San Jose Behavioral Health

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 46001 Based on interview and record review, the facility failed to obtain a physician’s order for the use of physical restraint techniques, (PRT, hands-on methods used by staff to restrict or control a person’s movement to prevent harm to the patient or others) and failed to document the required nursing service after the release of the restraint for one of 30 sampled patients (Patient 9). This failures could lead to inappropriate use of restraint and unsafe care for the patient. Findings: A review of Patient 9’s clinical record indicates that she is a 16-year-old female with a history of intellectual disability and mood disorder, admitted to the facility on 1/22/2026, for danger to self and others. 1. During an interview with the Director of Risk Management (DRM) on 4/23/2026, at 12:55 p.m., the DRM stated that Patient 9 had an extensive history of assaultive behavior. Patient 9 struck a glass window and assaulted the Social Worker (SW), who had responded to assist. During this incident, the SW and Behavioral Health Assistant (BHA) applied PRT to Patient 9 on 1/30/2026. During an interview and record review with the Director of Quality and Compliance (DQC) on 4/23/2026, at 1:30 p.m., the DQC reviewed Patient 9’s clinical record and confirmed that there was no physician’s order for PRT on 1/30/2026. The DQC stated that the nurses were required to obtain a PRT order following the emergency use of physical PRT. The DQC also stated the nurses working on the unit did not receive a report that PRT had been applied to Patient 9 on 1/30/2026. During a phone interview with the BHA on 4/28/2026 at 11:14 a.m., the BHA stated that Patient 9 was hitting the glass and attacking SW, both he and the SW applied the PRT after Patient 9 attacked the SW. After the restraint was released, he observed the SW speaking with a nurse and he assumed that the SW had reported the use of PRT, so he did not personally notify the nurse that PRT had been applied on 1/30/2026. During an interview with Registered Nurse (RN) A on 4/28/2026, at 11:55 a.m., RN A stated that he did not observed any PRT being used and did not receive any report that PRT had been applied to Patient 9. RN A further stated that in emergency situations, staff may initiate PRT immediately. After using PRT, staff are required to report it to the nurse, and the nurse should notify the physician to obtain a PRT order, typically within 5 minutes. During an interview with RN B on 4/28/2026, at 3:13 p.m., RN B stated that he did not receive any report from either the SW or BHA regarding the application of PRT to Patient 9 on 1/30/2026. RN B further stated that both staff who applied for PRT are required to report the intervention to the nurse in order to obtain a physician’s order. 2. During an interview and record review with the DQC on 04/23/2026, at 2:21 p.m., the DQC confirmed that there was no documented evidence, including a PRT packet, to indicate that the required nursing services were provided following the release of the restraint. During an interview with RN A on 4/28/2026 at 11:59 a.m., RN A stated that after a patient was released from PRT, the nurse was required to perform an assessment to evaluate for any injuries, obtain vital signs, and ensure the patient ’ s physical safety. RN A further explained that the nurse should have conduct a debriefing with the patient regarding the incident, including how it occurred and how it may be prevented in the future. RN A added that both the SW and BHA should report the intervention to the nurse, so the nurse could initiate the restraint documentation packet for the patient. During an interview with RN B on 4/28/2026 at 3:15 p.m., RN B stated that following the use of PRT, nursing staff are required to complete follow up care tasks and five types of documentation: restraint progress notes, restraint flowsheets, a restraint RN assessment, a face-to-face assessment, and a restraint patient debriefing. RN B further that these procedures need to be followed for every PRT event to ensure patient safety. A review of the facility’s policies and procedures, last revised 01/2024, titled “Restrain and Seclusion, PC-040,” indicates that “ ...Restrain may only be ordered by practitioners (Physician) ... After the episode, the nurse must talk with the patient about the incident. Debriefing ...the debriefing occurs after the patient is released from seclusion and/or restrain and must occur within 24 hours of patient’s release ...all seclusion/restrain episodes will have the following data collected and analyzed: Date, day of the week, time initiated, shift, staff initiating, type of restraint, precipitating behavior, diagnosis, gender, total time in seclusion or seclusion/retrains, less restrictive measure before application, physician order, any injuries obtained during seclusion or restrain. Nursing evaluator or LIP face-to-face assessment ...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 44577 Based on interview and record review, the facility failed to comply with the provisions in 42 CFR 489.20 and 489.24 when it failed to provide a medical screening exam (MSE, an examination completed by a qualified provider to determine whether or not an emergency medical condition exists) for one of 23 sampled patients (Patient 1) (Refer to A-2406) . This failure had the potential for patients with emergency medical conditions (EMC) seeking psychiatric care to not receive appropriate medical screening, assessment or counseling resulting in deterioration of the patient’s condition or death.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44577 Based on interview and record review, the hospital failed to provide a medical screening exam (MSE, an examination completed by a qualified provider to determine whether or not an emergency medical condition exists) to one of 23 sampled patients (Patient 1) when Patient 1 presented to the facility requesting treatment. 1. The hospital failed to ensure a medical screening exam (MSE) was offered to Patient 1 when Patient 1 was a walk in seeking psychiatric medications and treatment. 2. The hospital failed to ensure the MSE, conducted by an individual who was determined qualified by medical staff bylaws, completed orientation and a certificate of completion. These failures had the potential for placing the health of the individuals in jeopardy or causing serious impairment or dysfunction. During a concurrent interview and record review on 1/5/26 at 11:15 a.m. with the Direct of Quality (DQ) and the Director of Risk Management (DRM), the facilities documentation of the event was reviewed. The documentation indicated, “On 12/20/25, a woman and two males arrived at the front door to the facility. Intake staff answered the door through the camera speaker and advised that staff would be on their way to bring the individuals into the facility. ... three individuals ... the woman (Patient 1) had been experiencing a mental health decline for approximately 2 months, had a diagnosis of schizophrenia, had recently lost her job and needed medications. The adult female reportedly presented with aggression and disorganized cognition as she was pacing, pointing and using profanity ....