It documents the assessments of strengths and weaknesses of patients. Without it the therapy is inaccurate and inappropriate. You end up with a completely useless treatment plan.” They stated they could not find communication with his Conservator or any General Progress Notes for 12/12/23, about an incident that result in Patient 1 having a head laceration because of a patient-to-patient assault. They stated, “Patient 1 experienced harm and there was no indication if another patient experienced harm either because of the patient-to-patient assault.” Licensed Staff EE stated, “I would have expected a Progress Note describing the incident and investigation with interviews with the MHW and other patients who observed or had been involved.” They stated there should be a note about communicating with the Physician and Conservator, in addition to notifying the House Supervisor and Administrator, but there was no documentation of a head laceration, no pain assessment, and only notes about neuro checks ordered by a physician on 12/12/23 at 10:52 a.m. Unlicensed Staff EE stated the neuro checks were ordered every 15 minutes but only one was ever completed, and the rest were refused by patient 1. They stated, “It is like his behaviors and the injuries associated with him are normal.” During a concurrent interview with Licensed Staff EE and a record review on 3/22/24, at 12:55 p.m., for Patient 2, no Progress Notes about being assaulted on 12/11/23, were located in the medical record. Unlicensed Staff EE stated he could not find any documentation that Patient 2 was assaulted by another patient. They stated there was a pain assessment on 12/11/23, for left eye pain with administration of Tylenol, but there was no reassessment of the pain level after administration. They stated there should be documentation of the incident and assessment of Patient 2 to determine if he was harmed. During a concurrent interview with Licensed Staff EE and a record review on 3/22/24, at 12:55 p.m., for Patient 3, they stated there was no documentation on the assault by Patient 1 on 12/12/23, no assessment for injuries, no notifications to the physician. During a concurrent interview with Licensed Staff EE and a record review on 3/22/24, at 12:55 p.m., for Patient 5, they stated there was no documentation in the medical record that Patient 5 punched Patient 6 multiple times on two different attempts on two different days, except for two attempts to notify Patient 5’s father. During a concurrent interview with Licensed Staff EE and a record review on 3/22/24, at 12:55 p.m., for Patient 7, they stated Patient 7 assaulted Patient 11 on 12/8/23, but the medical record did not have any documentation about notification to Patient 7’s parents or physician, and no documentation of a second assault on Patient 11 on the same day. They stated the lack of documentation makes it seem like patient-to-patient assaults, “are normal.” During a concurrent document review and interview on 3/22/24 at 1:15 p.m., the Director of Quality Management Patient Risk was asked what was the P&P (Policy & Procedure) for investigating Abuse. He provided a document titled, “ABUSE PREVENTION,” revised 5/13/21, and he stated this was the only document the facility had. He stated there was no P&P for how to investigate an allegation or observation of abuse. He stated he did not know who the facility Abuse Coordinator, responsible for investigation and reporting abuse, was. He stated he did not know about reporting to the California Department of Public Health Licensing and Certification (CDPH L&C) for abuse allegations by patients or observations of patient-to-patient abuse. He stated he did not know what the regulatory requirements were for investigating and reporting to CDPH. The Director of Quality Management Patient Risk stated he thought the Department wanted the facility to wait until there were several Occurrence Report Incidents and just send in a summary to the CDPH. During a concurrent document review and interview on 3/22/24 at 1:15 p.m., with the Director of Quality Management Patient Risk, a review of a document titled, “Occurrence Report Summary, not dated, about the Entity-Reported Incidents: CA00875640, CA00875645, CA00875656, indicated, “TIME OF INCIDENT 12/11 17:50 (5:50 p.m.) Summary of Event: Incident 1 : Patient (1) was in the day room, when he stood up and assaulted another client (Patient 2) unprovoked. Staff member immediately intervened. Staff escorted pt to the quiet room. Manual hold initiated from 1750 - 1751 to administer emergent meds.....Investigation: Video Review: Incident 1: MHT (Mental Health Technician) was present within 5 ft of patient (1). Patient 1 stand [sic] up casually and walk past another patient (Patient 2) with no signs of aggression before turning towards the peer and punching several times. MHT immediately separates patients. Other staff enter room and escort Patient 1 out of room.” He stated there was no indication that a review of the situation was conducted to determine what caused the incident and how to prevent it from happening again. He stated that information might be in Patient 1 and Patient 2’s medical records. A review of the Complaint Intake information indicated incident one was reported to the Department 12/15/23 at 4:53, four days after the incident occurred. Further review of the document indicated, “TIME OF INCIDENT 12/11 9:30 Incident 2: Pt (1) was walking down the hallway when he suddenly went into peers’ (Patient 3) room and attacked peer unprovoked. Staff responded immediately and manually separated patient (1) from peer (Patient 3). Using manual hold, patient (1) was escorted to the quiet room where he was given emergent meds IMs (Intramuscular Injection) ... after which he was put in seclusion. Investigation: Incident 2: Patient (1) enters room and remains for 6 seconds before staff enter and remains in room for total of 22 seconds before being escorted out by MHTs. ...The patient (3) was hit on his upper left arm as he tried to block punches.” The Director of Quality Management Patient Risk, stated the investigation notes were not clear. A review of the Complaint Intake information indicated incident two was reported to the Department 12/18/23 at 8 a.m., seven days after the incident occurred. Further review of the document indicated, “TIME OF INCIDENT 12/12 9:30 a.m. Incident 3: Patient (1) unprovoked walked into another patient’s room (Patient 4) and punched him multiple times. Manual hold initiated to bring patient into the quiet room. Seclusion then initiated for safety. Patient(1) received laceration on head during the encounter....Investigation: Incident 3: One MHT present in hallway at time of incident. Patient 1 crosses the hall and enters room (Patient 4) for 52 seconds. Both patients then exit room, Patient 1 returns to his room while Patient 4 goes to RN station and reports incident.” A review of the Complaint Intake information indicated incident three was reported to the Department 12/15/2023 at 4:58 p.m., three days after the incident occurred. During a concurrent document review and interview on 3/22/24 at 1:15 p.m., the Director of Quality Management Patient Risk, reviewed a document titled, “Occurrence Report Summary,” not dated, about Entity-Reported Incident CA00878894, reported to the Department by the facility on 12/18/23 at 8 a.m. Review of the intake information indicated Patient 1 sustained a head laceration after an assault on Patient 4. Review of Patient 1’s medical record, a document titled, “General Progress Note,” dated 12/11/23 at 4:50 p.m., indicated, “Pt slapped buttocks of female staff member while conversing in the day room. 12/11/23 at 7:25 p.m., Client was in the day room and assaulted another client unprovoked. Staff escorted pt to quiet room. Manual hold initiated.....to administer emergent meds. Pt in seclusion for threatening and assaultive behavior as he is an immediate danger to others. 12/12/23 at 12:03 a.m., Pt (1) was walking down the hallway when he suddenly went into peers’ (4) room and attacked peer unprovoked. ...Via manual hold patient was escorted to the quiet where he was given emergent meds (IMs) ...after which he was put in seclusion. Pt (1)remained in seclusion until he was calm and not a threat to anyone. This was patients (Patient 1) second assault incident of the day....12/12/23 at 2:38 p.m. Pt (1) entered another patient’s (4) room and punched him as he laid in bed. 2nd pt got up and hit Patient 1. Patient 1 left 2nd pt’s room and returned to his own room, at this point, staff entered Patient 1’s room and escorted him to quiet room. In the quiet room, this nurse noticed that pt was bleeding from the head.” A review of the Complaint Intake information indicated incident two was reported to the Department 1/9/24 at 12:57 p.m., five days after the incident occurred. During a concurrent document review and interview on 3/22/24 at 1:15 p.m., the Director of Quality Management Patient Risk, reviewed a document titled, “Occurrence Report Summary,” not dated, about Entity-Reported Incident CA00875638, reported to the Department by the facility on 12/15/23, at 4:46 p.m., which indicated, on 12/8/23 at 8:42 a.m. and 2:02 p.m., Patient 7 punched Patient 8 multiple times in two separate incidents. The document indicated, “Summary of Event: Patient 7 came after the other pt (Patient 8) who backed up into her room and hit her 3 times, in the left cheek, left temporal area, and upper right of the chest. Staff intervened and Patient 7 was escorted to seclusion room at 8:42 a.m. ... Pt agreed to IM without manual restraint.....At approximately 2:02 Patient 7 went into the unit day room and went directly to the same patient (Patient 8) that she previously assaulted. She grabbed the patient’s hair and began punching her multiple times....Investigation: ...Video review confirms events as document by RN. One staff was monitoring hallway and one was conducting rounds in hall during assault. Staff member in day room during 2nd incident.” During an interview on 3/22/24, at 2:05 p.m., the Director of Quality Management Patient Risk stated he did not know the details about each incident. He stated the nurses wrote the details in the medical record. He stated all the incidents were tracked and presented to leadership at the morning meetings and at the Quality Committee Meeting. He was unable to answer what the facility had implemented to prevent future patient-to-patient assaults. During an interview on 3/22/24, at 2:10 p.m., Consultant U stated, “I could not find documentation of an abuse prevention program. It was mostly done by word of mouth.” She stated, without a P&P on the facility Abuse Prevention, it could potentially lead to confusion by staff and contribute to more abuse incidents. During an interview and document review on 3/22/24 at 3:25 p.m., the Director of Quality Management Patient Risk stated the data collected by the Quality Department indicated patient safety was worse at this time than in the last five years. He stated patient safety was not getting better if one looked at the number of patient assault incidents. During an interview on 3/22/24, at 3:40 p.m., the Chief Executive Officer stated she heard about patient abuse at the daily flash meetings and incident reports that were reviewed. She was unable to state who in leadership was responsible for the coordination of the Abuse Prevention Program at the facility. She was unable to state what the facility engaged in for abuse prevention or response and whether the Governing Body had any oversight of the facility Abuse Prevention Program. Review of a document titled, “Face sheet,” indicated Patient 1 was a 26-year-old male, admitted on 8/12/22, with diagnoses including Unspecified psychosis not due to a substance or known, physiological defect. He had a diagnosis of Schizophrenia and was conserved by a contracted professional who was responsible for finding long-term placement. He had medication orders for Thorazine, Lamotrigine, and PRN orders for Thorazine, Ativan and Tenex. The Rationale for inpatient stay was documented as, “For grave disability and danger to others.” Review of a document titled, “[GACH Facility Name] Progress/Visit Notes ED Physician Notes ...Reason for Hold A danger to others.” Review of a record for Patient 1 titled, “Seclusion and Manual Hold Audit,” indicated between 2/11/24 and 3/19/24, Patient 1 had been placed in a manual hold eight times, placed in seclusion five times, and had been emergently medicated three times, for punching a MHT, punching a Psychiatrist, Sexually Acting Out Behaviors with staff, spitting on staff. Patient 2 was a 26-year-old male, admitted 11/28/23, for Unspecified psychosis not due to a substance or known psychological defect. Comments from admission indicated, “26 yo Male. PT is paranoid and delusional, assaulted another cell mate while in jail due to believing they were trying to control him.” Patient 4 was a 30-year-old male, admitted 10/18/23, for Schizophrenia, unspecified. Comments from admission indicated, “30 yo male currently detained at Sonoma Co. Jail. PT was arrested and declared incompetent to stand trials. Attempts to restore competency at jail have failed.” Patient 5 was a 17-year-old male, admitted 1/2/24, from Inpatient Psych Juvenile Services. Admitted with Diagnoses of Major depressive disorder, single episode, unspecified. Comments from admission indicated, “17 yo Male. PT endorses SI with plan to cut self with a knife, says he is depressed for a friendship he ruined over the summer.” Patient 6 was a 17-year-old male, admitted 1/3/24, from inpatient Psych Juvenile Services for diagnoses that included bipolar disorder, unspecified. Comments from admission indicated, “Pt has been in the ED for 82 hours, still agitated, psychotic and assaultive, requiring chemical and physical restraints.” Patient 7 was a 16-year-old female, admitted 12/2/23, from inpatient Psych Juvenile Services for diagnoses of Major Depressive Disorder, single episode unspecified. Comments from admission indicated, “Pt is a 16-year-old female who ... made threat to kill herself by OD.” Patient 11 was a 14-year-old female, admitted 12/7/23, from inpatient Psych Juvenile Services for diagnoses that included Major depressive disorder, single episode, unspecified. Comments from admission indicated, “Pt’s SI (Suicidal Ideation) has been increasing over the past week and were in the ED a week ago for SI and safety plan that has been working till today. Pt has hx of suicide attempt, hx of mental illness.” During a review of the facility Policy and Procedure titled, “INCIDENT REPORTING & INVESTIGATION Policy Number: LD 110.01,” revised 8/5/19, indicated, “[Psych GACH Facility Name] will provide an effective mechanism for the reporting, investigation, and / or prevention of all incidents and injuries to patients ... Incidents may include: ...Confrontations between patients or involving staff.” During a review of the facility Policy and Procedure titled, “ABUSE REPORTING Policy Number RI 800.14 a,” reviewed 5/13/21, indicated, “Each patient receives care in a safe environment....This includes protection for patient’s emotional health and safety, as well as his/her physical safety. Respect, dignity and comfort would be components of an emotionally safe environment....Definition: Abuse: is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another.” During a review of the facility P&P titled, “CODE GREEN,” dated 12/7/23, it indicated, “a. Nursing Leadership (Chief Nursing Officer, Director of Nursing, House Nursing Supervisor, or designee) will monitor code response and delegate tasks to staff responding to the Code Green to ensure the following objectives are met. i. Hospital Safety: Ensure the safety and security of patients and staff across all units.””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 38335 Based on administrative document review and administrative staff interview, the hospital failed to ensure an effective Quality Assessment Performance Improvement (QAPI) program based on data gathered on quality indicators, patient care, and other relevant patient care and staffing data that was monitored and had measurable goals and clear expectations. The hospital failed to have a plan in place that showed performance improvement activities that measured successes, tracked performance, and ensured sustained improvements. Failure to develop a comprehensive program that identified opportunities for improvement, may result in compromised patient outcomes in relationship to the patient care services provided. Findings: During an interview on 3/22/24 at 10:05 a.m., the Director of Nursing (DON) was questioned about the focus and discussion of the QAPI meetings. The DON stated the QAPI presentations were more focused on the Plan of Correction (POCs) from previous surveys and did not include current problems as in Nursing Services, Staffing, and lack of group activities because of limited staffing. During an interview on 3/22/24 at 3:25 p.m., the Director of Quality and Risk Management (QM) was asked what the hospital identified as the current high-risk, problem-prone areas facing the facility and identified in the QAPI program. The Director of Quality stated the facility was currently working on the 2024, QAPI program, and staffing issues was at the top of the list. During a continued interview with the Director of Quality and Risk Management, he was queried about the new process, “Handle with Care” (an intervention used to de-escalate patient behaviors) vs the, “Crisis Prevention Intervention,” a process that was used for eight years. The QM was asked if the new process worked better than the old process. He stated they were still collecting data. When asked to review the process and how staff were trained, nothing was provided to the survey team. Review of the QAPI Agenda’s and Meeting minutes, dated, 10/19/23, 11/16/23, 12/28/23, and 1/18/24, did not show set priorities for performance improvement activities, such as ensuring adequate staffing for the facility patient care areas, safety solutions for patients and staff, and ensuring patients received activity-based treatments. The Director of Quality and Risk Management was asked if there was a written plan for each of the indicators identified in the QAPI plan and how the hospital would monitor and reach these goals. He stated the committee was working on these indicators for the 2024, QAPI plan. Review of the hospital QAPI plan, dated 2023, indicated, “The plan is a systematic, comprehensive, data-driven, proactive approach to performance management and improvement. This guide provides detailed information about the resources, data sources, and collaborative efforts of successfully implemented improvements.” Review of the hospital policy and procedure titled, “Quality Assurance/ Performance Improvement (QAPI) Program,” dated 5/6/22, indicated, “ll. Goals of Performance Improvement: ...D8. Track the status of identified problems and action plans to assure improvement or problem resolution...D11. Establish that treatment and services affecting the health and safety of patients are identified. Included are those that occur frequently or affect large numbers of patients; place patients at risk of serious consequences or deprivation of substantial benefit if care is not provided correctly or not provided when indicated; or care provided is not indicated, or those tending to produce problems for patients, their families, or staff.” Documentation to support the QAPI program indicators was requested but not provided by the hospital.”

