Bakersfield Behavioral Healthcare Hospital, LLC

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 39474 Based on observation, interviews and record review, the hospital failed to ensure medications were maintained in a secured pharmaceutical (medications) disposal receptacle to prevent unmonitored access by unauthorized individuals when a pharmaceutical disposal receptacle containing discarded pharmaceuticals was left unsecured. This deficient practice had the potential to allow unauthorized access to pharmaceuticals intended for destruction, increasing the risk of drug diversion (the unlawful transfer or of regulated pharmaceuticals from medical sources for illicit and unlawful use), tampering, and misuse. Findings: During an observation on 7/6/26 at 1:50 p.m., with Registered Nurse 3 (RN3) in the Unit 500 medication storage room, there was an unsecured wall mounted pharmaceutical disposal receptacle containing multiple pharmaceutical tablets and capsules inside. The wall mounted pharmaceutical disposal receptable was missing the tamper resistant lid which could allow access to the discarded medications. RN 3 stated, the unsecured wall mounted pharmaceutical disposal receptacle should have a tamper resistant lid to prevent unauthorized access. RN 3 stated unsecured medications could lead to drug diversion, tampering and misuse. During an interview on 7/7/26 at 9:45 a.m. with the Chief Nursing Officer (CNO), CNO stated, the unsecured wall mounted pharmaceutical disposal container should have a tamper resistant lid to reduce the potential for pharmaceutical diversion, tampering and misuse. CNO stated the wall mounted pharmaceutical disposal container should have had a receptacle inside, which was missing. During an interview on 7/8/26 at 8:00 a.m. with the Pharmacist in Charge (PIC), PIC stated, the unsecured wall mounted pharmaceutical disposal container should have a tamper resistant lid to reduce the potential for pharmaceutical diversion, tampering and misuse. PIC further stated the disposal container should have a tamper resistant lid, which was missing. Review of facility policy and procedure titled, “Pharmaceutical Waste Management” indicted, “Wasting pharmaceuticals in the patient care areas, expired or otherwise unusable medications within the facility are returned to the pharmacy for disposition. Nonhazardous pharmaceuticals no longer in the original container, partially used, dropped or contaminated, refused by the patient etcetera, are wasted as close to the point of origin as possible. Wasting controlled substances must render the product unusable and irretrievable...””

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 38479 Based on observation, interview, and document review, the hospital failed to label, store and prepare raw ground meat in accordance with professional standards for food service safety when two large packs of ground pork were left thawing for an extended period of time in the walk-in refrigerator on 07/07/2026. This failure had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (illness that results from ingesting contaminated foods) for patients, visitors and employees who received food from the kitchen. Findings: During the tour and dietary observation on 7/7/2026, at 9:20 a.m., with the Human Resources Director (HRD) and Director of Quality (DQ), the walk-in refrigerator was inspected. Two (2) large packs of raw ground pork were observed thawing. The ground pork was labeled with, “Prepared Date: 6/30/2026” and “Use by Date: 7/3/2026.” During a concurrent observation and interview with the Prep Cook (PC) on 7/7/2026, at 9:40 a.m., the PC stated that according to the label, the ground meat should have been consumed, used, or prepared on 7/3/2026. The prep cook stated food had to be labelled so it stays fresh, make sure meat is of quality, and does not go pass the expiration date when consumed. The prep cook stated labelling food was important so a patient does not get sick from something that’s going to harm them later. During a concurrent interview and record review with the Registered Dietitian (RD), the RD stated, “Food shall immediately be removed from service if use by date has expired to prevent it from being used for food consumption. Expired food used can cause harm to the patients.” A review of facility policy and procedure “P&P” titled, “FOOD & NUTRITION SERVICES,” dated 10/12/2025, indicated, “PURPOSE...To establish standardized procedures for monitoring refrigerator and freezer temperatures, maintaining safe food storage practices, identifying expired food products, and ensuring prompt removal and disposal of food items that may compromise patient safety...Management of Expired Food. Food shall immediately be removed from service if...Manufacturer expiration date has passed. Beyond-use/Use by date has expired...Expired food shall...Be removed immediately. Be discarded in accordance with facility waste procedures. Never be served to patients or staff. Never be re-labeled with a new expiration date...” A review of facility “P&P” titled, “FOOD & NUTRITION SERVICES,” dated 4/10/2025,indicated,”SUBJECT: Proper Food Handling Procedures...THAW FROZEN MEAT...Frozen potentially hazardous food must be cooked or sold for immediate consumption within 1 day of complete thawing...””