[Staff] advise the family to seek assistance [at another facility]. The woman and the sons left the premises without contact information or demographic data gathered by staff.” There was no evidence that a medical screening exam was offered or refused. During an interview on 1/8/26 at 12:30 p.m. with the Interim Assistant Director (IAD), the IDA stated, “When there is a walk in patient, if reception is available they notify intake staff, Intake RN goes to the door, ask pt would you like to have medical exam, they collect contraband and immediately to locked waiting area. Have the patient complete demographic then RN will come to complete MSE then psych concern addressed. The nurse consults both the medical and psychiatric MD. Every patient receives a MSE if they consent, if they refuse we ask them to sign a refusal or have 2 staff sign the refusal. If there is a medical emergency can call 911 complete transfer forms and document why not stable. If need medical in non emergency can call non-emergency transport or lift. If refused tx would sign /with risk & benefits would still call MD , provide resources. Everyone is added to the EMTALA log. Patient 1 was not added until the IAD was aware. Review of the log indicated 12/20/25 “Jane Doe (not the real name)” was added. During a follow up interview on 1/9/26 at 9:04 a.m. with IAD, the IAD stated ,” Normal process would be: ask if patient 1 would like to complete MSE for admission, would go to locked area when doing MSE and someone talk to sons for information. If could not consent - could initiate 5150 or could have MD contacted. Also may sign refusal paperwork. All patients who leave have a suicidal assessment completed for safety. Patient 1 did not have a suicidal assessment completed. During an interview on 1/12/26 at 9:00 a.m. with Registered Nurse A, Registered Nurse A stated, “Received a call from the supervisor that someone was at intake, could he escort the intake person. Walked into the lobby, went to greet them and let them, pt was talking aggressively, he did not think it would be easy to talk to her so spoke to family, invited family to provide information. Pt was talking at the same time, disrupting the conversation. He did not know someone could write a hold [5150], Son told him the situation - patient needed to be admitted and treated. He referred them to another facility. No insurance was discussed. No ID provided or requested. They spoke in the lobby. He never did an intake before. No paperwork was completed or log filled out. He does not do MSE. Intake person is an RN”. During a review of Registered Nurse (RN) A HealthStream (Employee education report), HealthStream generated date 1/6/26, indicated RN A Medical Screening Exam (MSE) skills checklist was completed 10/14/24, Emergency Medical Treatment and Labor Act (EMTALA) training was completed 5/30/25. During an interview on 1/12/26 at 10:02 a.m. with Registered Nurse (RN) B, RN B stated, “Her job status is an “Intake Nurse”, “She did not remember when she had training for MSE, she did not have training with anyone, just shown a form to complete if anyone walks in, did not observe a face to face MSE”. During a continued interview on 1/12/26 at 10:05 a.m. with RN B, RN B stated, “On 12/20/25, she received a call asked her to go outside [lobby] for a patient. She said the supervisor needed to go with her, it was her first time going to get a patient [walk in]. RN A was sent to meet her in the lobby. She assumed he knew what he was doing, he advised them to go to another facility, he spoke to the family. My role was to take papers to be completed, bring the patient to intake area to do medical screening and intake evaluations”. During an interview on 1/12/26 at 10:21 a.m. with the Director of Human Resources (DHR), and DQ, the DHR stated, “The Medical Screening Exam (MSE) is completed at hire only. It is a demonstration only and a post test, no material /documents are provided, staff observe an assessment being completed with another nurse, demonstrate an assessment on a patient, then take a test”. During an interview and record review on 1/12/26 at 11:00 a.m. with the Director of Human Resources (DHR), and DQ, Registered Nurse (RN) B, New Employee Orientation (NEO) training checklist, dated 9/8/25-9/12/25, was reviewed. The NEO checklist indicated RN B’s EMTALA training was completed 9/11/25, the NEO training was completed on 9/12/25, supervisory signatures are missing. There is no evidence RN B completed the “Unit Specific Orientation Checklist”. There is no evidence that RN B completed the MSE training. The DQ stated, Registered Nurse (RN) B is holding on to her NEO packet, it should have been turned in. DQ stated, “the Nursing Supervisor completed the MSE training on 12/2/25 with RN B, an attestation was signed 1/9/26”. There was no evidence the RN was performing MSE using standard procedures. During an interview on 1/12/26 at 12:02 p.m. with the Interim Assistant Director (IAD), the IAD stated, “There are always two staff on night shift, [for intake] one needs to stay in the admission area and two staff need to go to intake, second staff member is a support person, on this date it was RN A, the intake staff should be in control”. “5150 writers are always available on-call, the supervisor would have that information. There is no documentation on how to reach a 5150 writer, staff just know”. During a review of the facility’s Job Description for RN, dated 1/1/2020, the job description indicated, “Provided nursing care and services within the standards and scope of nursing practice as defined within the state Nurse practice Act Regulations, policies, procedures and protocols, as well as facility and corporate policies and procedures”. During a review of the facility’s policy and procedure (P&P) titled, “Training and Development”, dated 9/2025, the P&P indicated, “All newly hired employees must complete the designated new employee orientation within two weeks of beginning work. ....Department Orientation check list should be completed ...signed by the supervisor and the employee ...returned to Human Resources ...” During a review of the facility’s policy and procedure (P&P) titled, “EMTALA Compliance”, dated 4/2020, indicated, “It is the intent of the Hospital to provide the following services to all individuals who present to the Hospital with a request for examination and/or treatment: Appropriate medical screening examination performed by a qualified medical practitioner (QMP) (a practitioner in a category pf providers approved by the governing Board to perform medical screening examinations ...). ...If the patient refuses examination, treatment, or transfer, the Hospital will obtain, or attempt to obtain, written and informed refusal of examination, treatment, or appropriate transfer”. During a review of the facility’s Medical Staff bylaws Exhibit A, dated: undated, the Bylaws indicated, “Qualified Medical Professional (QMP). The following are recognized as qualified medical professionals: physicians; nurse practitioner; physician assistant and registered nurses. During a review of the facility’s training documents titled, “Medical Send-Out & MOT (Memorandum of Transfer), dated: undated, the document indicated, San Jose Behavioral Health-Walk-In Intake Process Guide; EMTALA/MSE Requirements. Anyone who comes to our facility seeking help must be offered a Medical Screening Exam (MSE) without delay. Only an RN can perform the MSE. Must be completed in chart before moving forward ... Step 1: Notification of Walk -in; When notified the arrival of a walk in 1. Record the following immediately a. time of arrival, b. full legal name, c. date of birth, d. address, e. phone number. 2. Enter this information on the EMTALA Log. Step 2: Greeting the patient 1. Meet the patient in the lobby within 15 minutes ...Step 3: Intake preparation ...Step 4: Medical Screening Exam (MSE), performed by RN , review with the medical team. Review of California Department of Public Health (CDPH) All Facilities Letter (AFL 09-37) dated 10/13/2009, the AFL indicated, “ MSEs must be conducted by qualified personnel, which may include physicians, nurse practitioners, physician’s assistants, or RNs trained to perform MSEs and acting within the scope of their State Practice Act.” ... “For those hospitals, there are steps that each hospital would have to take in order to establish that MSEs fall within the RN scope of practice. The steps to be completed by hospitals to establish this, ... include Having provisions for RNs to conduct MSEs in the Medical Staff Bylaws and/or rules and regulations. Having the provisions approved by the Hospital’s Governing Body. Developing and obtaining approval, by the Hospital per the above law and regulations, of Standardized Procedures for RN use that provide a. The conditions under which a RN can conduct MSEs, such as during an emergency or health care surge. b. The evidence used to determine that the RN has the necessary experience, training, and/or education to conduct MSEs. Review of California Business and Professions Code, Chapter 6. Nursing, Article 2. Scope of Regulation, Section 2725, Legislative intent, Practice of Nursing,(c) “Standardized procedures,” as used in this section, means either of the following: (1) Policies and protocols developed by a health facility licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code through collaboration among administrators and health professionals including physicians and nurses.”