“Staffing Requirements CFR(s): [Psychiatric hospitals must] Meet the staffing requirements specified in §482.62. This Standard is not met as evidenced by: 38088 Based on observation, interview and record review, the facility failed to ensure consistent staffing that met the needs for safety and beneficial therapeutic services, when: 1. The facility did not staff patient care units with Licensed Nurses and Mental Health Technicians which followed the staffing matrix plan, when the facility did not staff 51 nursing shifts and 88 Mental Health Technician shifts over 13 days. 2. The facility did not provide mandatory Social Services therapeutic milieu that met the goals on patients’ Master Treatment plans for three sampled patients (Sampled Patient 1, Sampled Patient 10 and Sampled Patient 12) out of 13 sampled patients. The facility’s failure to provide safe and consistent staffing had the potential for patient harm from physical and sexual abuse, increased staff sick calls, staff consistently not taking breaks or lunches, staff experiencing significant physical harm, and decreased patient access to social service activities and therapies. Findings: (Cross Reference A-263, A-1680, A-1704, A-1725, A-1726, ) 1. During an observation on 3/18/24, at 11:35 a.m., in Unit 500 (High Acuity, all Male unit for patients with behaviors that required more observation than other floors, for resident and staff safety), the community room (a room for patients to listen to music, watch movies or participate in therapy) was closed and locked. One Unlicensed Staff was monitoring patients in their bedrooms by rounding on each room with an ipad. The other Unlicensed Staff was standing outside of Room 501 for a 1:1 observation (A process where a staff watches a patient constantly for safety for themselves or others). There were no activities or therapists in the unit interacting with patients. Eight other patients were in their darkened rooms, covered by sheets or blankets. There was no music. The walls had multiple areas of unpainted plaster patches that were in various states of repair. The Director of Quality Management stated the unit was supposed to always have two nurses, and they were working out of ratio. He stated he thought maybe there was a sick call. During an interview with the Director of Quality Management and Patient Risk, on 3/18/24, at 9:35 a.m., the Director of Clinical Services stated the Director of Nursing (DON) was not available due to a House Supervisor who called in sick. He stated the DON was currently doing director patient care due to staff sick calls that morning and would not be available. The Director of Quality Management stated it happened frequently with all staff. He stated staffing was based on staff sick calls and patient acuity. He stated staff conducted patient safety rounding every 5, 10 or 15 minutes depending on assessment and orders. He stated nurses could place a patient on 1:1 (One staff watched one patient only for patient safety), or every five minutes for safety. He stated if a 1:1 was necessary, then staffing was adjusted. He stated Code Green Drills (A safety code called overhead to indicate a patient incident that required additional staff in a specific patient unit) would be conducted to help train staff and leadership dealt with who was supposed to go to what unit when a Code Green was called. He stated the most recent changes to the Code Green Policy and Procedure were more specifically related to the duties of staff and leadership to attend and what to do if there were simultaneous Code Greens. He stated the facility expectation was for three staff from the lower acuity units to be sent to wherever the Code Green was called. He stated, on the midnight shift (NOC shift) staff did not attend if staffing did not permit. He stated, for example, Unit 500 had a census of only ten patients (Capped), and a 1:1 pt, with three Mental Health Technicians (MHT) and two Nurses according to the staffing matrix. He stated Unit 500 would not be able to send anyone. He stated, on the daily sheet, staff were assigned to respond to a Code Green if one was called in the facility. Staffing was a huge challenge right now because in December, leadership terminated five to six staff. During an observation and interview on 3/18/24 at 10 a.m., a Mock (Practice) Code Green (An escalating psychiatric event or emergency that presented a potential need for staff to physically restrain a patient) was observed. The facility was a locked facility with restricted access into and out of each unit. During a Code Green, staff were supposed to arrive to provide support. The Director of Quality Management and Patient Risk and Director of Clinical Services stated, “The Director of Nursing and the House Supervisor were supposed to show up but did not, because the House Supervisor called in sick and the Director of Nursing was doing direct patient care, and there was no facility Chief Nursing Officer.” During an interview on 3/18/24, at 10:48 a.m., the Director of Nursing stated, “There is immense pressure from the Chief Executive Officer to get more patients to increase the census. There is so much pressure to get more patients, heads in beds.” He stated he was never consulted before patient admissions, if they had enough staffing to provide safe care for patients. The Director of Nursing stated the Chief Executive Officer was under huge pressure to get the census up because she talked about it all the time at leadership meetings. During a concurrent observation, interview and document review on 3/18/24 at 11:35 a.m., in Unit 500, the community room was closed and locked. A rainbow-colored activity therapy chart on the wall indicated an activity at 1:15 p.m. A review of a staffing assignment sheet titled, “NURSING SHIFT ASSIGNMENT SHEET,” dated 3/18/24, indicated, “Census 10,” 1 - 1:1 observation, and indicated one Licensed Staff, and four Mental Health Technicians (MHT). The Director of Quality Management and Patient Risk and Director of Clinical Services stated the patient care unit was supposed to have two Licensed Staff, for safety. He stated he thought maybe there was a sick call. During an interview on 3/18/24 at 11:50 a.m., Unlicensed Staff Z stated, “In December it started to get really unsafe in the facility. We worked out of ratio (Number of staff to number of patients) consistently on the weekends and nights.” She stated there had been an increase in Code Greens, and without enough staff, there was no one to respond. She stated the facility had admitted patients they could not safely take care of, violent, assaultive patients. She stated the patients got out of control and could not be de-escalated, and then patients and staff got hurt. Unlicensed Staff Z stated she has been hit and punched multiple times until she was sore. She stated she told the Director of Nursing and Administrators she was afraid, and there was not enough staff. During an interview on 3/18/24 at 12 p.m., Licensed Staff AA stated they were frequently without enough staff to monitor patients. She stated the last Chief Nursing Officer and the Chief Executive Officer terminated a lot of staff and it created a bad staffing shortage, and now people were afraid to speak up about safety and staffing. She stated they did not want to lose their jobs. She stated it was unsafe for patients and staff to work out of ratio. She stated, if they did not have staff, they could not consistently and safely assess and monitor patients for any escalating agitated behaviors. She stated the patient units were frequently short staffed and out of ratio, so patients would not be taken to the cafeteria for meals. Licensed Staff AA stated patients could not even eat in the unit community room because, without enough staff, they could not monitor the patients who ate in the community room and the patients who stayed in their rooms. She stated, as a result of short staffing, all patients had to eat in their rooms. She stated the patients all had to eat in their rooms like, “Caged animals.” She stated, “It is unsafe and worse on weekends.” Licensed Staff AA stated, “I have informed leadership of my concerns for staffing and safety, and their solution was to use the medication nurse to monitor patients during lunch.” She stated, today there was only one nurse. She stated the unit could not send someone to a Code Green. She stated in Unit 700, if they had two nurses, there were 23 patients who had medication pass, usually at breakfast and lunch, and if the medication nurse was not giving medications, then either she or Licensed Staff AA would not get their lunch and breaks because medication pass needed to be completed and lunch breaks had to start before 12 p.m., per California labor law. She stated patient staffing was unsafe. She stated, without complete staffing, Licensed Staff and MHT could not monitor patient behaviors. She stated patients physically and sexually assaulted each other and staff, because patients were cooped up, and there was no ability to monitor them to see if there was an escalation of their agitation. She stated it was worse on weekends. She stated poor staffing had led to more Code Greens being called for patients with escalating behaviors needing assistance. She stated the facility consistently did not have enough staff to send to Code Greens. During an interview on 3/19/24, at 9:45 a.m., Unlicensed Staff Y stated Patient 1 was a 1:1 patient. He stated he was on the 1:1 because he consistently engaged in assaultive behaviors against patients and staff. He stated patients and staff were not safe because of the staffing. Unlicensed Staff Y stated, on night shift there were only two Mental Health Workers (MHW). He stated one MHW was assigned to the 1:1 patient, and the other MHW observed the other patients every five to 15 minutes. He stated, if a patient began to escalate his behaviors and attacked either another patient or staff, there would not be enough staff available to keep the other patients safe. He stated it was a dangerous situation. He stated they worked out of ratio all the time. Unlicensed Staff Y stated Patient 1 had been here a couple of years and, because of his behavior, he was stuck in his room. He was confined to his room to keep him and other patients safe. He stated Patient 1 had punched and kicked him and other patients. Unlicensed Staff Y stated there were a lot of Code Greens called in Unit 500 and in the facility. He stated every day they ended up getting assigned to attend a Code Green in another unit, and it was dangerous for them to leave Unit 500 short staffed and out of ratio. He stated usually only the House Supervisor showed up for the Code Greens in the facility anyway. During an interview on 3/19/24, at 10:20 a.m., Unlicensed Staff BB stated there had been a lot of patient-to-patient assaults in the facility. He stated, recently the patients started a riot that was so bad the police were called and came into the facility with their guns drawn. He stated a lot of patients and staff were hurt. He stated, another time a patient stood up in the dining room and walked over to another patient and, “just checked him, I mean really punched him,” and then walked over to the wall and started banging his head and screaming he needed help. He tried to de-escalate, but he was so agitated, Unlicensed Staff BB had to use a physical hold and put him into a seclusion room, where he was emergently medicated. The lack of staffing contributed to the assaults because there were not enough staff to assess and monitor all the patients and respond to an escalation of behaviors. During an interview on 3/19/24, at 10:40 a.m., Unlicensed Staff CC stated it was really dangerous for patients when it was short staffed. Patient 1 was so aggressive and assaultive on other patients that at one point the doctor ordered him to be on a 2:1 observation (Two staff to watch one patient). He stated the facility took him off 2:1 because it was too many staff [to watch him]. During an interview on 3/19/24 at 11:05 a.m., Unlicensed Staff CC stated Administration prioritized heads in beds (Increase the patient census) and had no follow-up about staff concerns for safety and staffing shortages. He stated their actions showed them that patient safety was not a priority for facility Administration. He stated, without patient activities that promoted socialization and group activities and therapy, they were, “Just warehousing patients.” He stated it was getting worse and it was not appropriate. During an interview on 3/20/24 at 2 p.m., Physician DD stated Patient 1 was, “Essentially in solitary confinement for the duration of his due to his behaviors. It is hard to say it’s a therapeutic environment when he cannot socialize, participate in any therapies. His life was really quite terrible.” Physician DD stated Patient 1 would remain in a solitary confinement situation for the duration of his stay due to his behaviors. He stated Patient 1 had lost muscle mass as a result of being confined to his room and not getting any exercise. He stated this facility was far from a therapeutic environment. He stated Patient 1’s life was really quite terrible. He stated, “If they had more staff they could monitor him closely, develop a better relationship and perhaps allow for some cooperation, but staffing doesn’t allow that.” Physician DD stated, “Short staffing is something I am aware of. It affects the safety of the patients because of lack of monitoring, lack of therapeutic activities.” He stated he had not spoken to anyone in management about his concerns for staffing shortages. During an interview with Unlicensed Staff MM on 3/20/24, at 3:15 p.m., he stated not all staff can work in all patient units. He stated in Unit 500 they need special MHW who can work with high acuity patients who have assaultive and SAO behaviors. He stated No female staff MHW work in Unit 500 because of the danger to them and patients who required a lot of physical holds and seclusion. More than with other units. He stated this facility had a lot of sick calls. He stated the staffing matrix for units was three MHW for every unit on every shift and if there was a patient who required a 1:1 observation we would add an extra MHT. He stated the facility was supposed to staff 1 nurse for 10 patients. During an interview on 3/21/24 at 8 a.m., the Director of Quality Management and Patient Risk stated staffing was a lot of issues at the facility, and the Staffing Committee met every month to discuss. He stated all leadership could do was try and hire more people. During an interview on 3/21/24 at 8:30 a.m., the Director of Quality Management and Patient Risk stated the previous Chief Nursing Officer and the current Chief Executive Offices had set up the current staffing matrix to have two Licensed Staff and three MHW on every unit for every shift. He stated, from a quality data perspective, the facility for patient safety looked better four to five years ago, and he did not know why. During an interview on 3/21/24, at 9 a.m., the Interim Medical Director stated the only staffing issue discussed by the Medical Executive Committee and the Governing Board was the need for more staff training, and she was unaware of any staffing and safety issues that had impacted the therapeutic milieu for patient treatment. She stated Therapeutic Activities taught patients how to recognize when they experienced increased agitation and how they should respond. She stated it taught patients’ internal control and awareness, and it was a high risk to patients to not get these therapeutic activities. She stated, “Medication can only do so much,” for behaviors. She stated patients have to have skills for placement and, without access to learning, then the facility was not preparing them for placement. She stated there were, “No challenges with staffing in either nursing or social services.” During an interview on 3/21/24 at 10:30 a.m., the Director of Clinical Services stated the facility quality data audit results indicated patients were not getting therapeutic meetings, and the risk to patients was they got bored, got agitated, they were isolated, and staff saw increased Code Greens, Physical holds, seclusion, SAO and physical assaults. During an interview on 3/21/24 at 1:40 p.m., the House Supervisor stated the Admission process for this facility was to get heads in beds. She stated they never turned down a patient admission. She stated, “The problem was we do not have the appropriate staff.” The House Supervisor stated the facility Administration was not interested in hearing about the staffing issues and any patient safety issues. She stated the danger to patients was that there was not enough staff to detect increased agitation of patients and not enough staff to mitigate the circumstances. She stated, the more trained staff they had, the safer it was for patients and staff. She stated she told Administration they needed more staff. She stated everyone knew, but there was never any follow-up from leadership about how they planned to assess the staffing shortage. As a House Supervisor she got pulled into doing direct patient care all the time because they were short staffed, and staff called in sick. She stated she consistently got pulled out of her House Supervisor role at least a couple of times a month. She stated she knew the community rooms got closed because there was not enough staff, and staff needed to take their breaks and lunches. She stated there would be no one to monitor the halls and community rooms during breaks so they got closed. She stated the patients were the ones who were impacted by the closure of the community rooms. She stated, without the community rooms they could not go outside, could not have therapy meetings. She stated a therapist could only be in the community rooms for therapy if there was a MHW available for safety reasons. During an interview on 3/22/24, at 10:30 a.m., the Director of Nursing stated, due to staffing and sick calls he could not provide proper staffing. He stated staff had to work with a 1:24 (One Licensed Staff to 24 patients) ratio, and it was unsafe. He stated the facility admitted all patients without consulting him whether there was enough staff to provide care, and it was unsafe. “Everyday at the morning daily meeting I hear about patient-to-patient assaults.” He stated they were supposed to have enough staff to help reduce the number of patient assaults, but they could not hire enough nurses and staff. He stated, without proper staffing, more patient-to-patient assaults would occur. The Director of Nursing stated, “The facility’s priority of admitting patients without considering if we had enough staff to safely care for them has contributed to an unsafe environment for patients and staff.” The Director of Nursing stated one staff member was so traumatized by the patient riot and assaults that they had to move her to a different low-acuity unit to get her to come back to work. “Patients