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 48424 Based on interview and record review, the facility failed to ensure the discharge planning evaluation included a determination of the availability of appropriate post hospital services and patient’s access to those services for 1 of 10 sampled patients (Patient 1), when Patient 1 was discharged to a homeless shelter without confirmation of bed availability, without an alternative placement plan, and without determining how Patient 1 would access prescribed medications and follow-up services despite having no identification, money, or documented transportation/resources. This failure placed Patient 1, a medically and psychiatrically vulnerable patient, at risk for harm and resulted in Patient 1 experiencing distress after discharge, requiring mobile crisis response and subsequent psychiatric hospitalization. Findings: During a review of Patient 1’s Face Sheet (a medical record summary of patient information), the record indicated Patient 1 was admitted on 4/2/26 and discharged on 4/10/26. The record indicated Patient 1 had diagnoses which included major depressive disorder with psychotic symptoms (a mental health condition with severe sadness and loss of contact with reality), diabetes mellitus (a condition where the body cannot properly control blood sugar), and sheltered homelessness (lack of stable housing while relying on temporary shelter). During a review of Patient 1’s Discharge Summary, dated 4/10/26, the record indicated Patient 1 was diagnosed with multiple medical and mental health conditions, including major depressive disorder, diabetes mellitus, hypertension (high blood pressure), arthritis (joint pain and stiffness), chronic pain (pain that lasts or recurs for longer than three to six months), and homelessness. Upon discharge, Patient 1 was prescribed sertraline (medication for depression) and gabapentin (medication for nerve pain/seizures). Patient 1 was also instructed to follow-up with her own provider for additional medications and treatments, including amlodipine (medication to treat high blood pressure), metformin (medication for diabetes), sitagliptin (medication for diabetes), and blood sugar checks (requires using a small needle to obtain a drop of blood and special testing strips with a glucose meter) twice daily. The record indicated Patient 1 demonstrated poor judgment at discharge. During a review of Patient 1’s Social Service Progress Note, dated 4/10/26, the record indicated Patient 1 was to be discharged to a homeless shelter in another county, with the facility’s transport service scheduled to pick her up from the facility at 9:00 a.m. The record indicated Patient 1’s medications were sent to a pharmacy located approximately 25 miles from the shelter. There was no documentation that the facility verified the shelter would accept Patient 1 or that a bed was available. There was no documentation that the facility arranged an alternative placement if the shelter did not accept Patient 1. There was no documentation that the facility determined how Patient 1 would access the pharmacy located approximately 25 miles away from the shelter to obtain her medications. There was also no documentation that the facility determined whether Patient 1 had the resources needed to obtain medications, follow-up care, or shelter after discharge. During a review of Patient 1’s Patient Belongings record, dated 4/10/26, the record indicated Patient 1 was discharged with clothing, a walker, and a bag of food, but without identification, money, or medications in her possession. During a concurrent interview and record review on 4/30/26 at 9:17 a.m. with Case Manager (CM) 1, Patient 1’s Discharge Summary, dated 4/10/26, was reviewed. CM 1 stated Patient 1 became homeless prior to admission and was scheduled to be transported to a homeless shelter located in another county by the facility’s transport service. CM 1 stated Patient 1’s prescribed medications were sent to a pharmacy located approximately 25 miles from the shelter. CM 1 stated the outpatient case manager informed him the shelter did not guarantee beds, and CM 1 confirmed this with shelter staff. CM 1 acknowledged the facility discharged Patient 1 to the shelter despite knowing no bed was secured. CM 1 further acknowledged Patient 1 had no money or identification and no confirmed means to retrieve her medications from the pharmacy. CM 1 stated discharging Patient 1 to the shelter without a confirmed bed, alternative placement, or means to retrieve medications was considered displacing the patient (moving the patient without a secure place to go). During a phone interview on 4/30/26 at 10:12 a.m. with the Outpatient Case Manager (OCM), the OCM stated the facility did not inform her of Patient 1’s discharge date or time and did not involve her in discharge coordination. The OCM stated Patient 1 contacted her in distress after arriving at the shelter and finding no available bed and no staff available to assist her. The OCM stated Patient 1 was without identification, money, medications, or a means to access her medications. The OCM stated she deployed a mobile crisis team (a group that responds to mental health emergencies) to assist Patient 1, and Patient 1 was subsequently hospitalized on a 5270 psychiatric hold (an involuntary 30 day admission for ongoing mental health