“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: 48590 Based on interview and record review, the hospital failed to promote and protect patients’ rights to be free from abuse for two of four patients (Patient 1 and 17) when: 1. Behavioral Health Associate (BHA) D shoved (push) Patient 1; and 2. BHA G punched (strike with the fist) Patient 17 on the hip. These failures had the potential to cause physical harm, pain, and exacerbation of mental and psychological conditions of patients. Findings: 1. Review of Patient 1’s face sheet (summary of the patient’s medical history) indicated patient was admitted on 7/18/25 with a diagnosis of psychosis (a temporary state where someone loses touch with reality, experiencing things differently, often through vivid hallucinations [seeing/hearing things not there] or strong, false beliefs [delusions] that others don’t share, making it hard to tell fantasy from fact, like hearing voices or thinking the TV is sending secret messages). During an interview with the Director of Quality and Performance Improvement (DQPI), on 1/5/2 at 13:31 p.m., the DQPI stated Patient 1 pulled the hair piece of BHA D on 8/25/25. The DQPI stated BHA D admitted that she grabbed and pushed Patient 1. During an interview with BHA D, on 1/5/26 at 1:45 p.m., BHA D stated Patient 1 grabbed the bun (type of hairstyle in which the hair is wrapped in a circular coil) on her head. BHA D also stated she put her hand out toward Patient 1. BHA D also stated she probably did made contact with a part of Patient 1’s body. 2. Review of Patient 17’s face sheet indicated patient was admitted on 9/14/25 with a diagnosis of bipolar disorder (a mental health condition causing extreme mood swings). During an interview with the DQPI, on 1/6/26 at 2:46 p.m., the DQPI stated BHA G admitted to punching Patient 17 on 9/22/25 when he was assisting to physically restraint the patient. During an interview with BHA E, on 1/7/26 at 10:05 a.m., BHA E stated he assisted to physically restraint Patient 1. BHA E stated he was holding Patient 1’s shoulder, Registered Nurse (RN) H was holding one arm, BHA I was holding the other arm, BHA G was holding the legs. BHA E stated he heard Patient 1 say he was punched. BHA E replied to Patient 1 and stated nobody was punching him. BHA E stated Patient 1 replied “it’s the person holding my legs”. BHA E stated BHA G admitted punching Patient 1 when they were in the hallway. During an interview with RN F, on 1/7/26 at 12:32 p.m., RN F stated she saw BHA G hit Patient 1 in the hip twice while they were physically restraining the patient. RN F stated she told BHA G not to do that and he immediately stopped. BHA G and BHA I was unavailable for interview as they were no longer employed by the hospital at the time of the survey. During a review of the hospital’s policy and procedure (P&P), titled “Patient Rights”, dated 5/2025, indicated “Patients have the right to be protected by the Hospital from neglect; from physical, verbal, and emotional abuse (including corporal punishment), and from all forms of misappropriation and/or exploitation.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48590 Based on interview and record review, the hospital failed to ensure the treatment plan (the tool used by the physician and interdisciplinary team to implement the physician ordered services and move the patient toward the expected outcomes and goals) was developed for two of 15 patients (Patient 26 and 28) when: 1. The initial treatment plan was not initiated upon admission for Patient 26; and 2. The interdisciplinary treatment plan did not have interventions for Patient 28. These failures had the potential to result in lack of, or delay in appropriate care and monitoring of these patients. Findings: 1. Review of Patient 26’s face sheet (summary of the patient’s medical history) indicated patient was admitted on 9/17/25 with a diagnosis of major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities). During a concurrent interview and record review with the Health Information Management Director (HIMD), on 1/8/26 at 10:54 a.m., the HIMD confirmed that the initial treatment plan was not done. The HIMD also stated nursing staff should do the initial treatment plan upon admission. Review of the hospital’s policy and procedure (P&P), titled “Treatment Planning”, dated 1/2026, indicated “The nursing staff was responsible for developing the Initial Treatment Plan no later than 8 hours of admission”. 2. Review of Patient 28’s face sheet indicated patient was admitted on 9/18/25 with a diagnosis of unspecified psychosis (a temporary state where someone loses touch with reality, experiencing things differently, often through vivid hallucinations [seeing/hearing things not there] or strong, false beliefs [delusions] that others don’t share, making it hard to tell fantasy from fact, like hearing voices or thinking the TV is sending secret messages). Review of Patient 28’s Interdisciplinary Treatment Plan, dated 9/21/25, indicated the nurse attested that the documentation was completed in 9/21/25. During a concurrent interview and record review of Patient 28’s Interdisciplinary Treatment Plan, dated 9/21/25, with the HIMD, on 1/8/26 at 10:59 a.m., the HIMD confirmed that the Interdisciplinary Treatment Plan does not have interventions in place for the psychiatric problem. The HIMD stated there should have been interventions to properly document the care of the patient. Review of the hospital’s P&P, titled “Treatment Planning”, dated 1/2026, indicated “The Treatment Plan shall identify interventions developed to assist the patient in achieving the goals”.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48590 Based on interview and record review, the hospital failed to adhere to the policies and procedures (P&P) and nursing professional standards of practice when one of 15 patients (Patient 19) with a documented gluten allergy (allergic reaction to wheat-based foods) was served a regular diet. This failure had the potential to place the patient at risk for an adverse allergic reaction. Findings: Review of Patient 19’s face sheet (summary of the patient’s medical history) indicated patient was admitted on 9/29/25 with a diagnosis of unspecified psychosis (a temporary state where someone loses touch with reality, experiencing things differently, often through vivid hallucinations [seeing/hearing things not there] or strong, false beliefs [delusions] that others don’t share, making it hard to tell fantasy from fact, like hearing voices or thinking the TV is sending secret messages). Review of Patient 19’s Intake Assessment, dated 9/29/25, indicated Patient 19’s allergies included Olanzapine (antipsychotic medication used to treat behavior disorders), iodinated contrast media (used for imaging), Ativan (used to treat anxiety disorders), gluten (a protein found in certain cereal grains), milk, and was documented in the allergy review section as reviewed. During a concurrent interview and record review, with Registered Nurse (RN) A, on 1/7/26 at 2:56 p.m., RN A stated that they inform the physician of the patients’ allergies when getting the admission orders during the intake assessment. RN A confirmed that Patient 19 has allergy to gluten. RN A further stated the licensed nurse who did the intake assessment and placed the dietary order of regular diet no longer work at the hospital and was unable to be interviewed. Review of Patient 19’s Nursing Assessment, dated 9/29/25, indicated that gluten was documented in the comprehensive allergy list, and the allergy review section indicated the allergies had been reviewed. Review of Patient 19’s History and Physical Examination (H&P, a document where providers document the patient’s medical history and the treatment plan for the patient), dated 9/30/25, indicated the provider has reviewed Patient 19’s allergies which included gluten. During a concurrent interview and record review with RN B, on 1/7/26 at 3:03 p.m., RN B stated that she checks the patients’ allergy all the time and would notify the physician if a patient has allergy with gluten. RN B further stated that she would make sure that the patient will not get anything that was not gluten free. RN B verified that Patient 19 has allergy to gluten. No documentation of the physician being notified of the allergy. During a concurrent interview and record review with RN C, on 1/7/26 at 3:20 p.m., RN C stated she did not remember if she checked Patient 19’s diet order. RN C verified Patient 19 has allergy to gluten and would inform the physician. Review of Patient 19’s dietary order, dated 9/29/25, indicated the physician ordered regular diet (balanced meal plan with no food restrictions). Review of Patient 19’s AHC (Acadia Health Care) Progress Notes, dated 10/1/25, indicated that the Associate Marriage and Family Therapist (AMFT) spoke with Patient 19’s family member (FM) and stated “pt should be given gluten free meals, gluten will make him violently ill”. The AMFT does not work at the hospital and was unable to be interviewed. During a concurrent interview and record review with the Case Manager (CM), on 1/7/26 at 2:15 p.m., the CM stated she spoke with FM on 10/10/25. The CM further stated the FM was frustrated and angry because Patient 19 was not on gluten free diet. The CM also indicated that she was not sure if she followed up with the diet after informing a nurse. During a concurrent interview and record review with the Registered Dietician (RD), on 1/9/26 at 8:35 a.m., the RD stated nursing would place the gluten free diet and the diet manager would make sure patients that has gluten allergy will be placed on the right diet. The RD further stated the gluten allergy was not identified by nursing staff. Review of Patient 19’s dietary order, dated 10/10/25, indicated the physician ordered gluten free diet (food that does not contain the protein called gluten). Review of Patient 19’s Medical Consultation Report, dated 10/11/25, indicated that Patient 19 was complaining of stomach discomfort. During an interview with the Nurse Practitioner (NP), on 1/9/26 at 3:10 p.m., the NP stated she was not sure why Patient 19 was not put on gluten free diet. The NP verified Patient 19’s allergy was reviewed. During a review of the hospital’s policy and procedure (P&P), titled “Assessment/Reassessment”, dated 1/2026, indicated “All patients admitted to the hospital will receive a thorough assessment and evaluation ...Following review of the previous assessment and validation of information with the patient, the nursing assessment will include identifying information, vital signs, weight, height, and general current medications ...Physical Status Database includes information regarding ...nutritional screening ...” According to American Nurses Association (ANA) Nursing Scope and Standards of Practice, dated 2015, indicated “Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation ...Collects pertinent data, including but not limited to demographics, social determinants of health, health disparities, and physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic, ongoing process with compassion and respect for the inherent dignity, worth, and unique attributes of every person.””