in this unit have attacked the nurses and were afraid to come into work.” 2. During an interview on 3/18/24 at 12 p.m., Licensed Staff AA stated they did not have enough staff to do community meetings or open the community rooms. She stated patients could not go outside, watch a movie, or have leisure time to listen to music. She stated, with a closed community room, patients would not have access to therapy groups or behavioral activities. She stated an activity had to have a MHT and a Social Services therapist. She stated Social Services was short staffed as well. She stated, at the most, patients only had an average of one to two therapy groups per day, “on a good day.” She stated the patient care units were supposed to have four activities per day for patients to go to. She stated there were never activities, “ever” on the weekend. She stated group activities were supposed to be part of the therapy and treatment for patients, but between the census and patients’ acuity (how many 1:1’s, and 5-minute staff observations), there were no therapies or activities happening. She stated patients never got outside and never had time in the sun which helped them sleep. She asked, “How do you motivate patients to engage in therapy when there is nothing to do?” She stated there were no staff for patients to interact with in a meaningful manner and, “I would be bored and depressed too.” During an interview with Social Services Director, on 3/18/24 at 12:20 p.m., she stated she oversaw Social Services for the facility. She stated she staffed therapists, Assistant Activity therapists, and Chemical Dependency Councelors. She stated she did the scheduling of staff, and they were short eight therapy positions. She stated, to meet the therapeutic needs of patients, she had staff double-up on their assignments, and it was double the work. She stated therapists did assessments, activities, documentation, ran groups and did individual counseling with patients. She stated all of it was not happening consistently on all the units. She stated Group activities was supposed to have four to five staff, and they had only one activity assistant. She stated, for one year she did not had enough staff to consistently provide activities for the patients. She stated the risk for adolescent patients was that they would get bored, and there would be an increase in behaviors like Sexually Acting Out (SAO) or assaultive behaviors. She stated, today she had three call outs, staff were working hard in difficult situations, and they were short staffed, so people got burned out. She stated she had reported the problem about staffing and safety concerns to Facility Leadership, and they only kept saying to hire more people. She stated she informed them two months ago that staffing was so bad and patient therapies for activities were not occurring consistently, especially in the last six to nine days. She stated patients would not get the therapeutic milieu that was on their treatment plan, consistently. She stated her plan for staffing and sick calls was to look at patient units where activities were supposed to take place and then offer alternative activities like coloring. She stated she had two part-time staff who were supposed to be available but one of them called out sick today. During an interview on 3/18/24 at 2:15 p.m., Licensed Staff LL stated she had not seen patient activities being conducted on the units. She stated staffing in Social Services was bad and, as a result, there was inconsistent patient group meetings, therapy and activities. She stated, if the community rooms were open, all the patients did was sit and watch television on some units. She stated, if you spoke up about anything, the Administration never followed-up or did anything, and then they fired people who spoke up, which was unbelievable since staffing had been so poor. During an interview on 3/18/24 at 3:15 p.m., Licensed Staff A stated, in group therapy they tried to stick to the rainbow activity schedule for group meetings and activities. He stated it was not ideal if he could not do the groups and patients would not get therapeutic groups or activities. He would not state what the risk to patients was if there were no activities or therapy available for patients to participate in. During an interview and concurrent document review on 3/19/24 at 9:45 a.m., Unlicensed Staff Y stated there was no community meeting this morning because there was not enough staffing. A review of a document binder in Unit 500, indicated, “Community Meeting Binder,” dated 2024, indicated there was no community meeting documentation for the entire year. Unlicensed Staff Y stated there had not been community meetings or physical activity groups because there were no staff to provide those meetings or activities. He stated there was only one Activity Assistant who provided activities like going outside, doing yoga, but she needed to have one MHT with her, and they did not have extra staff to provide that. He stated, lack of staffing was a huge safety concern. He stated, on the midnight shift there was one nurse and two MHW’s for ten patients which included one 1:1 patient. He stated one MHW did the safety rounding every five minutes, and the other MHW stayed with the 1:1 patient. He stated they could not take breaks or lunches because if one of them left, it would leave the unit out of ratio for staffing, and it would leave patients and staff in a dangerous situation. He stated they worked without enough staff consistently. He stated Patient 1 had to stay in his room all the time because of his constant assaultive behaviors and the safety of other patients and staff. He stated he had not observed Patient 1 receive any therapies or activities and he needed more than just being stuck in his room. He stated they were always supposed to have four MHW’s staffed in Unit 500 because of the acuity of the patients, but we could not keep the community room open due to the staffing, and the unit was, “like jail” for the patients. He stated it was sad, like a joke. During an interview with Unlicensed Staff CC, on 3/19/24 at 10:40 a.m., he stated Staffing was just not available. He stated it had become really dangerous when there was not enough staff and an assaultive patient on 1:1 monitoring. Patient 1 was the 1:1 and he did not have any quality of life because he was stuck in his room and there were no activities or leisure time outside activities. He stated Patient 1 had been at the facility for two years, and his hospitalization was, “like a jail.” Unlicensed Staff CC stated leadership had fallen apart, and the only ones concerned with the staffing were the staff in the units. He stated they have had only one nurse and one MHT for Unit 500 because of sick calls that were not back filled. He stated staff got hurt and then called in sick, and that made matters worse. He stated staff were afraid to lose their jobs if they spoke up about staff and safety concerns. Patient 1 was so difficult, they could not get him to cooperate with anything without endangering him or other patients or staff. Unlicensed Staff CC stated everyone had told Administration that it was not safe for patients or staff when they were so short staffed. He stated nothing changed. He stated patients just sat in their rooms and listened to the voices in their heads, and it was dangerous. During an interview on 3/19/24 at 11:05 a.m., Unlicensed Staff CC stated Administration prioritized heads in beds (Increase the patient census) and had no follow-up about staff concerns for safety and staffing shortages. He stated their actions showed them that patient safety was not a priority for facility Administration. He stated, without patient activities that promoted socialization and group activities and therapy, they were, “Just warehousing patients.” He stated it was getting worse, and it was not appropriate. During a concurrent interview and record review for Patient 1, on 3/20/24 at 11:40 a.m., Licensed Staff EE stated Patient 1’s treatment plan was not updated since 2/13/23. During an interview on 3/21/24 at 9 a.m., the Interim Medical Director stated she was the Medical Director and also sat on the Governing Board. She stated her role was to address issues and resolve them. She stated the Governing Board had reviewed facility-reported incidents that involved patient-to-patient assaults. She stated she did not recall if there were any recommendations by the Governing Body to address those concerns. She stated she thought staff could use more training on how to de-escalate agitated patients. The Interim Medical Director stated she was unaware of any patient safety, social services or staffing issues that have impacted the therapeutic milieu (Therapy provided to patients in the form of 1:1 counseling, group meetings, group therapy, and activities) for patient treatment at the facility. During an interview on 3/21/24 at 10:20 a.m., the Director of Clinical Service stated he was aware that Social Services had some staffing challenges. He stated staffing therapists and therapy assistants was essential for the success of group therapy. He stated a big problem with the Social Services department was the assessment and documentation, by the staff, were not getting done in a timely fashion. He stated it may take days for the documentation to be completed. He stated the structure necessary for the success of Social Services was not being implemented by the Director to its full capacity. He stated they needed more staff, and audit results indicated the patients were not getting therapeutic meetings. It was a risk to patient care because they got bored, they got agitated, they were isolated and it resulted in increased Code Greens, physical holds, seclusion, Sexual Acting Out, and patient-to-patient assaults. He stated, any therapeutic activities were supposed to be documented in the group notes in the medical record. He stated, “I am confident documentation is not occurring.” He stated the documentation was to show the individualized social services activities for each patient, and there were supposed to do four group activities for each patient every day, per unit. He stated, “It is not occurring.” During an interview 3/21/24, at 1:40 p.m., the House Supervisor stated she knew the community rooms where patient therapies and activities were supposed to take place got shut down because there were not enough staff. She stated there were not enough staff to take breaks, to monitor halls or do rounding and 1:1 observations; because of this, the MHW’s were not available to go with the therapists and monitor in the community rooms. She stated without the community rooms, the patients could not have therapeutic meetings or activities. During a concurrent interview and record review for Patient 10, on 3/22/24, at 8:45 a.m., Licensed Staff EE stated the Master Treatment plan indicated he was supposed to have attended therapeutic meetings and activities. He stated the last Social Services Note was 3/12/24 at 3:48 p.m., and it indicated Patient 10 did not attend group activity. Licensed Staff EE stated review of the document titled, “Group Note,” indicated Patient 10, “DID NOT” attend group on 3/12/24 at 12:15 p.m., 3/13/24 at 2 p.m., 3/17/24 at 12:30 p.m. and 2:05 p.m., 3/19/24 at 12:15 p.m., and 3/20/24 at 10:30 p.m. During a concurrent interview and record review for Patient 12, on 3/22/24 at 8:50 a.m., Licensed Staff EE stated he did not submit a Social Services note within the mandated 72 hours from the time of admission. He stated there were no Social Services Group Notes on 3/18/24. He stated there were no Social Services notes from the time of his admission on 3/15/24 to 3/17/24. He stated the medical record indicated Patient 12 did not attend Therapeutic Activities or groups on 3/17/24 or 3/19/24. During an interview on 3/22/24 at 10:10 a.m., Licensed Staff C stated she reported to the Social Services Director, and her role was an inpatient therapist to run groups. She stated they did not have a lot of staff because of sick calls, and they needed to hire more staff. She stated they did not have enough staff to do the work, like assessments, documentation or activity groups. She stated they could not conduct all the therapy groups listed on the color therapy schedule because of the shortage of staff. She stated, if they could not conduct groups, they sometimes passed out alternative worksheets with coloring. She stated they did not have enough staff to provide any therapy or activities for Unit 500. She stated she was afraid to go there because of the high acuity of the patients that were there. During an interview on 3/22/24 at 10:50 a.m., the DON stated he just informed Administration he was voluntarily terminating his employment at the facility because he was so frustrated with the lack of support from Administration. He stated there was no system in place to check documentation for accuracy. He stated Social Services did not provide activities or groups for patients. He stated he had not observed activities or therapists in the units doing a lot. He stated the priority in the facility was the adolescent units, and so the other adult units simply did not get those Social Services. He stated, “They are not getting the therapeutic milieu that was on their Master Treatment Plan.” He stated, not having Social Services had a negative impact on all the patients. He stated, “Not one patient had consistently participated in or been offered four Social Services activities a day.” He stated staffing had been a constant struggle resulting in nurse-to-patient ratios of 1:24. He stated, “There is nothing other than a medication pass happening when the ratio is that low.” He stated the only intervention Administration offered consistently was to hire more people. During an interview 3/22/24 at 11:45 a.m., Unlicensed Staff B stated she was supposed to conduct three to five groups a day in the patient units, but it was not consistently happening for patients. She stated Social Services has had three directors in the last two years and three Activity Techs, and two therapy leaders had quit. She stated staffing changes had contributed to everyone quitting. She stated the, “Goal of the department was to have four activities a day for all patients.” She stated the activities were a part of the therapy and were on the treatment plan. She stated the adolescent units were the priority, and all the Social Services were directed towards them. She stated there was not enough staff to take Unit 500 outside, and they never got direct sunlight, and it was so unhealthy. She stated if she could not do activities in Unit 500, she would have alternative activities like coloring, but typically Unit 500 would not even get any alternative activities. She stated there were no Social Services on weekends or holidays. During an interview and record review with Licensed Staff EE on 3/22/24 at 12:50 a.m., he stated, “There was no Psychosocial Note for Patient 1 in the last 72 hours.” He stated, “I do not see any Psychosocial Notes in his medical record.” He stated the importance of the note was that it was the basis of therapy . He stated it documented the assessment of strengths and weaknesses of a patient and, without it, the therapy was inaccurate and inappropriate. He stated they ended up with a completely useless treatment plan. During an interview the Chief Executive Officer, on 3/22/24 at 3:40 p.m., when asked if the Governing Body had documented any issues or concerns about staffing or safety, she stated the staff need more training how to engage in robust de-escalation of patient behavior. Review of a document, not titled, not dated, referred to as the Social Services Activity Rainbow Colored Chart, indicated for Unit 500 on a daily basis, eight activities a day were supposed to be offered to residents by a combination of Therapists and MHTs. The activities indicated Community Morning Meetings (MHT twice daily for a total of 90 minutes per day, Activates Group in Gymnasium or group twice a day for two hours per day, psych Education Group / Chemical Dependency Group (Therapist) for a total of 90 minutes per day, Nursing / Pharmacy Group for 60 minutes per day, Interdisciplinary Group (Therapist / Nurse / Other ) for a total of one hour per day. Review of document titled, “STAFFING MEETING MINUTES,” dated 1/4/24, it indicated, “Safety Data Presentation Human Resources data shared with the Staffing Committee. Staff injuries requiring medical attention, November 2023, 11 employee injuries with 6 requiring medical attention. The number of injuries peaked in May 2023 at 25 total injuries and 7 requiring medical attention....Missed meal breaks peaked in November at 208 hours....The schedule does not include enough MHTs to cover for breaks. RN’s are expected to cover MHT breaks.” No action items were documented. No responsible person was documented, and there was no target date. Review of a document titled, “Governing Board MEETING MINUTES,” dated 1/25/24, indicated, “CEO Report: Staffing continues to be a challenger to hire RN’s and Therapists.... During Q4, 2023, we had census growth of the previous year.... Year over year, we saw an increase of 26% from 2022 to 2023. We hit an all-time record in Q4 of 109 patient census. However, due to staffing shortages in November and December the census decreased.” No action items were documented. No responsible person was documented, and there was no target date. Review of a document titled, “Governing Board MEETING MINUTES,” dated 10/26/23, indicated, “CEO Update: Staffing we continue to have challenges with staffing RN’s and Therapists.” No action items were documented. No responsible person was documented, and there was no target date. Review of documents titled, “Governing Board MEETING MINUTES,” dated 7/27/23, indicated no Governing Board agenda for discussion of staffing. Review of documents titled, “Governing Board MEETING MINUTES,” dated 4/27/23, indicated, “Recruitment continues to be a challenge to hire RN’s and Therapists.” No action items were documented. No responsible person was documented, and there was no target date. Review of document titled, “Santa Rosa Behavioral Healthcare Hospital Strategic Plan 2023,” indicated, “Our Story We recognize that each patient is an individual. We pride our hospital in providing the right type of care for the right individual and in the right amount. From day one, we tailor our diverse treatment programs to meet our patient’s specific and unique needs.... S.W.O.T Analysis Weakness Staffing challenges - hiring, training, & retention. Community perception of being difficult to work with....Strategic Priorities SAFETY Goal ... Objective 1: Increase patient participation in therapeutic programing. ...GROWTH Goal ...Objective 1: Expand inpatient acute bed capacity ... PEOPLE Goal: Objective 1. Reduce employee turnover rate by 15% from prior year rates. ORGANIZATIONAL DEPARTMENTAL GOALS Nursing Services Reduce overtime use by 25% beginning January 2023.” Review of a document, provided by Leadership, not titled, not dated, indicated for Therapist, Activity Therapy Aide and Chemical Dependency Counselor, there was a total of 32, “Call outs / Absences in the last thirty days. A total of 256 therapeutic hours, out of a possible 1,312 therapeutic hours of Social Service activities and groups, were not provided during the last thirty days. Review of a Policy and Procedure titled, “GROUP THERAPY AND GROUP NOTE,” approved 5/26/22, indicated, “The purpose of Group Notes is to document the patients progress that occurs in each group therapy session. The group notes serves purpose to communicate patient progress to members of the treatment team. Policy: To ensure that Group Therapy is provided per program description. To ensure there is a concise and accurate record of patient participation, interaction and response to group therapy. Documentation of patient participate will be done after each group session.” During a review and concurrent interview of facility staffing sheets titled, “DAILY ASSIGNMENT SHEET UNIT 500,” dated 3/18/24, it indicated, for a Census of 10 patients and one 1:1 observation, Unit 500 had one charge nurse scheduled for the day and evening shift. For the night shift there was no schedule provided by the facility by the end of survey. This indicated the unit was working out of safe patient-to-staff ratios. Review of a facility Policy and Procedure Titled, “STAFFING MATRIX AND ACUITY SYSTEM,” approval date 10/23/23, indicated, “Variation from staffing plans are documented with explanation by the Nursing Supervisor with Director of Nursing Involvement as needed.” The, “ASR (Aurora Substance Rehabilitation) UNIT STAFFING MATRIX,” indicated one Charge RN for every patient unit. For a patient census of 10 and under, no RN/LVN and one MHW and one Hall Monitor for every patient unit. For a patient census of 11-20, one RN / LVN, and one Hallway monitor was required. For a patient census of 15 - 25, two MHW’s were required. For a patient census of 21 - 25, two RN’s/LVN’s was required. The document indicated, “ABOVE MATRIX IS THE RECOMMEND STAFF TO PATIENT RATIO. ACTUAL RATIOS MAY VARY DEPENDING ON ACUITY. MINIMUM STAFFING OF 1 RN PER UNIT WILL BE MAINTAINED AT ALL TIMES.” During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 200,” dated 10/31/23, it indicated for a census of 16 and one 1:1 while asleep, Unit 200 was missing one day Nurse and missing two Night Shift MHT’s. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 300,” dated 11/1/23, it indicated for a census of 15, Unit 300 was missing one day and evening MHT for breaks and one night shift Nurse. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 400,” dated 11/1/23, it indicated for a census of 14, Unit 400 was missing two evening nurses. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 500,” dated 11/1/23, it indicated for a census of 12 (the unit was supposed to be capped at ten patients for safety reasons), and one 1:1 observation, Unit 500 was missing one break MHT for day, evening and night shift. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 600,” dated 11/1/23, it indicated for a census of 18, Unit 600 was missing a break MHT for day and evening shift. A request for the night shift staffing sheet was made and not received by the end of the survey. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 400,” dated 11/1/23, it indicated for a census of 14, Unit 400 was missing one night nurse and one night break MHT. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 700,” dated 11/1/23, it indicated for a census of 20 with one 1:1, Unit 700 was missing one night nurse and one day break MHT. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 200,” dated 12/15/23, it indicated Unit 700 was missing one day and evening nurse and one day break MHT. Unit 300 evening shift was missing one nurse, Unit 400 was missing one day break MHT, Unit 500 was missing one day nurse, one evening nurse, and Unit 500, for the night shift on an undocumented date, had a census of 12 and one 1:1 observation and was missing a break MHT. Unit 600 day shift was missing one day nurse and one break MHT, one evening nurse and one night break MHT. Unit 700 night shift was missing one nurse. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 200,” dated 1/5/24, it indicated Unit 500 was missing one day nurse, one evening nurse and one evening break MHT, one night nurse and one night break MHT. During a review of staffing sheets from 3/14/24 to 3/17/24, indicated a total of 14 missing nurse shifts and 17 MHT shifts. During a review of staffing sheets from 11/2/23 to 11/6/24, indicated a total of 20 Missing Nurse shifts and 47 MHT shifts.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 38088 Based on observation, interview and record review, the facility failed to ensure consistent staffing that met the needs for safety and beneficial therapeutic services for 8 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 11), when: 1. There was insufficient staff to keep patients safe, respond to patient safety incidents and remain in safe staffing ratio on all the patient care units. 2. Community rooms used to provide required patient therapies, meetings and group activities required on patient treatment plans, were closed due to insufficient staffing. 3. The Policy and Procedure for staffing patient care units with Licensed Nurses and Mental Health Technicians was not followed. The facility’s failure to provide safe and consistent staffing had the potential for patient harm from physical and sexual abuse, patient harm, decreased patient access to social service activities and therapies, increased staff sick calls, staff consistently not taking breaks or lunches. Findings: (Cross Reference A-263, A-1680, A-1725, A-1726) 1. During an interview with the Director of Quality Management and Patient Risk, on 3/18/24, at 9:35 a.m., the Director of Clinical Services stated the Director of Nursing (DON) was not available due to a House Supervisor who called in sick. He stated the DON was currently doing direct patient care due to staff sick calls that morning and would not be available. The Director of Quality Management stated it happened frequently with all staff. He stated staffing was based on staff sick calls and patient acuity. He stated staff conducted patient safety rounding every 5, 10 or 15 minutes depending on assessment and orders. He stated nurses could place a patient on 1:1 (One staff watched one patient only for patient safety) or every five minutes for safety. He stated, if a 1:1 was necessary, then staffing was adjusted. He stated Code Green Drills (A safety code called overhead to indicate a patient incident that required additional staff in a specific patient unit) would be conducted to help train staff and leadership dealing with who was supposed to go to what unit when a Code Green was called. He stated the most recent changes to the Code Green Policy and Procedure were more specifically related to the duties of staff and leadership to attend and what to do if there were simultaneous Code Greens. He stated the facility expectation was for three staff from the lower-acuity units to be sent to wherever the Code Green was called. He stated, on the midnight shift (NOC shift) staff did not attend if staffing did not permit. He stated, for example, Unit 500 had a census of only ten patients (Capped), and a 1:1 pt, with three Mental Health Technicians (MHT’s) and two Nurses according to the staffing matrix. He stated Unit 500 would not be able to send anyone. He stated on the daily sheet, staff were assigned to respond to a Code Green if one was called in the facility. Staffing was a huge challenge right now because in December, leadership terminated five to six staff. During an observation and interview on 3/18/24 at 10 a.m., a Mock (Practice) Code Green (An escalating psychiatric event or emergency that presented a potential need for staff to physically restrain a patient) was observed. The facility was a locked facility with restricted access into and out of each unit. During a Code Green, staff were supposed to arrive to provide support. The Director of Quality Management and Patient Risk and Director of Clinical Services stated, “The Director of Nursing and the House Supervisor were supposed to show up but did not, because the House Supervisor called in sick, and the Director of Nursing was doing direct patient care, and there was no facility Chief Nursing Officer.” During a concurrent observation, interview and document review on 3/18/24 at 11:35 a.m., in Unit 500, the community room was closed and locked. A rainbow-colored activity therapy chart on the wall indicated an activity at 1:15 p.m. A review of a staffing assignment sheet titled, “NURSING SHIFT ASSIGNMENT SHEET,” dated 3/18/24, indicated, “Census 10,” 1 - 1:1 observation and indicated one Licensed Staff, and four Mental Health Technicians (MHT’s). The Director of Quality Management and Patient Risk and Director of Clinical Services stated the patient care unit was supposed to have two Licensed Staff, for safety. He stated he thought maybe there was a sick call. During an interview on 3/18/24 at 12 p.m., Licensed Staff AA stated they were frequently without enough staff to monitor patients. She stated the last Chief Nursing Officer and the Chief Executive Officer terminated a lot of staff, and it created a bad staffing shortage, and now people were afraid to speak up about safety and staffing. She stated they did not want to lose their jobs. She stated it was unsafe for patients and staff to work out of ratio. She stated, if they did not have staff, they could not consistently and safely assess and monitor patients for any escalating agitated behaviors. She stated the patient units were frequently short staffed and out of ratio, so patients would not be taken to the cafeteria for meals. Licensed Staff AA stated patients could not even eat in the unit community room because, without enough staff, they could not monitor the patients who ate in the community room and the patients who stayed in their rooms. She stated, as a result of short staffing, all patients had to eat in their rooms. She stated the patients all had to eat in their rooms like, “Caged animals.” She stated, “It is unsafe and worse on weekends.” Licensed Staff AA stated, “I have informed leadership of my concerns for staffing and safety, and their solution was to use the medication nurse to monitor patients during lunch.” She stated today there was only one nurse. She stated the unit could not send someone to a Code Green. She stated, in Unit 700, if she had two nurses, there were 23 patients who had medication pass, usually at breakfast and lunch, and if the medication nurse was not giving medications, then either she or Licensed Staff AA would not get their lunch and breaks because medication pass needed to be completed, and lunch breaks had to start before 12 p.m., per California labor law. She stated patient staffing was unsafe. She stated, without complete staffing, Licensed Staff and MHT’s could not monitor patient behaviors. She stated patients’ physically and sexually assaulted each other and staff, because patients were cooped up, and there was no ability to monitor them to see if there was an escalation of their agitation. She stated it was worse on weekends. She stated, poor staffing had led to more Code Greens being called for patients with escalating behaviors needing assistance. She stated the facility consistently did not have enough staff to send to Code Greens. During an interview on 3/19/24, at 9:45 a.m., Unlicensed Staff Y stated Patient 1 was a 1:1 patient. He stated he was on the 1:1 because he consistently engaged in assaultive behaviors against patients and staff. He stated patients and staff were not safe because of the staffing. Unlicensed Staff Y stated, on night shift, there were only two Mental Health Workers (MHW). He stated one MHW was assigned to the 1:1 patient, and the other MHW observed the other patients every five to 15 minutes. He stated, if a patient began to escalate his behaviors and attacked either another patient or staff, there would not be enough staff available to keep the other patients safe. He stated it was a dangerous situation. He stated they worked out of ratio all the time. Unlicensed Staff Y stated Patient 1 had been there a couple of years and, because of his behavior, he was stuck in his room. He was confined to his room to keep him and other patients safe. He stated Patient 1 had punched and kicked him and other patients. Unlicensed Staff Y stated there were a lot of Code Greens called in Unit 500 and in the facility. He stated every day they ended up getting assigned to attend a Code Green in another unit, and it was dangerous for them to leave Unit 500 short staffed and out of ratio. He stated, usually only the House Supervisor showed up for the Code Greens in the facility anyway. During an interview on 3/19/24, at 10:20 a.m., Unlicensed Staff BB stated there had been a lot of patient-to-patient assaults in the facility. He stated, recently the patients started a riot that was so bad the police were called and came into the facility with their guns drawn. He stated a lot of patients and staff were hurt. He stated another time a patient stood up in the dining room and walked over to another patient and, “just checked him, I mean really punched him” and then walked over to the wall and started banging his head and screaming he needed help. He tried to de-escalate, but the patient was so agitated, Unlicensed Staff BB had to use a physical hold and put him into a seclusion room, where he was emergently medicated. The lack of staffing contributed to the assaults because there were not enough staff to assess and monitor all the patients and respond to an escalation of behaviors. During an interview on 3/19/24, at 10:40 a.m., Unlicensed Staff CC stated it was really dangerous for patients when it was short staffed. Patient 1 was so aggressive and assaultive on other patients that at one point the doctor ordered him to be on a 2:1 observation (Two staff to watch one patient). He stated the facility took him off 2:1 because it was too many staff [to observe Patient 1]. During an interview with Unlicensed Staff MM on 3/20/24, at 3:15 p.m., he stated not all staff could work in all patient units. He stated, in Unit 500, they needed special MHW’s who could work with high acuity patients who have assaultive and SAO behaviors. He stated no female staff MHW’s worked in Unit 500 because of the danger to them and patients who required a lot of physical holds and seclusion. More than with other units, he stated this facility had a lot of sick calls. He stated the staffing matrix for units was three MHW’s for every unit on every shift and, if there was a patient who required a 1:1 observation, they would add an extra MHT. He stated the facility was supposed to staff one nurse for ten patients. During an interview on 3/21/24 at 8 a.m., the Director of Quality Management and Patient Risk stated staffing was a lot of issues at the facility, and the Staffing Committee met every month to discuss. He stated all leadership could do was try and hire more people. During an interview on 3/21/24 at 8:30 a.m., the Director of Quality Management and Patient Risk stated the previous Chief Nursing Officer and the current Chief Executive Offices had set up the current staffing matrix to have two Licensed Staff and three MHW on every unit for every shift. He stated, from a quality data perspective, the facility for patient safety looked better four to five years ago, and he did not know why. During an interview on 3/21/24, at 9 a.m., the Interim Medical Director stated the only staffing issue discussed by the Medical Executive Committee and the Governing Board was the need for more staff training, and she was unaware of any staffing and safety issues that had impacted the therapeutic milieu for patient treatment. She stated Therapeutic Activities taught patients how to recognize when they experienced increased agitation and how they should respond. She stated it taught patients internal control and awareness and it was a high risk to patients to not get these therapeutic activities. She stated, “Medication can only do so much,” for behaviors. She stated patients had to have skills for placement and, without access to learning, then the facility was not preparing them for placement. She stated that there were, “No challenges with staffing in either nursing or social services.” During an interview on 3/21/24 at 10:30 a.m., the Director of Clinical Services stated the facility quality data audit results indicated patients were not getting therapeutic meetings, and the risk to patients was they got bored, got agitated, they were isolated, and they saw increased Code Greens, Physical holds, seclusion, SAO and physical assaults. During an interview on 3/21/24 at 1:40 p.m., the House Supervisor stated the Admission process for this facility was to get heads in beds. She stated they never turned down a patient admission. She stated, “The problem was we do not have the appropriate staff.” The House Supervisor stated the facility Administration was not interested in hearing about the staffing issues and any patient safety issues. She stated the danger to patients was that there was not enough staff to detect increased agitation of patients and not enough staff to mitigate the circumstances. She stated, the more trained staff they had, the safer it was for patients and staff. She stated she told Administration they needed more staff. She stated everyone knew, but there was never any follow-up from leadership about how they planned to assess the staffing shortage. As a House Supervisor, she got pulled into doing direct patient care all the time because they were short staffed, and staff called in sick. She stated she consistently got pulled out of her House Supervisor role at least a couple of times a month. She stated she knew the community rooms got closed because there was not enough staff, and staff needed to take their breaks and lunches. She stated there would be no one to monitor the halls and community rooms during breaks so they got closed. She stated the patients were the ones who were impacted by the closure of the community rooms. She stated, without the community rooms, they could not go outside, could not have therapy meetings. She stated a therapist could only be in the community rooms for therapy if there was a MHW available, for safety reasons. During an interview on 3/22/24, at 10:30 a.m., the Director of Nursing stated, everyday at the morning daily meeting he heard about patient-to-patient assaults. He stated they were supposed to have enough staff to help reduce the number of patient assaults, but they could not hire enough nurses and staff. He stated, without proper staffing, more patient-to-patient assaults would occur. The Director of Nursing stated, “The facility’s priority of admitting patients without considering if we had enough staff to safely care for them has contributed to an unsafe environment for patients and staff.” The Director of Nursing stated one staff member was so traumatized by the patient riot and assaults that they had to move her to a different low-acuity unit to get her to come back to work. “Patients in this unit have attacked the nurses and were afraid to come into work.” 2. During an observation on 3/18/24, at 11:35 a.m., in Unit 500 (High Acuity, all Male unit for patients with