needs). The OCM stated that if the facility had informed her of Patient 1’s discharge, she could have assisted with securing placement and ensuring access to services. During a concurrent interview and record review on 4/30/26 at 10:38 a.m. with the Case Management Director (CMD), Patient 1’s Patient Belongings record, dated 4/10/26, and text message communication were reviewed. The records indicated Patient 1 was discharged without money or identification, and the text messages did not include Patient 1’s discharge date or time. The CMD stated it was not standard practice to discharge a patient to a shelter without confirming a bed was available or ensuring the patient had access to basic resources. The CMD stated staff should have coordinated with the outpatient team and ensured Patient 1 had the resources needed for a safe discharge. During a concurrent interview and record review on 4/30/26 at 11:04 a.m. with Medical Doctor (MD) 1, Patient 1’s Discharge Summary, dated 4/10/26, and Patient Belongings record, dated 4/10/26, were reviewed. The Discharge Summary indicated Patient 1 had been evicted from her home and was to be discharged on 4/10/26 with prescribed medications. The Patient Belongings record indicated Patient 1 had no money or identification at discharge. MD 1 stated Patient 1 appeared clinically ready for discharge and no discharge concerns were brought forward by staff. MD 1 stated if staff had informed him that Patient 1 did not have a confirmed shelter bed, lacked resources to access medications and follow-up care, or that discharge had not been coordinated with the outpatient team, he would have delayed the discharge. MD 1 stated communication with the outpatient team was important to ensure safe discharge planning and continuity of care. During a review of the facility’s policy and procedure titled, “Clinical Services Discharge Planning,” dated 4/1/25, the policy indicated the purpose of discharge planning was to assist patients and families in making the transition and adjustment from hospital to home or to another facility. During a review of the facility’s policy and procedure titled, “Nursing Services-Inpatient Mental Health Unit Discharge Planning,” dated 1/20/25, the policy indicated social services would attempt to find adequate and appropriate living arrangements for all patients discharged from the Mental Health Unit. During a review of the facility’s policy and procedure titled, “Clinical Services Scope of Service,” dated 12/25, the policy indicated the treatment team coordinates with community resources, outpatient providers, and the patient’s support system to ensure continuity of care. During a review of the facility’s policy and procedure titled, “Multidisciplinary Treatment Planning,” dated 4/10/25, the policy indicated the discharge plan and goals shall address living situation, continuing treatment/aftercare, medication, safety, and supports.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 39474 Based on interview and record review, the facility failed to coordinate a discharge and transmit necessary discharge information to the outpatient psychiatric care team responsible for the patient’s follow-up care for 1 of 10 sampled patients (Patient 1). This failure resulted in a lack of continuity of care after discharge and contributed to Patient 1 requiring mobile crisis intervention and subsequent psychiatric hospitalization. Findings: During a review of Patient 1’s Social Service Progress Note, dated 4/10/26, the record indicated Patient 1 was to be discharged to a homeless shelter in another county. There was no documentation that the facility notified Patient 1’s outpatient psychiatric care team of the discharge date or time. There was no documentation that the facility transmitted necessary discharge information to the outpatient psychiatric care team or coordinated with the outpatient team regarding Patient 1’s shelter placement, medication access, follow-up care, or post-discharge support needs. During an interview and concurent record review on 4/30/26 at 9:17 a.m. with Case Manager (CM 1), CM 1 acknowledged he did not communicate further with Patient 1’s psychiatric outpatient care team prior to discharge. CM 1 acknowledged the outpatient psychiatric care team should have been notified of Patient 1’s discharge date and time. During an interview and concurrent record review in 4/30/36 at 10:38 a.m., with the Case Management Director (CMD), The CMD stated staff were expected to coordinate with outpatient providers and document coordination efforts prior to discharge. The CMD acknowledged this was not done for Patient 1. During an interview and concurrent record review on 4/30/36 at 11:04 a.m. with Medical Doctor (MD 1), MD 1 stated communication with the psychiatric outpatient care team was necessary to ensure safe discharge and continuity of care for Patient 1. MD 1 stated if staff had informed him that the outpatient psychiatric team had not been notified or that discharge coordination had not occurred, he would have delayed the discharge. During a review of the facility’s policy and procedure titled, “Clinical Services Scope of Service,” dated 12/25, the policy indicated the treatment team coordinates with community resources, outpatient providers, and the patient’s support system to ensure continuity of care.”