“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: 37686 Based on observation, interview, and record review, the hospital failed to provide a safe setting for one of 30 sampled patients (Patient 3) when a door that led from the cafeteria into the kitchen was propped open. This failure enabled Patient 3 to elope (the act of leaving without supervision and without authorization) from the hospital. Findings: Review of Patient 3’s clinical record indicated he was admitted on 2/3/25 and had diagnoses including psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with reality). Review of Patient 3’s Progress Notes, dated 2/9/25, indicated, “Patient was at dinner today and eloped from the dining room through the kitchen.” The Progress Notes further indicated, “Patient was in the cafeteria and went in through the kitchen and out the maintenance door.” During an interview with the Interim Facility Risk Manager (IFRM) on 3/10/25, at 9:49 a.m., the IFRM explained Patient 3 went into the kitchen through a door that was propped open. The IFRM further explained Patient 3 was able to open two more doors because these doors did not need to be unlocked in order to be opened. During an observation and concurrent interview with the Director of Quality and Performance Improvement (DQAPI) on 3/10/25, at 10:10 a.m., the location of Patient 3’s elopement was inspected. There was a door that led from the cafeteria into the kitchen. The DQAPI confirmed that if this door was closed, it would have locked. Inside the kitchen, the was a door that led to an adjacent hallway. The DQAPI confirmed this door did not need to be unlocked in order to be opened. At the end of the hallway, there was a door that led to the outside. The DQAPI confirmed this door was not alarmed and did not need to be unlocked in order to be opened. During an interview with Behavioral Health Associate A (BHA A) on 3/11/25, at 2:30 p.m., BHA A confirmed he was assigned to Patient 3 during the elopement incident on 2/9/25. BHA A stated Patient 3 was standing in the cafeteria waiting for lunch to be served and another patient asked BHA A for some coffee. BHA A stated he went into the kitchen to get the coffee, and when he came back into the cafeteria, he noticed Patient 3 was not there anymore. BHA A stated the door that led from the cafeteria into the kitchen was already open when staff and patients arrived in the cafeteria. BHA A confirmed this door remained open while he was in the kitchen getting coffee for another patient. BHA A confirmed this door was typically supposed to remain closed. During an interview with the DQAPI on 3/12/25, at 9:12 a.m., the DQAPI confirmed the door that led from the cafeteria into the kitchen should not have been propped open. The DQAPI stated the hospital did not have a policy that specified this, but the safety protocol was to not leave doors propped open. Review of the hospital’s Incident Investigation Report, dated 2/17/25, indicated, “On Sunday, February 9, 2025, [Patient 3] eloped from the facility during dinner time.” “The investigation revealed that the patient was able to elope from the dining hall through the kitchen, as the kitchen door had been propped open. This allowed the patient to walk out through the kitchen and into the maintenance hallway. It was determined that staff failed to monitor the door closely due to a sense of complacency, as they had become accustomed to the door being closed and did not anticipate it being left open. This lack of situational awareness contributed to the patient’s ability to elope.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 44577 Based on interview and record review of employee files the hospital failed to follow the hospital policy when: 1. Three of seven reviewed employee files had no evidence of yearly evaluations completed. 2. One of seven reviewed employee files had no evidence of yearly abuse training completed. This failures had the potential to not identify gaps in an employee’s skills or knowledge, placing the patients at risk, and could cause harm to the patients. Findings: During a concurrent interview and record review, on 1/16/25 at 1:55 p.m. with the Human Resource (HR) Generalist, employee files for Behavioral Health Associate A (BHA A) was reviewed. The employee file indicated BHA A was hired 11/16/22 and terminated employment 2/5/24, there was no documented evidence that BHA A had an evaluation in 2023. HR stated BHA A should have had an evaluation November or December 2023. Evaluations are done annually during the review period. During a concurrent interview and record review, on 1/16/25 at 2:05 p.m. with HR, employee files for BHA B was reviewed. The employee file indicated BHA B was hired 2/20/23 and terminated employment 3/28/24, there was no documented evidence that BHA B had an evaluation in 2023. HR confirmed BHA B should have had an evaluation November/December 2023. During a concurrent interview and record review, on 1/16/25 at 2:32 p.m. with the HR, employee files for BHA C was reviewed. The employee file indicated BHA C was hired 3/2/20 and terminated employment 2/6/24, there was no documented evidence that BHA C had an evaluation since 2020. HR confirmed BHA C should have had an evaluation November/December 2021, 2022, and 2023. During a concurrent interview and record review, on 1/16/25 at 2:48 p.m. with the HR, employee files for BHA D was reviewed. The employee file indicated BHA D was hired 3/1/21, there was no documented evidence that BHA D had completed abuse training since 10/5/22. HR confirmed BHA D should have completed Abuse training 2023 and 2024. Review of the Hospital policy, Performance Evaluation Process”, revision dated 9/1/22, indicated” ..employees will receive performance evaluations annually during the facility wide review period established by facility management.”. Review of the Hospital’s policy, “Abuse and Neglect”, last review date 9/22, indicated, “All staff, including medical staff, will receive training on identification of abuse and neglect, and the required reporting requirements and processes. This training will occur as part of the new hire orientation, annually and ongoing as needed based on isolated incidents or trends identified through the Risk Management program.”.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48590 Based on interview and record review, the facility failed to comply with the Conditions of Participation for Nursing Services as evidenced by: 1. Failure to supervise and evaluate the care for one of 26 sampled patients (Patient 4) when the Registered Nurse did not assess the patient’s health status and supervise Behavioral Health Associate (BHA) (Refer to A-395). 2. Failure to ensure behavioral health associates (BHAs) received sufficient training to competently assess to determine patients were breathing while asleep for three of five BHA interviews (Refer to A-397). 3. Failure to ensure policies and procedures were followed regarding properly documenting medication refusal, physician noltification, carry-out physician order and patient code blue resuscitation (act of reviving a person from apparent death) for one of one sampled patient (Patient 1). (Refer to A-398). 4. Failure to ensure medications were administered in accordance with the hospital’s policy and procedures, or per manufacturer’s guidelines, or Centers for Disease Control (CDC) guidelines for 11 of 11 sampled patients (Patient 31, 35, 36, 37, 38, 39, 40, 41, 42, 43 and 44). (Refer to A-405) The cumulative effects of these systemic problems resulted in the facility’s inability to ensure the provision of quality care in a safe environment.”