behaviors that required more observation than other floors, for resident and staff safety), the community room (a room for patients to listen to music, watch movies or participate in therapy) was closed and locked. One Unlicensed Staff was monitoring patients in their bedrooms by rounding on each room with an ipad. The other Unlicensed Staff was standing outside of Room 501 for a 1:1 observation (A process where a staff watches a patient constantly for safety for themselves or others). There were no activities or therapists in the unit interacting with patients. Eight other patients were in their darkened rooms, covered by sheets or blankets. There was no music. The walls had multiple areas of unpainted plaster patches that were in various states of repair. During an interview on 3/18/24, at 10:48 a.m., the Director of Nursing stated, “There is immense pressure from the Chief Executive Officer to get more patients to increase the census. There is so much pressure to get more patients, heads in beds.” He stated he was never consulted before patient admissions whether they had enough staffing to provide safe care for patients. The Director of Nursing stated the Chief Executive Officer was under huge pressure to get the census up because she talked about it all the time at leadership meetings. During an interview on 3/18/24 at 11:50 a.m., Unlicensed Staff Z stated, “In December it started to get really unsafe in the facility. We worked out of ratio (Number of staff to number of patients) consistently on the weekends and nights.” She stated there had been an increase in Code Greens, and without enough staff, there was no one to respond. She stated the facility had admitted patient they could not safely take care of, violent, assaultive patients. She stated the patients got out of control and could not be de-escalated, and then patients and staff got hurt. Unlicensed Staff Z stated she had been hit and punched multiple times until she was sore. She stated she told the Director of Nursing and Administrators she was afraid, and there was not enough staff. During an interview on 3/18/24 at 12 p.m., Licensed Staff AA stated, “We don’t have enough staff to do community meetings or open the community rooms.” She stated patients could not go outside, watch a movie, or have leisure time to listen to music. She stated, with a closed community room, patients would not have access to therapy groups or behavioral activities. She stated an activity had to have a MHT and a Social Services therapist. She stated Social Services was short staffed as well. She stated, at the most patients only had an average of one to two therapy groups per day, “on a good day.” She stated the patient care units were supposed to have four activities per day for patients to go to. She stated there were never activities, “ever,” on the weekend. She stated group activities were supposed to be part of the therapy and treatment for patients, but between the census and patients’ acuity (how many 1:1’s, and 5-minute staff observations), there were no therapies or activities happening. She stated patients never got outside and never had time in the sun which helped them sleep. She asked, “How do you motivate patients to engage in therapy when there is nothing to do?” She stated there were no staff for patients to interact with in a meaningful manner and, “I would be bored and depressed too.” During an interview with the Social Services Director, on 3/18/24 at 12:20 p.m., she stated she oversaw Social Services for the facility. She stated she staffed therapists, Assistant Activity therapists, and Chemical Dependency Councelors. She stated she did the scheduling of staff, and they were short eight therapy positions. She stated, to meet the therapeutic needs of patients she had staff double-up on their assignments, and it was double the work. She stated therapists did assessments, activities, documentation, ran groups and did individual counseling with patients. She stated all of it was not happening consistently on all the units. She stated Group activities was supposed to have four to five staff, and they had only one Activity Assistant. She stated, for one year she had not had enough staff to consistently provide activities for the patients. She stated the risk for adolescent patients was that they would get bored, and there would be an increase in behaviors like Sexually Acting Out (SAO) or assaultive behaviors. She stated today she had three call outs, staff were working hard in difficult situations, and they were short staffed, so people got burned out. She stated she had reported the problem about staffing and safety concerns to Facility Leadership, and they only kept saying to hire more people. She stated she informed them two months ago that staffing was so bad, and patient therapies for activities were not occurring consistently, especially in the last six to nine days. She stated patients would not get the therapeutic milieu that was on their treatment plan, consistently. She stated her plan for staffing and sick calls was to look at patient units where activities were supposed to take place and then offer alternative activities like coloring. She stated she had two part-time staff who were supposed to be available, but one of them call out sick today. During an interview on 3/18/24 at 2:15 p.m., Licensed Staff LL stated she had not seen patient activities being conducted on the units. She stated staffing in Social Services was bad and, as a result, there was inconsistent patient group meetings, therapy and activities. She stated, if the community rooms were open, all the patients did was sit and watch television on some units. She stated, if they spoke up about anything, the Administration here never followed-up or did anything, and then they fired people who spoke up, which was unbelievable since the staffing had been so poor. During an interview on 3/18/24 at 3:15 p.m., Licensed Staff A stated, in group therapy, they tried to stick to the rainbow activity schedule for group meetings and activities. He stated it was not ideal if he could not do the groups and patients would not get therapeutic groups or activities. He would not state what the risk to patients was if there were no activities or therapy available for patients to participate in. During an interview and concurrent document review on 3/19/24 at 9:45 a.m., Unlicensed Staff Y stated there was no community meeting this morning because there was not enough staffing. A review of a document binder in Unit 500, indicated, “Community Meeting Binder” dated 2024, indicated there was no community meeting documentation for the entire year. Unlicensed Staff Y stated there had not been community meetings or physical activity groups because there were no staff to provide those meetings or activities. He stated there was only one Activity Assistant who provided activities like going outside and doing yoga but she needed to have one MHT with her, and they did not have extra staff to provide that. He stated, lack of staffing was a huge safety concern. He stated on the midnight shift there was one nurse and two MHW’s for ten patients that included one 1:1 patient. He stated one MHW did the safety rounding every five minutes, and the other MHW stayed with the 1:1 patient. He stated they could not take breaks or lunches because, if one staff left, it would leave the unit out of ratio for staffing, and it would leave patients and staff in a dangerous situation. He stated they worked without enough staff consistently. He stated Patient 1 had to stay in his room all the time because of his constant assaultive behaviors and the safety of other patients and staff. He stated he had not observed Patient 1 receive any therapies or activities, and he needed more than just being stuck in his room. He stated they were always supposed to have four MHW’s staffed in Unit 500 because of the acuity of the patients, but we could not keep the community room open due to the staffing, and the unit was, “like jail” for the patients. He stated it was sad, like a joke. During an interview with Unlicensed Staff CC, on 3/19/24 at 10:40 a.m., he stated Staffing was just not available. He stated it had become really dangerous when there was not enough staff and an assaultive patient on 1:1 monitoring. Patient 1 was the 1:1, and he did not have any quality of life because he was stuck in his room, and there were no activities or leisure time outside activities. He stated Patient 1 had been at the facility for two years and his hospitalization was, “like a jail.” Patient 1 was so difficult, staff could not get him to cooperate with anything without endangering him or other patients or staff. Unlicensed Staff CC stated leadership had fallen apart, and the only ones concerned with staffing were the staff in the units. He stated they had only one nurse and one MHT for Unit 500 because of sick calls that were not back-filled. He stated staff got hurt and then called in sick, and that made matters worse. He stated staff were afraid to lose their jobs if they spoke up about staff and safety concerns. He stated nothing changed. He stated patients just sat in their rooms and listened to the voices in their heads, and it was dangerous. During an interview on 3/19/24 at 11:05 a.m., Unlicensed Staff CC stated Administration prioritized heads in beds (Increase the patient census) and had no follow-up about staff concerns for safety and staffing shortages. He stated their actions showed them patient safety was not a priority for facility Administration. He stated, without patient activities that promoted socialization and group activities and therapy, they were, “Just warehousing patients.” He stated it was getting worse, and it was not appropriate. During a concurrent interview and record review for Patient 1, on 3/20/24 at 11:40 a.m., Licensed Staff EE stated Patient 1’s treatment plan was last updated 2/13/23. During an interview on 3/20/24, at 2 p.m., Physician DD He stated Patient 1 would remain in a solitary confinement situation for the duration of his stay due to his behaviors. He stated Patient 1 had lost muscle mass as a result of being confined to his room and not getting any exercise. He stated this facility was far from a therapeutic environment. He stated Patient 1’s life was really quite terrible. He stated, “If they had more staff they could monitor him closely, develop a better relationship and perhaps allow for some cooperation, but staffing doesn’t allow that. He is really resource intensive.” Physician A stated, “Short staffing is something I am aware of. It affects the safety of the patients because of lack of monitoring, lack of therapeutic activities.” He stated he had not spoken to anyone in management about his concerns for staffing shortages. During an interview on 3/21/24 at 9 a.m., the Interim Medical Director stated she was the Medical Director and also sat on the Governing Board. She stated her role was to address issues and resolve them. She stated the Governing Board had reviewed facility-reported incidents that involved patient-to-patient assaults. She stated she did not recall if there were any recommendations by the Governing Body to address those concerns. She stated she thought staff could use more training on how to de-escalate agitated patients. The Interim Medical Director stated she was unaware of any patient safety, Social Services or staffing issues that have impacted the therapeutic milieu (Therapy provided to patients in the form of 1:1 counseling, group meetings, group therapy, and activities) for patient treatment at the facility. During an interview on 3/21/24 at 10:38 a.m., the Director of Clinical Services stated the facility quality data audit results indicated patients were not getting therapeutic meetings, and the risk to patients was they got bored, got agitated, they were isolated, and they saw increased Code Greens, physical holds, seclusion, SAO and physical assaults. He stated therapeutic activities were supposed to be documented in the medical record. He stated he was confident documentation was not occurring. He stated there should be documentation to show individualized Social Services therapy and activities for each patient. He stated patients were supposed to have access to four Social Services group activities every day in each unit, and that has not occurred. During an interview on 3/22/24 at 10:10 a.m., Licensed Staff C stated she reported to the Social Services Director, and her role was an inpatient therapist to run groups. She stated they did not have a lot of staff because of sick calls, and they needed to hire more staff. She stated they did not have enough staff to do the work, like assessments, documentation or activity groups. She stated they could not conduct all the therapy groups listed on the color therapy schedule because of the shortage of staff. She stated, if they could not conduct groups, they sometimes passed out alternative worksheets with coloring. She stated they did not have enough staff to provide any therapy or activities for Unit 500. She stated she was afraid to go there because of the high acuity of the patients that were there. During an interview on 3/22/24 at 10:30 a.m., the Director of Nursing stated, “Due to staffing and sick calls I cannot provide proper staffing.” He stated staff had to work with a 1:24 (One Licensed Staff to 24 patients) ratio, and it was unsafe. He stated the facility admitted all patients without consulting him whether there was enough staff to provide care, and it was unsafe. During an interview on 3/22/24 at 10:50 a.m., the DON stated he just informed Administration the was voluntarily terminating his employment at the facility because he was so frustrated with the lack of support from Administration. He stated there was no system in place to check documentation for accuracy. He stated Social Services did not provide activities or groups for patients. He stated he had not observed activities or therapists in the units doing a lot. He stated the priority in the facility was the adolescent units, and so the other adult units simply did not get those Social Services. He stated, “They are not getting the therapeutic milieu that was on their Master Treatment Plan.” He stated, not having Social Services had a negative impact on all the patients. He stated, “Not one patient had consistently participated in or been offered four Social Services activities a day.” He stated staffing had been a constant struggle resulting in nurse-to-patient ratios of 1: 24. He stated, “There is nothing other than a medication pass happening when the ratio is that low.” He stated the only intervention Administration offered consistently was to hire more people. During an interview on 3/22/24 at 11:45 a.m., Unlicensed Staff B stated she was supposed to conduct three to five groups a day in the patient units, but it was not consistently happening for patients. She stated Social Services has had three directors in the last two years and three Activity Techs, and two therapy leaders had quit. She stated staffing changes had contributed to everyone quitting. She stated the, “Goal of the department was to have four activities a day for all patients.” She stated the activities were a part of the therapy and were on the treatment plan. She stated the adolescent units were the priority, and all the Social Services were directed towards them. She stated there was not enough staff to take Unit 500 outside, and they never got direct sunlight, and it was so unhealthy. She stated if she could not do activities in Unit 500, she would hand out alternative activities like coloring, but typically Unit 500 would not even get any alternative activities. She stated there are no Social Services on weekends or holidays. During an interview and record review with Licensed Staff EE on 3/22/24 at 12:50 a.m., he stated, “There was no Psychosocial Note for Patient 1 in the last 72 hours.” He stated, “I do not see any Psychosocial Notes in his medical record.” He stated the importance of the note was that it was the basis of therapy . He stated it documented the assessment of strengths and weaknesses of a patient and, without it, the therapy was inaccurate and inappropriate. He stated they ended up with a completely useless treatment plan. During an interview with the Chief Executive Officer, on 3/22/24 at 3:40 p.m., when asked if the Governing Body had documented any issues or concerns about staffing or safety, she stated the staff needed more training how to engage in robust de-escalation of patient behavior. Review of a document, not titled, not dated, referred to as the Social Services Activity Rainbow Colored Chart, indicated for Unit 500 on a daily basis, eight activities a day were supposed to be offered to residents by a combination of Therapists and MHT’s. The activities indicated Community Morning Meetings (MHT twice Daily for a total of 90 minutes per day, Activates Group in Gymnasium or group twice a day for two hours per day, Psych Education Group / Chemical Dependency Group (Therapist) for a total of 90 minutes per day, Nursing / Pharmacy Group for 60 minutes per day, Interdisciplinary Group (Therapist / Nurse / Other ) for a total of one hour per day. Review of document titled, “ STAFFING MEETING MINUTES,” dated 1/4/24, it indicated, “Safety Data Presentation Human Resources data shared with the Staffing Committee. Staff injuries requiring medical attention, November 2023, 11 employee injuries with 6 requiring medical attention. The number of injuries peaked in May 2023 at 25 total injuries and 7 requiring medical attention....Missed meal breaks peaked in November at 208 hours....The schedule does not include enough MHTs to cover for breaks. RN’s are expected to cover MHT breaks.” No action items were documented. No responsible person was documented, and there was no target date. Review of a document titled, “Governing Board MEETING MINUTES,” dated 1/25/24, indicated, “CEO Report: Staffing continues to be a challenger to hire RN’s and Therapists.... During Q4, 2023, we had census growth of the previous year. ... Year over year, we saw an increase of 26% from 2022 to 2023. We hit an all-time record in Q4 of 109 patient census. However, due to staffing shortages in November and December the census decreased.” No action items were documented. No responsible person was documented, and there was no target date. Review of a document titled, “Governing Board MEETING MINUTES,” dated 10/26/23, indicated, “CEO Update: Staffing We continue to have challenges with staffing RN’s and Therapists.” No action items were documented. No responsible person was documented, and there was no target date. Review of documents titled, “Governing Board MEETING MINUTES,” dated 7/27/23, indicated no Governing Board agenda for discussion of staffing. Review of documents titled, “Governing Board MEETING MINUTES,” dated 4/27/23, indicated, “Recruitment continues to be a challenge to hire RN’s and Therapists.” No action items were documented. No responsible person was documented, and there was no target date. Review of document titled, “Santa Rosa Behavioral Healthcare Hospital Strategic Plan 2023,” indicated, “Our Story We recognize that each patient is an individual. We pride our hospital in providing the right type of care for the right individual and in the right amount. From day one, we tailor our diverse treatment programs to meet our patient’s specific and unique needs.... S.W.O.T Analysis Weakness Staffing challenges - hiring, training, & retention. Community perception of being difficult to work with....Strategic Priorities SAFETY Goal ... Objective 1: Increase patient participation in therapeutic programing. ...GROWTH Goal ...Objective 1: Expand inpatient acute bed capacity ... PEOPLE Goal: Objective 1. Reduce employee turnover rate by 15% from prior year rates. ORGANIZATIONAL DEPARTMENTAL GOALS Nursing Services Reduce overtime use by 25% beginning January 2023.” Review of a document, provided by Leadership, not titled, not dated, indicated for Therapist, Activity, Therapy Aide and Chemical Dependency Counselor, there was a total of 32, “Call outs / Absences in the last 30 days. A total of 256 therapeutic hours, out of a possible 1,312 therapeutic hours, of Social Service activities and groups were not provided during the last 30 days. Review of a Policy and Procedure titled, “GROUP THERAPY AND GROUP NOTE,” approved 5/26/22, indicated, “The purpose of Group Notes is to document the patients progress that occurs in each group therapy session. The group notes serves purpose to communicate patient progress to members of the treatment team. Policy: To ensure that Group Therapy is provided per program description. To ensure there is a concise and accurate record of patient participation, interaction and response to group therapy. Documentation of patient participate will be done after each group session.” 