“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: 47734 Based on interview and record review, the facility failed to ensure three of three sampled patients (Patient 1, Patient 11, and Patient 14) completed informed consent forms prior to administration of psychotropic medications (drugs that affect brain activity and are used to treat mental health conditions). This failure had the potential for patients to not have all the information needed to make an informed decision. Findings: During an interview on 6/18/25 at 8:55 a.m. with Chief Nursing Officer (CNO), CNO stated the hospital did not have an informed consent policy. During a review of Patient 1’s “Discharge Summary” (DS), dated 6/12/25, the DS indicated, Patient 1 had an admission diagnosis of Schizoaffective disorder (mental health condition characterized by hallucinations and delusions), bipolar (mental health conditions characterized by extreme shifts in mood) type. During a review of Patient 1’s “Physician Orders” (PO), dated 6/5/25, the PO indicated, Patient 1 was prescribed Tegretol (seizure medication also used to treat bipolar disorder) 100 mg twice a day, Zyprexa (used to treat manic or mixed episodes) 10 mg at night, and Ativan (treatment for anxiety) 0.5 mg daily as needed. During a review of Patient 1’s “Medication Administration Record” (MAR), dated June 2025, the MAR indicated, Patient 1 was given the following: Tegretol 100 mg on 6/5/25 at 9:50 a.m. Tegretol 100 mg on 6/5/25 at 9 p.m. Zyprexa 10 mg on 6/5/25 at 9 p.m. Ativan 0.5 mg on 6/5/25 at 8:43 p.m. Tegretol 100 mg on 6/6/25 at 9 a.m. Tegretol 100 mg on 6/6/25 at 9 p.m. Zyprexa 10 mg on 6/6/25 at 9 p.m. Tegretol 100 mg on 6/7/25 at 9 a.m. Tegretol 100 mg on 6/7/25 at 9 p.m. Zyprexa 10 mg on 6/7/25 at 9 p.m. Ativan 0.5 mg on 6/7/25 at 8:37 p.m. Tegretol 100 mg on 6/8/25 at 9 a.m. Tegretol 100 mg on 6/8/25 at 9 p.m. Zyprexa 10 mg on 6/8/25 at 9 p.m. Tegretol 100 mg on 6/9/25 at 9 a.m. Tegretol 100 mg on 6/9/25 at 9 p.m. Zyprexa 10 mg on 6/9/25 at 9 p.m. Ativan 0.5 mg on 6/9/25 at 8:58 a.m. Tegretol 100 mg on 6/10/25 at 9 a.m. Tegretol 100 mg on 6/10/25 at 9 p.m. Zyprexa 10 mg on 6/10/25 at 9 p.m. Ativan 0.5 mg on 6/10/25 at 8:08 p.m. Tegretol 100 mg on 6/11/25 at 9 a.m. Tegretol 100 mg on 6/11/25 at 9 p.m. Zyprexa 10 mg on 6/11/25 at 9 p.m. Ativan 0.5 mg on 6/11/25 at 9:42 p.m. Tegretol 100 mg on 6/12/25 at 9 a.m. During a review of Patient 1’s “Medication Information & Consent” (MIC), dated 6/5/25, the MIC indicated, Patient 1 did not sign the box that indicated, “I have discussed and received a copy of this information. Risks, benefits, side effects, alternatives, and the risks of not taking this medication have been explained to me. I understand that this consent may be withdrawn at any time. I consent to the medication prescribed by my provider.” During a review of Patient 11’s DS, dated 4/23/25, the DS indicated, Patient 11 had an admission diagnosis of Psychosis (mental health conditions characterized by loss of touch with reality), unspecified. During a review of Patient 11’s PO, dated 4/19/25, the PO indicated, Patient 11 was prescribed Remeron (treatment for depression) 15 mg every night, Prozac (treatment for depression) 40 mg every morning, and Seroquel (treatment for psychosis)100 mg every night. During a review of Patient 11’s MAR, dated April 2025, the MAR indicated, Patient 11 was given the following: Prozac 40 mg on 4/19/25 at 1:25 p.m. Remeron 15 mg on 4/19/25 at 9 p.m. Seroquel 100 mg on 4/19/25 at 9 p.m. Prozac 40 mg on 4/20/25 at 9 a.m. Remeron 15 mg on 4/20/25 at 9 p.m. Seroquel 100 mg on 4/20/25 at 9 p.m. Prozac 40 mg on 4/21/25 at 9 a.m. Remeron 15 mg on 4/21/25 at 9 p.m. Seroquel 100 mg on 4/21/25 at 9 p.m. Prozac 40 mg on 4/22/25 at 9 a.m. Remeron 15 mg on 4/22/25 at 9 p.m. Seroquel 100 mg on 4/22/25 at 9 