“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: 10918 Based on interview and record review, the hospital’s process improvement program (PIP) failed to identify quality of care concerns regarding proper assessment during patient monitoring by Behavioral Health Associate (BHA), not following the CDC guidelines in the use of Nicotine gum, and inaccurate documentation of medication compliance. This failure resulted in a missed opportunity to improve care and or ensure patient safety. Findings: Patient 4 had a physician’s order, dated 9/17/24, to observe the patient every 15 minutes for suicide risk. Review of Patient’s Behavioral Health - Monitoring Sheet from 9/29/24 at midnight to 10/5/25 at 9:45 a.m. were complete except for five entries. There was multiple coding of AS indicating the patient appeared to be asleep with chest rising/falling. During an interview on 10/29/24 at 9:19 a.m., BHA F stated he observed the chest fluttering. During an interview on 11/1/24 at 12:05 p.m., the BHA F stated on the morning of 10/5/24, he checked on Patient 4 multiple times, called his name and he did not respond. BHA F stated he had training for patient monitoring but did not remember what was discussed. During an interview and viewing of the hospital’s mandatory healthstream (web based learning management platform) video on 11/1/24 at 2:13 p.m., indicated observe for the rise and fall of the chest if patient sleeping but it did not offer further guidance on what to do if breathing was not detected. During the concurrent interview with BHA G, he stated he was to train and educate staff, the snoring or fluttering chest movements was not considered breathing and it was “common sense” for behavioral health assistants (BHAs) to report to nurses for guidance when questions arose. BHA G also stated the training documentation addressing what staff should have done when patients’ rise and fall of chest was not observed during sleep was requested and not provided. Review of the August 2024 PIP documentation addressing patient monitoring indicated there was daily oversight of the monitoring system reported by Nursing Oversite, re-education were completed as needed and there was 99% compliance. The documentation did not identify whether staff were correctly observing patients or if the training material contain sufficient information to enable staff to conduct accurate assessments. During an interview on 11/1/24 at 5:15 p.m., the Director of Quality Compliance (DOQC) stated the hospital adopted a new system (proximity based monitoring system consisting of a band applied to patients and connected to a tablet) to assist staff to monitor patient whereabout, activity/behavior, and when the next observation was due. The system did not detect human signs of life such as pulse and respiration. The DOQC stated during daily rounds staff randomly watch BHAs monitor patients but did not follow them into rooms when assessing for sleep and there was no audit tool. The DC stated the hospital did not measure the quality of rounds which is a “human factor” and acknowledged the performance improvement project was insufficient. During an interview on 10/28/24 at 2:55 p.m., the Pharmacy Director (PD) stated the hospital followed the Centers for Disease Control and Prevention(CDC, the nation’s leading science-based, data-driven service organization designed to protect public health) guidance for the use of nicotine gum. According to cdc.gov under nicotine gum, it was indicated nicotine gum was not used like ordinary chewing gum. It instructed to chew it a few times, “park” it between cheek and gums, hold it for about a minute and repeat the chew and park process until the tingling stops (usually about 30 minutes). Review of 11 of 11 sampled patients who were prescribed nicotine gum (Patient 31, 35, 36, 37, 38, 39, 40, 41, 42, 43, and 44), the physician’s order did not follow the CDC guidelines. During the same interview on 11/1/24 at 5:30 p.m., the DOQC stated the PIP committee did not identify the problem of nicotine gum orders not following CDC guidelines and will address this in the next meeting. Review of Patient 4’s record indicated he was admitted with diagnoses including high blood pressure, history of CABG (coronary artery bypass graft, a major surgery to improve blood flow to the heart) and chronic viral infection. On 9/14/24, 9/15/23, 9/16/24 and 9/24/24, the record indicated Patient 4 refused medications for his heart condition and infection. Nursing notes on those days did not consistently indicate the patient was noncompliant with taking medications and did not notify the physician. During an interview on 11/1/24 at 5:39 p.m., the DOQC stated the PIP committee did not identify the concern of staff not communicating patient refusal of medications to other nurses and physician. Review of the Process Improvement Program policy, dated 01/2024, indicated the hospital was dedicated to providing measurement-based, quality of care and services for all patients in a safe, clean and therapeutic environment. The Program emphasized ongoing assessment of performance, including surveillance of health care delivery.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48590 Based on interview and record review, the hospital failed to ensure implementation of safe standards of practice when the Registered Nurse did not assess and evaluate the physical condition of one of 26 sampled patients, and supervise patient monitoring by Behavior Health Associate (BHA). This failure had the potential to affect patient’s health and safety at risk. Findings: During a review of Patient 4’s facesheet, indicated Patient 4 was admitted to the hospital on 9/13/24 at 11:57 a.m. The “Admission Form” indicated Patient 4 had an admitting diagnosis of unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiologic condition. During a review of Patient 4’s “Incident Report Form”, dated 10/5/24, the “Incident Report Form” indicated at approximately 9:40 a.m., patient was found by medication nurse unresponsive. Code Blue was called several times. CPR (Cardiopulmonary Resuscitation, emergency procedure consisting of chest compressions often combined with artificial ventilation, or mouth to mouth in an effort to save a life) initiated at approximately 9:40 a.m.. At approximately 9:48 a.m., patient was still unresponsive. At 9:40 a.m., no shock advised. At approximately 9:50 a.m., EMT (Emergency Medical Technicians) arrived and told to stop CPR and took over. Per EMT, “patient looks like he passed away overnight”. During an interview with Registered Nurse (RN) A, on 10/25/24, at 10:03 a.m., RN A was assigned as the Medication Nurse on 10/5/24 dayshift for Patient 4. RN A entered Patient 4’s room around 9:40 a.m., called out his name but did not respond. RN A then shook Patient 4 and he felt cold. RN A then checked Patient 4’s pulse but no pulse and not breathing. RN A stated he initiated CPR. During an interview with RN M, on 10/25/24 at 10:12 a.m., RN M worked night shift on 10/4/24 from 11:00 p.m. to 7:30 a.m.. RN M stated she saw Patient 4 at the beginning of the shift asleep. RN M stated she did not go into Patient 4’s room for the rest of the shift. RN M stated nurses don’t go into the patient’s room to check if the patient is breathing. During an interview with RN B, on 10/25/24, at 10:31 a.m., RN B was working day shift as the charge nurse on 10/5/24 and her shift start at 7:00 a.m.. RN B stated she did not go inside to check Patient 4 until the medication nurse informed her that Patient 4 was not responsive around 9:40 a.m. RN B stated she was supposed to go inside and check their patients at the beginning of the shift. RN B stated she did not do assessment on Patient 4. During an interview with Behavior Health Associate (BHA) C, on 