3. During an interview on 3/18/24 at 11:35 a.m., in patient Unit 500, the Director of Quality Management stated the unit was supposed to always have two nurses, and they were working out of ratio. He stated he thought maybe there was a sick call. During a review and concurrent interview of facility staffing sheets titled, “DAILY ASSIGNMENT SHEET UNIT 500,” dated 3/18/24, it indicated for a Census of ten patients and one 1:1 observation, Unit 500 had one charge nurse scheduled for the day and evening shift. For the night shift there was no schedule provided by the facility by the end of survey. This indicated the unit was working out of safe patient to staff ratios. Review of a facility Policy and Procedure titled, “STAFFING MATRIX AND ACUITY SYSTEM,” approval date 10/23/23, indicated, “Variation from staffing plans are documented with explanation by the Nursing Supervisor with Director of Nursing Involvement as needed.” “ASR (Aurora Substance Rehabilitation) UNIT STAFFING MATRIX,” indicated one Charge RN for every patient unit. For a patient census of ten and under no RN/LVN and one MHW and one Hall Monitor for every patient unit. For a patient census of 11-20, one RN / LVN, and one Hallway monitor was required. For a patient census of 15 - 25, two MHW’s were required. For a patient census of 21 - 25, two RN’s/LVN’s were required. The document indicated, “ABOVE MATRIX IS THE RECOMMEND STAFF TO PATIENT RATIO. ACTUAL RATIOS MAY VARY DEPENDING ON ACUITY. MINIMUM STAFFING OF 1 RN PER UNIT WILL BE MAINTAINED AT ALL TIMES.” During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 200,” dated 10/31/23, it indicated for a census of 16 and one 1:1 while asleep, Unit 200 was missing one day Nurse and missing two Night Shift MHT’s. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 300,” dated 11/1/23, it indicated for a census of 15, Unit 300 was missing one day and evening MHT for breaks and one night shift Nurse. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 400,” dated 11/1/23, it indicated for a census of 14, Unit 400 was missing two evening nurses. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 500,” dated 11/1/23, it indicated for a census of 12 (The unit was supposed to be capped at ten patients for safety reasons) and one 1:1 observation, Unit 500 was missing one break MHT for day, evening and night shift. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 600,” dated 11/1/23, it indicated for a census of 18, Unit 600 was missing a break MHT for day and evening shift. A request for the night shift staffing sheet was made and not received by the end of the survey. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 400,” dated 11/1/23, it indicated for a census of 14, Unit 400 was missing one night nurse and one night break MHT. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 700,” dated 11/1/23, it indicated for a census of 20 with one 1:1, Unit 700 was missing one night nurse and one day break MHT. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 200,” dated 12/15/23, it indicated Unit 700 was missing one day and evening nurse, and one day break MHT. Unit 300 evening shift was missing one nurse, Unit 400 was missing one day break MHT, Unit 500 was missing one day nurse, one evening nurse, and Unit 500, for the night shift on an undocumented date, had a census of 12 and one 1:1 observation and was missing a break MHT. Unit 600 day shift was missing one day nurse and one break MHT, one evening nurse and one night break MHT. Unit 700 night shift was missing one nurse. During a review of a document titled, “DAILY ASSIGNMENT SHEET UNIT 200,” dated 1/5/24, it indicated Unit 500 was missing one day nurse, one evening nurse and one evening break MHT, one night nurse and one night break MHT. During a review of staffing sheets from 3/14/24 to 3/17/24, it indicated a total of 14 missing nurse shifts and 17 MHT shifts. During a review of staffing sheets from 11/2/23 to 11/6/24, it indicated a total of 20 Missing Nurse shifts and 47 MHT shifts.”

“Therapeutic Activities - Program CFR(s): The program must be appropriate to the needs and interests of patients and be directed toward restoring and maintaining optimal levels of physical and psychosocial functioning. This Standard is not met as evidenced by: 40402 Based on observation, interview and record review, the facility failed to follow doctors’ orders by not providing sufficient staff to facilitate Activities Therapies Groups on Unit 300 for three out of three sampled patients (Patient 13, Patient 14, and Patient 15). This failure resulted in Patient 13, Patient 14 and Patient 15 not obtaining prescribed treatment, then feeling depressed, bored, and fatigued when they could not go outside, to the gym or attend educational activities groups. Findings: During a record review of Unit 300’s weekly Activity Therapies Group schedule, Gymnasium group was listed seven days a week from Sunday to Saturday. Other Groups also listed on Unit 300’s weekly Activity Therapies schedule for seven days a week were Psych Education Group, Nursing / Pharmacy Group, and Journaling Group. During an interview with Licensed Staff D on 3/19/24 at 8:45 a.m., Licensed Staff D was queried when the next Activities Group would be held for the patients on Unit 300. Licensed Staff D stated she was not sure because the facility’s Social Service Department was short staffed, and the groups were not always held when they were scheduled. Licensed Staff D was queried as to the next time Patient 13, Patient 14, and Patient 15 would be escorted outside or to the Gym. Licensed Staff D responded she could not be certain because the Social Service Department needed two therapists to take patients outside and to the Gym, so the outside activities and gym classes were not occurring according to the Activities schedule. During an observation and interview with Patient 13 on 3/19/24 at 9 a.m., on Unit 300, Patient 13 was shown a Unit 300 schedule of Activity Therapies Groups and asked if she had attended any of these groups. Patient 13 responded she had never seen any of those groups occur but wished they would hold them because she got bored. Patient 13 expressed concern about wanting to go outside as well as to the gym to exercise, but the facility did not have enough staff to take them out. Patient 13 was queried if she attended any of the Psych Education Groups, Pharmacy Groups, or Journaling Groups. Patient 13 stated she had not gone to any groups, except for a pet group which was run by a volunteer from the outside who brought in her social therapy dog. During a record review of Patient 13’s chart, a doctor’s order, dated 3/15/24, authored by Psychiatrist E, indicated: Involve patient in all aspects of unit program including Activity Therapies Groups. During an interview with Patient 14 on 3/19/24 at 11:30 a.m., Patient 14 was shown the Unit 300 Activity Therapies Group schedule and asked if she had attended any of these groups. Patient 14 stated she thought she had gone to one group which was the chemical Dependency Group, but the other groups were never held. Patient 14 was queried if she was able to go outside or use the gym when it was on the Activities Group schedule. Patient 14 responded she had not but would like to because she got bored and depressed just sitting indoors watching TV in the day room. During a record review of Patient 14’s chart, a doctor’s order, dated 3/13/24, authored by Psychiatrist F, indicated: Involve patient in all aspect of unit program including Activity Therapies groups. During an interview with Patient 15 on 3/19/24 at 12:30 p.m., Patient 15 was shown Unit 300 Activity Therapies group schedule and was queried if he had attended any of these groups. Patient 15 responded he had gone to one group for Chemical Dependency, but they did not ask him to attend any more groups. Patient 15 stated he was laying down on his bed bored and someone came in his room without saying anything and dropped a piece of paper on his table and then walked out. Patient 15 stated he did not know what he was supposed to do with the paper. He later found out it was supposed to be a group alternative, but he never filled it out because no one assisted him with the alternative assignment. Patient 15 stated he wished the therapists were more assertive about waking patients up to go to the Activities groups, as well as taking them outside and to the Gym. Patient 15 was queried as to what he was doing with his time if he was not attending Activities Groups. Patient 15 responded he watched a lot of Television. During a record review of Patient 15’s chart, an MD order, dated, 3/14/24, indicated: Involve in all aspects of unit program including Activity Therapies Group. During an interview with the Director of Social Services on 3/22/24 at 2:40 p.m., the Director of Social Services was shown the Activity Therapies Group schedule for Unit 300 and was queried about the frequency that those groups were being held for the patients. The Director of Social Services stated she had been short staffed for the past year and was actively working on recruiting more therapists. The Director of Social Services stated she should have nine therapists scheduled today to support the census, but she only had five on the schedule today leaving the patients short by four therapists. The Director of Social Service was queried as to how the lack of therapists affected the treatment program for Unit 300. The Director of Social Service stated she did not think it was fair to the patients who needed to get out and exercise and go to Activities Groups. During a zoom interview in the administrative conference room, with the Interim Medical Director on 3/21/24 at 9 a.m., the Interim Medical Director was queried as to her expectations for the patients to be attending the Activity Therapies Groups. The Interim Medical Director stated she expected those groups to be held daily. When the Interim Medical Director was queried if she knew the Activity Therapies Groups were not being held daily, she stated she was unaware the groups were not being held daily. The Interim Medical Director was queried as to how not engaging the patients on Unit 300 in Activity Groups affected their progress. The Interim Medical Director stated she believed the Activity Groups were an integral part of the patients’ treatment and they should be receiving this treatment for the progression of their mental health. During an interview with Unlicensed Staff B on 3/22/24 at 11:30 a.m., Unlicensed Staff B shown the Activity’s Therapies Group Schedule for Unit 300 and was queried how frequently these groups were being held. Unlicensed Staff B said not very often due to the Social Service Department being short staffed. Unlicensed Staff B stated it was just her trying to meet the needs of five different units and she could not be everywhere at one time. Unlicensed Staff B stated she had shared her concerns with her boss, the Director of Social Service, who was aware there was not enough staff to implement the Activities Therapy Groups. Unlicensed Staff B was queried as to how it was documented when a patient was not able to attend the Activities Group due to lack of staff to hold the groups. Unlicensed Staff B stated she and other therapists only documented a Group Note when the patient attended the group. Unlicensed Staff B stated there was no documentation indicating when the patient did not attend the Activities Therapy Groups. During a review of the Director of Social Service’s Job description, under Key Responsibilities: “Directs activities of Clinicians and Activities Therapists. This includes ensuring compliance with all treatment plan requirements including weekly review and updates with the patient....Provides in-service training for social service staff and other employees as needed....Provides guidance to staff to assist them in continually improving all aspects of care....Provides group process-oriented therapy as well as conducts educational and other didactic groups for patients and family members using various professional treatment modalities....Responsible for scheduling and staffing to ensure adequate coverage....Attends regular treatment team meetings to provide social work perspectives to total case management of the patient by discussing progress notes charts and communicating any state or local agency legal requirement for case management with the interdisciplinary team....Oversees maintenance of clinical records and reports to ensure compliance with local state and federal laws.” During a review of the facility’s policy and procedure titled, “Multidisciplinary Treatment Planning” dated, 5/26/22, it indicated, “Purpose: to provide a process and guidelines for implementation of a comprehensive, individualized multidisciplinary treatment plan for every patient....Treatment Meeting Process. A) A member of the multidisciplinary team provides a brief synopsis of patient’s presentation to the multidisciplinary team members including an RN, Clinician, and other disciplines as applicable. B) Each discipline presents relevant information about the patient (provider nursing, social services, and other disciplines as applicable. C) There is a brief discussion to identify problems to be addressed during this admission ...E) Multidisciplinary team members describe their recommended interventions, and the provider provides additional direction to the team.....The Master Treatment Plan Review shall include: ...Group Attendance and Participation.” During a review of the facility’s policy and procedure titled, “Group Therapy and Group Note” dated, 5/26/22, it indicated, “Purpose: The purpose of the Group Notes is to document the patients’ progress that occurs in each group therapy session. The group note serves purpose to communicate patient progress to members of the treatment team. Policy: To ensure that Group Therapy is provided per program description. To ensure there is a concise and accurate record of patient participation, interaction, and response to group therapy. Documentation of patient participation will be done after each group session. This documentation will be concise, legible, and accurate. Procedure: Group size will be appropriate to the setting of the environment. Staff members assigned to group therapy will be competent to perform the specific group they have been assigned through degree, experience, orientation and /or demonstration of competency. Following each group therapy session, the therapist is responsible for timely documentation of the group by utilizing the Group Note. All areas are to be completed as noted on the form including: Patients name, Time, date, and length of time of counseling session, Staff signature and professional credential and/or job title, group focus, treatment goals addressed, patient behavior/response, cognitive and affective assessment, level quality of patient’s participation , modes of intervention, In the event that a patient does not attend group alternative treatment and will be provided followed by documentation.””