10/25/24 at 11:08 a.m., BHA C was working night shift from 11:00 p.m. to 7:30 a.m. on 10/4/24. BHA C stated he was told to check for the rise and fall of chest when the patient is sleeping. BHA C stated Patient 4’s room was dark, and no light and BHA C went up to the foot of the bed and listen to Patient 4 snoring. BHA C stated he did not see the rise and fall of Patient 4’s chest. BHA C stated if Patient 4 was not snoring, he would get up to the side of the patient’s bed to check the rise and fall of the chest. BHA C stated he will check the physical condition like skin color if the light was on. During an interview with BHA D, on 10/25/24 at 11:52 a.m., BHA D stated he was working night shift on 10/4/24. BHA D stated during monitoring, he would listen for snoring and see the moving of chest up and down if patient is sleeping. BHA D stated Patient 4 was asleep with no light in the room, and he did not use flashlight when he went into the room because he did not think using a flashlight in the room was a necessity at that time. BHA D stated he listened for snoring, but he could not tell if Patient 4 was snoring because the roommate was snoring extremely loud. During an interview with Registered Nurse (RN) H, on 10/28/24 at 10:55 a.m., RN H stated based on P&P, RN should have check the Patient 4 during rounds at the beginning of the shift to make sure the patients are breathing. During an interview with Chief Nursing Officer (CNO), on 10/28/24, at 3:03 PM, CNO stated after shift report the RN should have visual check on their patients. During an interview with BHA E, on 10/29/24 at 9:19 a.m., BHA E stated he went to Patient 4’s room and saw the back of the patient and documented it as sleeping. BHA E saw a movement on Patient 4’s chest and described it as a subtle flutter. BHA E stated Patient 4 was not snoring and he did not try to wake up Patient 4. During an interview with Nursing Supervisor (NS), on 11/1/24 at 11:00 a.m., NS stated BHA were told to call the patient’s name if they can’t see the chest rising and they are sleeping. NS stated BHA were instructed to wake up the patient even if they have blanket over them. During an interview with BHA F, on 11/1/24 at 12:05 p.m., BHA F stated he worked dayshift on 10/5/24 and during rounds Patient 4 has a blanket over him, called Patient 4’s name but he didn’t respond. BHA F stated if you don’t see the respirations, to wake them up or move the blanket. BHA F stated he did not move Patient 4’s blanket when he did not see the respirations. During an interview with BHA G, on 11/1/24 at 2:13 p.m., BHA G stated he trained the BHA and uses a module in Healthstream to train, which indicated “If this check had occurred during sleeping hours, the proper procedure was to ensure that the patient’s head is not covered with blankets and observe 3 full breaths before continuing with your rounds.” BHA G stated its common sense to investigate more if there was no chest rising. BHA G stated BHA should see the rise and fall of the chest and not just hear the patient snoring. During a review of the facility’s policy and procedure (P&P), titled “Assessment/Reassessment”, dated 3/2016, the P&P indicated “Reassessments are completed by the Registered Nurse on day and evening shifts and documented ...Each patient is reassessed as necessary based on the patient’s plan for care or change in their condition ...” During a review of the facility’s P&P, titled “Observations, Patient”, revised date 4/23, indicated “During the rounds staff are to observe sleeping patients close enough to confirm they are breathing and not in any physical distress ...””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 10918 Based on staff interview and record review the hospital failed to ensure behavioral health associates (BHAs) received sufficient training to competently assess to determine patients were breathing while asleep for three of five BHA interviews. This failure led to inaccurate assessments of patient status for Patient 4 who was monitored every 15 minutes for suicide risk and found unresponsive. Findings: During an interview on 11/1/24 at 2:36 p.m., registered nurse (RN) B stated when she was performing artificial ventilation for Patient 4 on the morning of 10/5/24 around 9:40 a.m, the patient’s arms and leg were cold and rigid. When the emergency medical service team arrived, hospital staff were instructed to stop resuscitation (act of reviving a person from apparent death) because the patient passed away overnight. Patient 4 had a physician’s order dated 9/15/24 to observe the patient every 15 minutes for suicide risk. Review of Patient’s Behavioral Health - Monitoring Sheet, dated 10/4/24 at 10:45 p.m. to 10/5/24 6:45 a.m. and 10/5/24 on 7:30 a.m. to 8:15 a.m., was coded AS, indicating the patient appeared to be sleeping with chest rising/falling. On 10/5/24 from 9 a.m. to 9:30 a.m. the same sheet indicated Patient 4 was calm. During an interview on 10/29/24 at 9:19 a.m., BHA E stated he saw Patient 4’s chest fluttering. During an interview on 11/1/24 at 12:05 p.m., the BHA F stated on 10/5/24 he was assigned to take patient vital signs (temperature, pulse, respiration rate and blood pressure), pass meal trays, and on other days he had assignments to monitor patients. The BHA stated on the morning of 10/5/24, he checked on Patient 4 multiple times, called his name and the patient did not respond. The BHA stated he had orientation training for patient monitoring but did not remember what was discussed. During viewing of the hospital’s mandatory healthstream (web based learning management platform) video on 11/1/24 at 2:13 p.m., it was indicated when performing checks when patients were sleeping was to ensure patient’s head was not covered and observe for three full breaths. The video did not offer further guidance on what to do if breathing was not detected. During the review of the video the BHA G, whose duty included training and orienting staff stated it was mandatory inservice training upon hire for all care staff to view the healthstream for patient observation. The BHA G stated snoring or fluttering chest movements was not confirmation for breathing and it was “common sense” for BHAs to report to nurses for guidance. The BHA G also stated during orientation BHAs in addition to one week orientation had one to one training with an experienced staff for at least five days and there was no written instructions indicating what to do if patient breathing was not observed. Review of the Training and Development policy, dated 9/1/15, indicated the hospital provided orientation, on-going training, in-service training and other educational training and development opportunities to increase staff knowledge and maintain compliance with regulatory requirements.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48590 Based on interview and record review the hospital failed to ensure policies and procedures were followed regarding properly documenting medication refusal and physician notification, vital signs not taken as ordered by the physician and patient code blue resuscitation (act of reviving a person from apparent death) for one of one sampled patient (Patient 4). This failure resulted in inaccurate documentation of medical record. Findings: 1. During a review of Patient 4’s “Admissions Form”, dated 9/13/24, indicated the facility’s staff admitted Patient 4, to the hospital on 9/13/24 at 11:57 a.m.. The “Admission Form” indicated Patient 4 had an admitting diagnosis of unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiologic condition. During a review of Patient 4’s “Physician Orders”, dated 9/13/24, included an order that indicated, “ vital signs twice a day”. During a concurrent interview and record review, with the Director of Quality Compliance (DOQC), on 10/24/24 at 12:52 p.m., she reviewed Patient 4’s vital signs record. The DOQC stated the vital signs on Patient 4 was not taken on 10/5/24. During an interview with Registered Nurse H, on 10/28/24 at 10:55 a.m., RN H stated vital signs are taken after the nurse shift report. RN H stated the BHA takes the vital signs. During an interview with Chief Nursing Officer (CNO), on 10/28/24 at 3:03 p.m., CNO stated vital signs are taken at the beginning of the shift by the BHA. During an interview with BHA F, on 11/1/24 at 12:05 p.m., BHA F stated he did not take Patient 4’s vital signs because he thought patient was in deep sleep. During an interview with RN B, on 11/1/24 at 2:26 p.m., RN B stated she saw the BHA doing rounds for vital signs but did not ask if the Behavioral Health Associate (BHA) took Patient 4’s vital signs. During a review of the facility’s policy and procedure (P&P), titled “Vital Signs and Weights”, dated 3/2016, the P&P indicated “vital signs will be taken at the time of admission, as ordered by the practitioner and no less frequently than twice a day.” During a review of Patient 4’s Medication Administration Record (MAR), on 10/25/24, indicated Patient 4 refused to take his medications Raltegravir (to treat virus), Atorvastatin (to treat high cholesterol), Metoprolol (Lopressor, to treat high blood pressure), Biktarvy (to treat infection), Aspirin (to treat pain), Gabapentin (to treat anxiety), Clonazepam (Klonopin, to treat anxiety), and Sertraline (Zoloft, to treat depression) on 9/14/24, 9/15/24, 9/1/24, and 9/29/24. During a review of Patient 4’s Medical Consultation Report Form, dated 9/20/24, indicated medical diagnoses including Coronary Artery Disease (CAD, buildup of plaque causing narrowing of coronary arteries), Hypertension (high blood pressure), Hyperlipidemia (high cholesterol in the blood), HIV (Human Immunodeficiency Virus that attacks the body’s immune system), History of CABG (Coronary Artery Bypass Grafting, surgical procedure that improves blood flow to the heart). During an interview with CNO, on 10/29/24 at 10:09 am, CNO stated RN are required to notify the physician if patient refused medication. During an interview with Medical Doctor (MD), on 10/31/24 at 11:07 a.m., MD stated he does not recall being informed that Patient 4 has refused his medications. During a concurrent interview and record review with RN I, on 10/31/24 at 12:46 p.m., RN I verified that she documented in the nursing note that Patient 4 was compliant with all his medications and did not indicate if MD was notified on 9/15/24. RN I verified that Patient 4’s medications were not given as documented in the MAR. During a concurrent interview and record review with RN J, on 10/31/24 at 1:03 p.m., RN J verified that she documented in the nursing note, dated 9/16/24, that Patient 4 was compliant with all his medications and did not notify the MD. RN J verified that patient 4’s medications were not given as documented in the MAR. RN J stated she did not update the nursing note. During a concurrent interview and record review with RN K, on 10/31/24 at 3:34 p.m., RN K verified that he documented in the nursing note, dated 9/29/24, that Patient 4 was compliant with all his medications and did not notify the MD. RN K verified that Patient 4’s medications were not given as documented in the MAR. RN K stated his documentation must have been based on the information the day before. RN K stated he would have charted differently if he knew that the patient refused his cardiac medications. During a concurrent interview and record review with RN L, on 10/31/24 at 3:33 p.m., RN L verified that she documented in the nursing note, dated 9/14/24, that Patient 4 was compliant with all medications and MD not notified. RN L verified that Patient 4’s medications were not given on 9/14/24 as documented in the MAR. RN L stated she would update the nursing note if she was informed by the medication nurse that the patient refused his medications and notify the MD. During a review of the facility’s P&P, titled “Medication Administration”, dated 3/2016,, the P&P indicated “Document all refused drugs on the patient’s MAR. Notification of the practitioner is also to be documented in the progress note.” During a review of the facility’s P&P, titled “Documentation Protocol”, dated 1/24, the P&P indicated “Facility records, reports, charts and documentation are to be accurate, truthful, timely, and complete.” 10918 2. During an interview on 11/1/24 at 11:40 a.m., registered nurse (RN) A stated on the morning of 10/5/24 when he approached Patient 4 to pass medications the patient was in his bed, cold, stiff and did not have a pulse. Review of Patient 4’s Progress Note, dated 10/5/24 at 10:48 a.m. indicated the patient was found unresponsive at 9:40 a.m. and resuscitation (act of reviving a person from apparent death) was started. It did not indicate patient condition other than unresponsiveness, his location, what staff were present and what role they were serving and how the patient left the hospital. During an interview on 11/1/24 at 10:11 a.m., the chief nursing officer (CNO) stated during code blue (person having life threatening medical emergency) situation one nurse was to perform chest compression, another nurse was to place a rebreathing mask (device used to deliver oxygen to a person), and another staff was to call for help. The code blue documentation was to include how many cycles of chest compressions were performed and list of staff providing intervention. Review of Patient 4’s completed Code Blue Evaluation form, dated 10/5/24 did not include to evaluate for completeness of documentation. Review of the Code Blue Response - Medical Emergency/Cardiac Arrest policy, dated 01/2017, indicated to document in patient’s medical record patient assessment of condition, place found, what was done by staff, patient response to what was done, when and what condition the patient left the facility.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48590 Based on interview and record review, the hospital failed to ensure medications were administered in accordance with the hospital’s policy and procedures, or per manufacturer’s guidelines, or Centers for Disease Control (CDC) guidelines for 11 of 11 sampled patients (Patient 31, 35, 36, 37, 38, 39, 40, 41, 42, 43 and 44) when: 1. Patient 31 shared the nicotine gum to another patient (Patient 1); 2. Manufacturer’s and CDC guidelines were not followed. This failure had the potential to affect the patients’ health and safety. Findings: 1. During a review of Patient 31’s “Admission Form”, indicated the facility’s staff admitted Patient 31 to the hospital on 6/29/24 at 3:25 pm, with an admitting diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Patient 31’s “Physician Orders”, dated 6/29/24, included an order that indicated Nicotine Polacrilex (Nicotine Gum) 2 milligrams (mg, unit of measurement) orally every three hours PRN (as needed). During a review of Patient 1’s “Admission Form”, indicated the facility’s staff admitted Patient 1 to the hospital on 6/27/24 at 2:21 pm, with an admitting diagnosis of major depressive disorder. During a review of Patient 31’s Omnicell (automated machine for dispensing drugs) transactions report, dated 10/30/24, indicated Nicotine gum was dispensed on 6/30/24 at 8:00 pm. During a review of Patient 1’s “Progress Note”, dated 6/30/24, indicated “At 2000 patient was seen in the hallway with another peer. Both redirected to be more visible. Approximately 5 minutes later patient was seen chewing gum. When asked about it, patient spit the gum out and gave it to staff. It was the nicotine gum that was given to another peer.” During a review of Patient 1’s “Medication Consent”, dated 6/28/24, indicated