“Therapeutic Activities - Staffing CFR(s): The number of qualified therapists, support personnel, and consultants must be adequate to provide comprehensive therapeutic activities consistent with each patient’s active treatment program. This Standard is not met as evidenced by: 38088 Based on observation, interview and record review, the facility failed to ensure consistent Social Services staffing that met patients needs for a therapeutic activities and services, when the facility did not staff Social Services with enough Therapists and Therapy Assistants to provide therapies and activities documented on patients’ Master Treatment Plans, for 8 out 8 Sampled Patients (Patient 1, Patient 10, Patient 12, Patient 13, Patient 14, Patient 15, Patient 23, and Patient 24). The failure resulted in all patients not having consistent access to therapeutic and rehabilitative services set in the patient’s treatment plan, and lack of timely monitoring and evaluation of the quality and appropriateness of the services delivered to patients. Findings: (Cross Reference A-263, A-1680, A-1704, A-1725) During an interview on 3/18/24, at 10:48 a.m., the Director of Nursing stated, “There is immense pressure from the Chief Executive Officer to get more patients to increase the census. There is so much pressure to get more patients, heads in beds.” He stated he was never consulted before patient admissions if they had enough staffing to provide safe care for patients. The Director of Nursing stated the Chief Executive Officer was under huge pressure to get the census up because she talked about it all the time at leadership meetings. During an observation on 3/18/24, at 11:35 a.m., in Unit 500 (High Acuity, all Male unit for patients with behaviors that required more observation than other floors, for resident and staff safety), the community room (a room for patients to listen to music, watch movies or participate in therapy) was closed and locked. One Unlicensed Staff was monitoring patients in their bedrooms by rounding on each room with an ipad. The other Unlicensed Staff was standing outside of Room 501 for a 1:1 observation (A process where a staff watched a patient constantly for safety for themselves or others). There were no activities or therapists in the unit interacting with patients. Eight other patients were in their darkened rooms, covered by sheets or blankets. There was no music. The walls had multiple areas of unpainted plaster patches in various states of repair. During an interview on 3/18/24 at 11:50 a.m., Unlicensed Staff Z stated, “In December it started to get really unsafe in the facility. We worked out of ratio (Number of staff to number of patients) consistently on the weekends and nights.” She stated there had been an increase in Code Greens, and without enough staff, there was no one to respond. She stated the facility had admitted patients they could not safely take care of, violent, assaultive patients. She stated the patients got out of control and could not be de-escalated and then patients and staff got hurt. Unlicensed Staff Z stated she has been hit and punched multiple times until she was sore. She stated she told Director of Nursing and Administrators she was afraid, and there was not enough staff. During an interview on 3/18/24 at 12 p.m., Licensed Staff AA stated, “We don’t have enough staff to do community meetings or open the community rooms.” She stated patients could not go outside, watch a movie, or have leisure time to listen to music. She stated, with a closed community room, patients would not have access to therapy groups or behavioral activities. She stated an activity had to have a MHT and a Social Services therapist. She stated Social Services was short staffed as well. She stated, at the most patients only had an average of one to two therapy groups per day, “on a good day.” She stated the patient care units were supposed to have four activities per day for patients to go to. She stated there were never activities, “ever,” on the weekend. She stated group activities were supposed to be part of the therapy and treatment for patients, but between the census and patients’ acuity (how many 1:1’s, and 5-minute staff observations), there were no therapies or activities happening. She stated patients never got outside and never had time in the sun which helped them sleep. She asked, “How do you motivate patients to engage in therapy when there is nothing to do?” She stated there were no staff for patients to interact with in a meaningful manner and, “I would be bored and depressed too.” During an interview with the Social Services Director, on 3/18/24 at 12:20 p.m., she stated she oversee Social Services for the facility. She stated she staffed therapists, Assistant Activity therapists, and Chemical Dependency Councelors. She stated she did the scheduling of staff, and they were short eight therapy positions. She stated, to meet the therapeutic needs of patients she had staff double-up on their assignments, and it was double the work. She stated therapists did assessments, activities, documentation, ran groups and did individual counseling with patients. She stated all of it was not happening consistently on all the units. She stated Group activities was supposed to have four to five staff, and they had only one Activity Assistant. She stated, for one year she had not had enough staff to consistently provide activities for the patients. She stated the risk for adolescent patients was that they would get bored, and there would be an increase in behaviors like Sexually Acting Out (SAO) or assaultive behaviors. She stated today she had three call outs, staff were working hard in difficult situations, and they were short staffed, so people got burned out. She stated she reported the problem about staffing and safety concerns to Facility Leadership, and they only kept saying to hire more people. She stated she informed them two months ago that staffing was so bad and patient therapies for activities were not occurring consistently, especially in the last six to nine days. She stated patients would not get the therapeutic milieu that was on their treatment plan, consistently. She stated her plan for staffing and sick calls was to look at patient units where activities were supposed to take place and then offer alternative activities like coloring. She stated she had two part-time staff who were supposed to be available but one of them called out sick today. During an interview on 3/18/24 at 2:15 p.m., Licensed Staff LL stated she had not seen patient activities being conducted on the units. She stated staffing in Social Services was bad, and as a result, there was inconsistent patient group meetings, therapy and activities. She stated, if the community rooms were opened all the patients did was sit and watch television on some units. She stated, if staff spoke-up about anything, the Administration never followed-up or did anything, and then they fired people who spoke up, which was unbelievable since staffing had been so poor. During an interview on 3/18/24 at 3:15 p.m., Licensed Staff A stated, in group therapy they tried to stick to the rainbow activity schedule for group meetings and activities. He stated it was not ideal if he could not do the groups and patients would not get therapeutic groups or activities. He would not state what the risk to patients was if there were no activities or therapy available for patients to participate in. During an interview and concurrent document review on 3/19/24 at 9:45 a.m., Unlicensed Staff Y stated there was no community meeting that morning because there was not enough staffing. A review of a document binder in Unit 500, indicated, “Community Meeting Binder,” dated 2024, which indicated there was no community meeting documentation for the entire year. Unlicensed Staff Y stated there had not been community meetings or physical activity groups because there were no staff to provide those meetings or activities. He stated there was only one Activity Assistant who provided activities like going outside, doing yoga, but she needed to have one MHT with her, and they did not have extra staff to provide that. He stated, lack of staffing was a huge safety concern. He stated, on the midnight shift there was one nurse and two MHW’s for ten patients which included one 1:1 patient. He stated one MHW did the safety rounding every five minutes, and the other MHW stayed with the 1:1 patient. He stated they could not take breaks or lunches because if one of them left, it would leave the unit out of ratio for staffing, and it would leave patients and staff in a dangerous situation. He stated they worked without enough staff consistently. He stated Patient 1 had to stay in his room all the time because of his constant assaultive behaviors and the safety of other patients and staff. He stated he had not observed Patient 1 receive any therapies or activities, and he needed more than just being stuck in his room. He stated they were always supposed to have four MHW staffed in Unit 500 because of the acuity of the patients, but they could not keep the community room open due to the staffing, and the unit was, “like jail” for the patients. He stated it was sad, like a joke. During an interview with Unlicensed Staff CC, on 3/19/24 at 10:40 a.m., he stated Staffing was just not available. He stated it had become really dangerous when there was not enough staff and an assaultive patient on 1:1 monitoring. Patient 1 was the 1:1, and he did not have any quality of life because he was stuck in his room, and there were no activities or leisure time outside activities. He stated Patient 1 had been at the facility for two years, and his hospitalization was, “like a jail.” Patient 1 was so difficult, staff could not get him to cooperate with anything without endangering him or other patients or staff. Unlicensed Staff CC stated stated leadership had fallen apart, and the only ones concerned with the staffing were the staff in the units. He stated they had only one nurse and one MHT for Unit 500 because of sick calls that were not back filled. He stated staff got hurt and then called in sick, and that made matters worse. He stated staff were afraid to lose their jobs if they spoke up about staff and safety concerns. He stated nothing changed. He stated patients just sat in their rooms and listened to the voices in their heads, and it was dangerous. During an interview on 3/19/24 at 11:05 a.m., Unlicensed Staff CC stated Administration prioritized heads in beds (Increase the patient census) and had no follow-up about staff concerns for safety and staffing shortages. He stated their actions showed them that patient safety was not a priority for facility Administration. He stated, without patient activities that promoted socialization and group activities and therapy, they were, “Just warehousing patients.” He stated it was getting worse, and it was not appropriate. During a concurrent interview and record review for Patient 1, on 3/20/24 at 11:40 a.m., Licensed Staff EE stated, “Patient 1’s treatment plan was last updated 2/13/23.” During an interview on 3/20/24 at 2 p.m., Physician DD stated Patient 1 was, “Essentially in solitary confinement for the duration of his stay due to his behaviors. It is hard to say it’s a therapeutic environment when he cannot socialize, participate in any therapies....His life was really quite terrible.” He stated Patient 1 had lost muscle mass as a result of being confined to his room and not getting any exercise. Physician A stated, “Short staffing is something I am aware of. It affects the safety of the patients because of lack of monitoring, lack of therapeutic activities.” He stated, “If they had more staff they could monitor him closely, develop a better relationship and perhaps allow for some cooperation, but staffing doesn’t allow that. He is really resource intensive.” He stated he had not spoken to anyone in management about his concerns for staffing shortages. During an interview on 3/21/24 at 9 a.m., the Interim Medical Director stated she was the Medical Director and also sat on the Governing Board. She stated her role was to address issues and resolve them. She stated the Governing Board had reviewed facility-reported incidents that involved patient-to-patient assaults. She stated she did not recall if there were any recommendations by the Governing Body to address those concerns. She stated she thought staff could use more training on how to de-escalate agitated patients. The Interim Medical Director stated she was unaware of any patient safety, Social Services or staffing issues that have impacted the therapeutic milieu (Therapy provided to patients in form of 1:1 counseling, group meetings, group therapy, and activities) for patient treatment at the facility. During an interview on 3/21/24 at 10:38 a.m., the Director of Clinical Services stated the facility quality data audit results indicated patients were not getting therapeutic meetings, and the risk to patients was they got bored, got agitated, they were isolated, and they saw increased Code Greens, Physical holds, seclusion, SAO and physical assaults. He stated therapeutic activities were supposed to be documented in the medical record. He stated he was confident documentation was not occurring. He stated there should be documentation to show individualized Social Services therapy and activities for each patient. He stated patients were supposed to have access to four Social Services group activities every day in each unit, and that has not occurred. During a concurrent interview and record review for Patient 10, on 3/22/24, at 8:45 a.m., Licensed Staff EE stated the Master Treatment Plan indicated he was supposed to have attended therapeutic meetings and activities. He stated the last Social Services Note was 3/12/24 at 3:48 p.m., and it indicated Patient 10 did not attend group activity. Licensed Staff EE stated review of the document titled, “Group Note,” indicated Patient 10, “DID NOT” attend group on 3/12/24 at 12:15 p.m., 3/13/24 at 2 p.m., 3/17/24 at 12:30 p.m. and 2:05 p.m., 3/19/24 at 12:15 p.m., 3/20/24 at 10:30 p.m.. During a concurrent interview and record review for Patient 12, on 3/22/24 at 8:50 a.m., Licensed Staff EE stated he did not submit a Social Services Note within the mandated 72 hours from the time of admission. He stated there were no Social Services Group Notes on 3/18/24. He stated there were no Social Services Notes from the time of his admission on 3/15/24 to 3/17/24. He stated the medical record indicated Patient 12 did not attend Therapeutic Activities or groups on 3/17/24 or 3/19/24. During an interview on 3/22/24 at 10:10 a.m., Licensed Staff C stated she report to the Social Services Director, and her role was an inpatient therapist to run groups. She stated they did not have a lot of staff because of sick calls, and they needed to hire more staff. She stated they did not have enough staff to do the work, like assessments, documentation or activity groups. She stated they could not conduct all the therapy groups listed on the color therapy schedule because of the shortage of staff. She stated, if they could not conduct groups, they sometimes passed out alternative worksheets with coloring. She stated they did not have enough staff to provide any therapy or activities for Unit 500. She stated she was afraid to go there because of the high acuity of the patients that were there. During an interview on 3/22/24 at 10:30 a.m., the Director of Nursing stated, “Due to staffing and sick calls I cannot provide proper staffing.” He stated staff had to work with a 1:24 (One Licensed Staff to 24 patients) ratio, and it was unsafe. He stated the facility admitted all patients without consulting him whether there was enough staff to provide care, and it was unsafe. During an interview on 3/22/24 at 10:50 a.m., he stated he just informed Administration that he was voluntarily terminating his employment at the facility because he was so frustrated with the lack of support from Administration. He stated there was no system in place to check documentation for accuracy. He stated Social Services did not provide activities or groups for patients. He stated he had not observed activities or therapists in the units doing a lot. He stated the priority in the facility was the adolescent units, and so the other adult units simply did not get those Social Services. He stated, “They are not getting the therapeutic milieu that was on their Master Treatment Plan.” He stated, not having Social Services had a negative impact on all the patients. He stated, “Not one patient had consistently participated in or been offered four Social Services activities a day.” He stated staffing had been a constant struggle resulting in nurse-to-patient ratios of 1:24. He stated, “There is nothing other than a medication pass happening when the ratio is that low.” He stated the only intervention Administration offered consistently was to hire more people. During an interview 3/22/24 at 11:45 a.m., Unlicensed Staff B stated she was supposed to conduct three to five groups a day in the patient units, but it was not consistently happening for patients. She stated Social Services has had three directors in the last two years, and three Activity Tech’s, and two therapy leaders had quit. She stated staffing changes had contributed to everyone quitting. She stated the, “Goal of the department was to have four activities a day for all patients.” She stated the activities were a part of the therapy and were on the treatment plan. She stated the adolescent units were the priority, and all the Social Services were directed towards them. She stated there was not enough staff to take Unit 500 outside, and they never got direct sunlight, and it was so unhealthy. She stated, if she could not do activities in Unit 500, she would hand out alternative activities like coloring, but typically Unit 500 would not even get any alternative activities. She stated there were no Social Services on weekends or holidays. During an interview and record review with Licensed Staff EE on 3/22/24 at 12:50 a.m., he stated, “There was no Psychosocial Note for Patient 1 in the last 72 hours.” He stated, “I do not see any Psychosocial Notes in his medical record.” He stated the importance of the note was that it was the basis of therapy . He stated it documented the assessment of strengths and weaknesses of a patient and, without it, the therapy was inaccurate and inappropriate. He stated they ended up with a completely useless treatment plan. During an interview with the Chief Executive Officer, on 3/22/24 at 3:40 p.m., when asked if the Governing Body had documented any issues or concerns about staffing or safety, she stated staff need more training how to engage in robust de-escalation of patient behavior. Review of a document, not titled, not dated, referred to as the Social Services Activity Rainbow Colored Chart, indicated for Unit 500 on a daily basis, eight activities a day were supposed to be offered to residents by a combination of Therapists and MHT’s. The activities indicated Community Morning Meetings (MHT twice Daily for a total of 90 minutes per day, Activates Group in Gymnasium or group twice a day for two hours per day, Psych Education Group / Chemical Dependency Group (Therapist) for a total of 90 minutes per day, Nursing / Pharmacy Group for 60 minutes per day, Interdisciplinary Group (Therapist / Nurse / Other ) for a total of one hour per day. Patient 1 was a 26-year-old male, admitted 8/12/22, with history of unspecified Psychosis not due to substance or known physiological defect. He had a diagnosis of Schizophrenia and was conserved by a contracted professional who was responsible for finding long-term placement. He had medication orders for Thorazine, Lamotrigine, PRN orders for Thorazine, Ativan and Tenex. His Rationale for inpatient stay was documented as, “For grave disability and danger to others.” A document titled, “Master Treatment Plan Review,” indicated the last review of Patient 1’s plan was 12/16/23, and it indicated, “Intervention - Social Services will conduct group (Discharge planning, process, educational, Chemical Dependency, expressive, self-regulation) or individual session aimed at increasing positive serl-regulation skill ONCE A DAY.....Intervention - Social Services will assist Patient in recognizing their specific triggers that have led to danger to others, homicidal ideation, and/or physical aggression during group or individual sessions ONCE A DAY.” Patient 10 was a 42-year-old male, admitted 3/10/24, with admitting diagnoses of Unspecified psychosis not due to a substance or known psychological. A document titled, “Facesheet,” indicated, “Pt [patient] is delusional, disorganized and making bizarre statements. Pt was found at a light station, unable to say who he was, or how he would care for self. Pt is not able to meet his basic needs. A document titled, “Master Treatment Plan,” dated 3/12/24, indicated Short-Term and Long-Term goals that included, “Therapist will assist patient in realizing the benefits of being medication compliant.....Patient will identify 2 negative effects of impulsive behavior / poor coping skills have had on their life and report in group over the next 1 week.... Intervention - Social Services will conduct group 9 Discharge planning, process, educational, Chemical Dependency, expressive, serl-regulation) or individual session aimed at increasing positive serl-regulation skills ONCE A DAY.” Patient 12 was a 47-year-old male, admitted 3/15/24, with admitting diagnoses of Unspecified psychosis not due to a substance or known physiological.” A document titled, “Facesheet,” indicated, “47 yo Male. PT is paranoid and claiming that he was hearing people telling him his food is being poisoned.” A document titled, “Master Treatment Plan,” dated 3/18/24, indicated, “Intervention - Social Services will conduct group (Discharge planning, process, educational, Chemical Dependency, expressive, serl-regulation) or individual session aimed at increasing positive serl-regulation skill As Needed.” Review of a document titled, “Face sheet,” indicated Patient 1 was a 26-year-old male admitted on 8/12/22, with diagnoses including Unspecified psychosis not due to a substance or known physiological defect. Review of a document titled, “[GACH Facility Name] Progress/Visit Notes ED Physician Notes ...Reason for Hold A danger to others.” Review of document titled, “ STAFFING MEETING MINUTES,” dated 1/4/24, it indicated, “Safety Data Presentation Human Resources data shared with the Staffing Committee. Staff injuries requiring medical attention, November 2023, 11 employee injuries with 6 requiring medical attention. The number of injuries peaked in May 2023 at 25 total injuries and 7 requiring medical attention.....Missed meal breaks peaked in November at 208 hours....The schedule does not include enough MHT’s to cover for breaks. RN’s are expected to cover MHT breaks.” No action items were documented. No responsible person was documented, and there was no target date. Review of a document titled, “Governing Board MEETING MINUTES,” dated 1/25/24, indicated, “CEO Report: Staffing continues to be a challenge to hire RN’s and Therapists.....During Q4, 2023, we had census growth of the previous year. ... Year over year, we saw an increase of 26% from 2022 to 2023. We hit an all-time record in Q4 of 109 patient census. However, due to staffing shortages in November and December the census decreased.” No action items were documented. No responsible person was documented, and there was no target date. Review of a document titled, “Governing Board MEETING MINUTES,” dated 10/26/23, indicated, “CEO Update: Staffing we continue to have challenges with staffing RN’s and Therapists.” No action items were documented. No responsible person was documented, and there was no target date. Review of documents titled, “Governing Board MEETING MINUTES,” dated 7/27/23, indicated no Governing Board agenda for discussion of staffing. Review of documents titled, “Governing Board MEETING MINUTES,” dated 4/27/23, indicated, “Recruitment continues to be a challenge to hire RN’s and Therapists.” No action items were documented. No responsible person was documented, and there was no target date. Review of a document titled, “Santa Rosa Behavioral Healthcare Hospital Strategic Plan 2023,” indicated, “Our Story We recognize that each patient is an individual. We pride our hospital in providing the right type of care for the right individual and in the right amount. From day one, we tailor our diverse treatment programs to meet our patient’s specific and unique needs.....S.W.O.T Analysis Weakness Staffing challenges - hiring, training, & retention. Community perception of being difficult to work with....Strategic Priorities SAFETY Goal ... Objective 1: Increase patient participation in therapeutic programing. ...GROWTH Goal ...Objective 1: Expand inpatient acute bed capacity ... PEOPLE Goal: Objective 1. Reduce employee turnover rate by 15% from prior year rates. ORGANIZATIONAL DEPARTMENTAL GOALS Nursing Services Reduce overtime use by 25% beginning January 2023.” Review of a document, provided by Leadership, not titled, not dated, indicated for Therapist, Activity Therapy Aide and Chemical Dependency Counselor, there was a total of 32, “Call outs / Absences in the last 30 days. A total of 256 therapeutic hours, out of a possible 1,312 therapeutic hours of Social service activities and groups, were not provided during the last 30 days. Review of a Policy and Procedure titled, “GROUP THERAPY AND GROUP NOTE,” approved 5/26/22, indicated, “The purpose of Group Notes is to document the patients progress that occurs in each group therapy session. The group notes serves purpose to communicate patient progress to members of the treatment team. Policy: To ensure that Group Therapy is provided per program description. To ensure there is a concise and accurate record of patient participation, interaction and response to group therapy. Documentation of patient participate will be done after each group session.” 38335 During an observation and concurrent interview of Unit 400 on 3/18/24 at 9:15 a.m., patients were walking in and out of the day room and in the hallways. Several patients were sitting in the day room watching TV, with no activities going on. A multicolored weekly schedule of activities was posted outside the day room on Unit 400. A community morning meeting was scheduled for 9:30 a.m. When asking Unlicensed Staff KK what went on in the Community Morning meetings, she stated it was a meet and greet for the new admissions. When asked if there would be a meeting, she stated, according to the schedule there should a meeting at 9:30 a.m. No meeting was observed. Unlicensed Staff KK was asked about the next activity, she looked at the schedule and stated it was an Activities Group. When asked what went on at the Activities Group meeting, she stated the patients could play cards, color, listen to music, or watch TV. No organized group activity meeting was observed; patients continued to walk in and out of the day room and walk in the hallways; several patients were at the medication window receiving their medications. During an interview on 3/18/24 at 10 a.m., Licensed Staff JJ was asked how often patient activities occurred. She stated she did not remember the last time there was an activity therapist available to conduct the activity sessions on the schedule. She stated there were not enough activity therapists to conduct the therapies for Unit 400. The patients on the 400 and 500 Units had a higher acuity level (the level of care a patient required) than other patients on other units. During an interview on 3/18/24 at 11 a.m. MHT HH stated there had not been many activity or therapy sessions for the patients due to short staffing. During an observation on 3/18/24 at 11:30 a.m., on Unit 400, Patient 23 and Patient 24 were walking in and out of the day room and up and down the hallway, with no apparent direction. During an observation on 3/18/24 at 2 p.m., Patient 23 was in the hallway crying and appeared anxious. Licensed Staff KK went over to Patient 23 and spoke with him. Patient 23 was crying and saying he, “hated this place and he needed to get out of here.” When asked if Patient 23 was ok, Licensed Staff 23 stated, “He’ll be ok, he says he just needs to see his daughter.” No further intervention was observed for Patient 23 and no documentation was in the medical record for this incident or whether a psychiatrist had been notified. During an interview on 3/18/24 at 3:15 p.m., the Director of Social Services (LCSW) stated there were not many group activities going on due to staffing constraints. “We are working on an irregular schedule with a higher patient acuity that has contributed to an increase in the number of CODE Greens (an emergent situation where patients exhibit escalated behaviors) with lack of staff.” During an observation and concurrent interview on 3/19/24 at 9:44 a.m., on unit 400, a hall MHW was asked when the next scheduled activity was. She stated this was the patients’ free time when they could have a snack and play cards or listen to music. Patients were walking in and out of the day room and walking in the hallways, with no apparent direction. When asked about the next scheduled activity, Licensed Staff KK stated it was Psych Education Group at 10:15 a.m. No activity occurred for the patients at that time. A MHW stated they were waiting for a therapist to be assigned to Unit 400. Patient 23 was a 23-year-old male admitted to the hospital on 3/16/24, on a 5150 for an attempted suicide. The medical record review on 3/19/24, showed Patient 23 had a history of Bipolar Disorder, Attention Deficit Hyperactivity Disorder (ADHD) and Post-traumatic stress disorder (PTSD). The Psychiatric evaluation initial treatment plan indicated, “Involve in all aspects of unit program including individual, group, and AT groups.” Patient 23 did not attend any groups. A Master Treatment Plan with short- and long-term goals was not completed for Patient 23. Patient 24 was a 30-year-old female admitted to the hospital on 3/15/24, on a 5150 for a danger to others. The Medical record review on 3/19/24, showed Patient 24 had an unknown Psych history with a Primary Diagnosis of Psychosis and a Urine Toxicology (Utox) report that was positive for Meth (Methamphetamine is a powerful, highly addictive stimulant that affects the central nervous system) and THC (Tetrahydrocannabinol, a cannabinoid molecule in cannabis that has long been recognized as the main psychoactive ingredient that causes people to feel high). Group notes indicated Patient 24 refused to attend any group activities or therapies. The Psychiatric Progress Note indicated, “Continue to encourage the patient to participate in treatment modalities offered.” 40402 During a record review of Unit 300’s weekly Activity Therapies Group schedule, Gymnasium group was listed seven days a week from Sunday to Saturday. Other Groups also listed on Unit 300’s weekly Activity Therapies schedule for seven days a week were Psych Education Group, Nursing / Pharmacy Group, and Journaling Group. During an interview with Licensed Staff D on 3/19/24 at 8:45 a.m., Licensed Staff D was queried when the next Activities Group would be held for the patients on Unit 300. Licensed Staff D stated she was not sure because the facility’s Social Service Department was short staffed, and the groups were not always held when they were scheduled. Licensed Staff D was queried as to the next time Patient 13, Patient 14, and Patient 15 would be escorted outside or to the Gym. Licensed Staff D responded she could not be certain because the Social Service Department needed two therapists to take patients outside and to the Gym, so the outside activities and gym classes were not occurring according to the Activities schedule. During an observation and interview with Patient 13 on 3/19/24 at 9 a.m., on Unit 300, Patient 13 was shown a Unit 300 schedule of Activity Therapies Groups and asked if she had attended any of these groups. Patient 13 responded she had never seen any of those groups occur but wished they would hold them because she got bored. Patient 13 expressed concern about wanting to go outside as well as to the gym to exercise but the facility did not have enough staff to take them out. Patient 13 was queried if she attended any of the Psych Education Groups, Pharmacy Groups, or Journaling Groups. Patient 13 stated she had not gone to any groups, except for a pet group which was run by a volunteer from the outside who brought in her social therapy dog. During a record review of Patient 13’s chart, a doctors order, dated 3/15/24, authored by Psychiatrist E, indicated: Involve patient in all aspects of unit program including Activity Therapies Groups. During an interview with Patient 14 on 3/19/24 at 11:30 a.m., Patient 14 was shown the Unit 300 Activity Therapies Group schedule and asked if she had attended any of these groups. Patient 14 stated she thought she had gone to one group which was the chemical Dependency Group, but the other groups were never held. Patient 14 was queried if she was able to go outside or use the gym when it was on the Activities Group schedule. Patient 14 responded she had not but would like to because she got bored and depressed just sitting indoors watching TV in the day room. During a record review of Patient 14’s chart, a doctor’s order, dated 3/13/24, authored by Psychiatrist F, indicated: Involve patient in all aspect of unit program including Activity Therapies groups. During an interview with Patient 15 on 3/19/24 at 12:30 p.m., Patient 15 was shown Unit 300 Activity Therapies group schedule and was queried if he had attended any of these groups. Patient 15 responded he had gone to one group for Chemical Dependency, but they did not ask him to attend any more groups. Patient 15 state, he was laying down on his bed bored, and someone came in his room without saying anything and dropped a piece of paper on his table and then walked out. Patient 15 stated he did not know what he was supposed to do with the paper. He later found out it was supposed to be a group alternative, but he never filled it out because no one assisted him with the alternative assignment. Patient 15 stated he wished the therapists were more assertive about waking patients up to go to the Activities groups, as well as taking them outside and to the Gym. Patient 15 was queried as to what he was doing with his time if he was not attending Activities Groups. Patient 15 responded he watched a lot of Television. During a record review of Patient 15’s chart, an MD order, dated, 3/14/24, indicated: Involve in all aspects of unit program including Activity Therapies Group. During an interview with the Director of Social Services on 3/22/24 at 2:40 p.m., the Director of Social Services was shown the Activity Therapies Group schedule for Unit 300 and was queried about the frequency those groups were being held for the patients. The Director of Social Services stated she had been short staffed for the past year and was actively working on recruiting more therapists. The Director of Social Services stated she should have nine therapists scheduled this day to support the census, but she only has five on the schedule, leaving the patients short by four therapists. The Director of Social Service was queried as to how the lack of therapists affected the treatment program for Unit 300. The Director of Social Service stated she did not think it was fair to the patients who needed to get out and exercise and go to Activities Groups. During a zoom interview in the administrative conference room, with the Interim Medical Director on 3/21/24 at 9 a.m., the Interim Medical Director was queried as to her expectations for the patients to be attending the Activity Therapies Groups. The Interim Medical Director stated she expected those groups to be held daily. When the Interim Medical Director was queried if she knew the Activity Therapies Groups were not being held daily, she stated she was unaware the groups were not being held daily. The Interim Medical Director was queried as to how not engaging the patients on Unit 300 in Activity Groups affected their progress the Interim Medical Director stated she believed the Activity Groups were an integral part of the patients’ treatment, and they should be receiving this treatment for the progression of their mental health. During an interview with Unlicensed Staff B on 3/22/24 at 11:30 a.m., Unlicensed Staff B was shown the Activity’s Therapies Group Schedule for Unit 300 Schedule and was queried how frequently these groups were being held. Unlicensed Staff B said not very often due to their Social Service Department being short staffed. Unlicensed Staff B stated it was just her trying to meet the needs of five different units, and she could not be everywhere at one time. Unlicensed Staff B stated she had shared her concerns with her boss, the Director of Social Service, who was aware there was not enough staff to implement the Activities Therapy Groups. Unlicensed Staff B was queried as to how it was documented when a patient was not able to attend the Activities Group due to lack of staff to hold the groups. Unlicensed Staff B stated she and other therapists only documented a Group Note when the patient attended the group. Unlicensed Staff B stated there was no documentation indicating when the patient did not attend the Activities Therapy Groups. During a review of the Director of Social Service’s Job description, under Key Responsibilities: “Directs activities of Clinicians and Activities Therapists. This includes ensuring compliance with all treatment plan requirements including weekly review and updates with the patient....Provides in-service training for social service staff and other employees as needed....Provides guidance to staff to assist them in continually improving all aspects of care....Provides group process-oriented therapy as well as conducts educational and other didactic groups for patients and family members using various professional treatment modalities....Responsible for scheduling and staffing to ensure adequate coverage....Attends regular treatment team meetings to provide social work perspectives to total case management of the patient by discussing progress notes charts and communicating any state or local agency legal requirement for case management with the interdisciplinary team....Oversees maintenance of clinical records and reports to ensure compliance with local state and federal laws.” During a review of the facility’s policy and procedure titled, “Multidisciplinary Treatment Planning,” dated, 5/26/22, it indicated, “Purpose: to provide a process and guidelines for implementation of a comprehensive, individualized multidisciplinary treatment plan for every patient....Treatment Meeting Process. A) A member of the multidisciplinary team provides a brief synopsis of patient’s presentation to the multidisciplinary team members including an RN, Clinician, and other disciplines as applicable. B) Each discipline presents relevant information about the patient (provider nursing, social services, and other disciplines as applicable. C) There is a brief discussion to identify problems to be addressed during this admission ...E) Multidisciplinary team members describe their recommended interventions, and the provider provides additional direction to the team....The Master Treatment Plan Review shall include: ...Group Attendance and Participation.” During a review of the facility’s policy and procedure titled, “Group Therapy and Group Note,” dated, 5/26/22, it indicated, “Purpose: The purpose of the Group Notes is to document the patients’ progress that occurs in each group therapy session. The group note serves purpose to communicate patient progress to members of the treatment team. Policy: To ensure that Group Therapy is provided per program description. To ensure there is a concise and accurate record of patient participation, interaction, and response to group therapy. Documentation of patient participation will be done after each group session. This documentation will be concise, legible, and accurate. Procedure: Group size will be appropriate to the setting of the environment. Staff members assigned to group therapy will be competent to perform the specific group they have been assigned through degree, experience, orientation and /or demonstration of competency. Following each group therapy session, the therapist is responsible for timely documentation of the group by utilizing the Group Note. All areas are to be completed as noted on the form including: Patients name, Time, date, and length of time of counseling session, Staff signature and professional credential and/or job title, group focus, treatment goals addressed, patient behavior/response, cognitive and affective assessment, level quality of patient’s participation, modes of intervention, In the event that a patient does not attend group alternative treatment and will be provided followed by documentation.””