Patient 1’s medications included Fluoxetine HCL (Prozac, used to treat depression) and Guanfacine (Tenex, to treat attention deficit hyperactivity disorder). During a concurrent interview and record review with Director of Quality Compliance (DOQC), on 10/23/24 at 1:50 PM, DOQC stated Patient 1 got the nicotine gum from another patient and was identified as Patient 31. During an interview with Chief Nursing Officer (CNO), on 10/23/24 at 1:58 pm, CNO stated they do not check later if patient still have the nicotine gum or not. During an interview with Registered Nurse (RN) N, on 10/23/24 at 2:58 p.m., RN N stated Patient 31 asked for a nicotine gum. RN N stated she saw Patient 31 and Patient 1 in the hallway close together and saw them move hands that seem like they passed something. RN N stated she realized that Patient 1 was chewing and asked to spit out. RN N stated it was the nicotine gum from the other patient. According to the manufacturer’s guidelines for nicotine gum, revised date 10/2020, indicated a drug warning to “keep out of reach of children. Pieces of nicotine gum may have enough nicotine to make children sick.” During a review of the facility’s policy and procedure (P&P), titled “Medication Administration”, revised date 8/2022, indicated “No drugs shall be administered except by licensed personnel authorized to administer drugs and upon the order of a person lawfully authorized to prescribe.” 2. During a review of Patient 31, 35, 36, 37, 38, 39, 40, 41, 42, 43 and 44’s Physician order for nicotine gum, on 10/25/24, indicated specific instructions for medication administration was not included. According to the manufacturer’s guidelines for nicotine gum, revised date 10/2020, indicated “Chew the gum slowly until it tingles. Then park it between your cheek and gum, When the tingle is gone, begin chewing again, until the tingle returns. Repeat this process until most of the tingle is gone (about 30 minutes). Wrap the used nicotine gum in paper and throw away.” According to CDC guidelines on how to use nicotine gum, dated 9/2023, indicated “To use it correctly, bite down slowly on the gum until you feel a tingling in your mouth. Then “park” the gum between the inside of your cheek and your gums. Hold it for about a minute to let the nicotine absorb into your body. Then repeat this “chew” and “park” process until the tingling stops (usually about 30 minutes), occasionally changing where you “park” the gum in your mouth.” During an interview with Medical Doctor (MD) P, on 10/25/24 at 11:41 a.m., MD P stated he follows the CDC guidelines when prescribing nicotine gum to patients. During an interview with RN H, on 10/28/24 at 10:55 a.m., RN H stated she told the patient to chew the nicotine gum for two hours. During an interview with RN Q, on 10/28/24 at 11:43 a.m., RN Q stated she tell the patient to give the nicotine gum to the nurse once they are done chewing. RN Q stated she does not tell the patient how long they will chew the nicotine gum. During an interview with RN R, on 10/28/24 at 2:10 p.m., RN R stated she will let the patient chew the nicotine gum until they are done. RN R stated she would not chase the patient for a piece of gum just to check if they still have the nicotine gum in their mouth. During an interview with the Pharmacy Director (PD), on 10/28/24 at 2:55 p.m., the PD stated there is no specific instructions on how to administer the nicotine gum in the medication order. The PD stated the facility follows the CDC guidelines. The PD stated, “I assumed the nurses know how to administer nicotine gum”.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 44577 Based on interview, observation, and record review the facility failed to ensure one hour face to face assessments are completed within a timely manner for two of two patients (Patient 26 & 32). This failure placed the patient at risk for not being accurately assessed for change of condition and safety while in seclusion. Findings: During a review of Patient 26’s “Psychiatric Evaluation (PE)” dated 5/5/24, the PE indicated Patient 26 was admitted as an inpatient on a 5150 (legal hold) for DTS (danger to self) and DTO (danger to others). During a review of Patient 26’s orders dated 8/2024, an order was entered 6/12/24 at 8:20 a.m. for Resident 26’s seclusion/restraint (S/R) (interventions used in the treatment and management of disruptive and violent behaviors in psychiatry), the order indicated, “Continuation S/R”. There was no evidence of the type of seclusion/restraint in the physician’s order. There was no indication of an initial order for seclusion restraints. During review of Patient 26’s one hour face to face assessment document dated 6/12/24, the face to face assessment indicated the “Initiation of intervention (seclusion the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) was 6/12/24 at 4:20 a.m., the “Face to Face assessment” was 6/12/24 at 5:23 a.m. p.m. During a review of Patient 26’s orders dated 8/2024, an order was entered on 7/2/24 at 9 p.m. for Resident 26’s seclusion/restraint. There was no evidence of the type of restraint in the physician order. During a review of Patient 26’s one hour face to face assessment document, dated 7/2/24, the face to face assessment indicated the “Initiation of intervention (seclusion) was at 7/2/24 at 5:16 p.m., the Face to Face assessment was 7/2/24 at 6:25 p.m. During a review of Patient 32’s “Psychiatric Evaluation (PE)” dated 7/16/24, the PE indicated Patient 32 was admitted as an inpatient voluntarily for auditory hallucinations (the perception of hearing sounds or voices that aren’t there.). During a review of Patient 32’s orders dated 8/2024, an order was entered 7/19/24 at 4:57 p.m. for seclusion/restraint. The order indicated physical restraint (a coercive approach that involves restricting a patient’s movement to prevent harm to themselves or others), maximum duration four hours. During a review of Patient 32’s one hour face to face assessment document, dated 7/19/24, the face to face assessment indicated the “Initiation of intervention was 7/19/24 at 6:29 p.m., the Face to Face assessment was 7/19/24 at 6:29 p.m., “Treatment Recommendations” discussed with medical staff 7/2/24 at 4:51 p.m. Type of intervention indicated physical restraint and seclusion. During an interview on 8/21/24 at 3:49 with Director of quality management (DQM), the DQM stated the order for Patient 32 on 7/19/24 did not include seclusion, the nurse did not put “yes” when took the verbal order. The DQM confirmed the face to face assessment should have been completed within one hour. During an interview on 8/21/24 at 4:07 p.m. with Registered Nurse (RN) A, RN A stated if need hands on then a physical restraint order was needed, if seclusion a seclusion order was needed. The face to face assessment is completed when patient was already out of seclusion once they calm down. The order should have indicate the type of restraint. During a review of the facility’s policy and procedure titled, “Restraint and Seclusion, dated 1/2024, the policy and procedure indicated, “The order shall indicate the reason and maximum duration”. “Orders for physical restraints shall not exceed 30 minutes”. “Seclusion may only be ordered by a Practitioner”. “A licensed Independent Practitioner or trained Registered Nurse shall conduct an in-person evaluation of the patient with in one hour of initiation of seclusion to assess physical and psychological status. The in-person evaluation includes the patient’s immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the intervention. If the in-person evaluation is conducted by a trained Registered Nurse, the Registered Nurse must consult with the attending/covering practitioner as soon as possible, but not to exceed one hour ...”.”