p.m. Prozac 40 mg on 4/23/25 at 9 a.m. During a review of Patient 11’s MIC, dated 4/19/25, the MIC indicated, Patient 11 did not sign the box that indicated, “I have discussed and received a copy of this information. Risks, benefits, side effects, alternatives, and the risks of not taking this medication have been explained to me. I understand that this consent may be withdrawn at any time. I consent to the medication prescribed by my provider.” During a review of Patient 14’s “Facesheet,” undated, the “Facesheet” indicated, Patient 14 had an admission diagnosis of Bipolar disorder. During a review of Patient 14’s PO, dated 6/4/25, the PO indicated, Patient 14 was prescribed Depakote (medication used to treat bipolar disorder) 500 mg twice a day and Zyprexa 10 mg twice a day. During a review of Patient 14’s PO, dated 6/7/25, the PO indicated, Patient 14’s Depakote dosing was increased to 1000 mg every night and 500 mg in the morning. During a review of Patient 14’s MAR, dated June 2025, the MAR indicated, Patient 14 was given the following: Depakote 500 mg on 6/4/25 at 8 p.m. Zyprexa 10 mg on 6/4/25 at 8 p.m. Depakote 500 mg on 6/5/25 at 9 a.m. and at 8 p.m. Zyprexa 10 mg on 6/5/25 at 9 a.m. and 9 p.m. Depakote 500 mg on 6/6/25 at 9 a.m. and at 8 p.m. Zyprexa 10 mg on 6/6/25 at a.m. and 9 p.m. Depakote 500 mg on 6/7/25 at 9 a.m. and 1000 mg at 9 p.m. Zyprexa 10 mg on 6/7/25 at 9 a.m. and 9 p.m. Depakote 500 mg on 6/8/25 at 9 a.m. and 1000 mg at 9 p.m. Zyprexa 10 mg on 6/8/25 at 9 a.m. and 9 p.m. Depakote 500 mg on 6/9/25 at 9 a.m. and 1000 mg at 9 p.m. Zyprexa 10 mg on 6/9/25 at 9 a.m. and 9 p.m. Depakote 500 mg on 6/10/25 at 9 a.m. and 1000 mg at 9 p.m. Zyprexa 10 mg on 6/10/25 at 9 a.m. During a review of Patient 14’s MIC, dated 6/4/25, the MIC indicated, Patient 14 did not sign the box that indicated, “I have discussed and received a copy of this information. Risks, benefits, side effects, alternatives, and the risks of not taking this medication have been explained to me. I understand that this consent may be withdrawn at any time. I consent to the medication prescribed by my provider.” During an interview on 6/19/25 at 1:53 p.m. with Quality and Risk Manager (QRM), QRM stated the consent box should have been checked by patients who agreed to take the psychotropic medications and acknowledged they received risks, benefits, and alternatives to the medication use, even if they refused to sign the consent form. During a review of the facility’s policy and procedure (P&P) titled, “Consent to Psychotropic Medication,” dated 3/12/25, the P&P indicated, “4. If patient gives verbal consent, and is unable to sign due to a disability or is unwilling to sign due to symptoms, this will be indicated on the consent form and signed by the RN witness. . .7. Written documentation of the patient’s decision to consent must be maintained.””

“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: 40516 Based on interview and record review, the hospital failed to: 1. Ensure non-clinical employees refrained from making clinical interventions. 2. Follow their policy and procedure (P&P) titled, “72-Hour Hold for Evaluation and Treatment” for four of 30 sampled patients (Patient 13, Patient 19, Patient 20, and Patient 21). This failure had the potential for Patient 13, Patient 19, Patient 20, and Patient 21 to not fully understand their rights. 3. Ensure the hospital’s Clinical Liaison was qualified for the position. These failures had the potential to result in unsafe care settings. Findings: 1. During an interview on 6/18/25 at 9:30 a.m. with Chief Nursing Officer (CNO), CNO stated Patient 30 was brought to the hospital on 5/16/25 on a 5150 hold (an involuntary 72-hour psychiatric hold for individuals who are deemed a danger to themselves or others, or who are gravely disabled due to a mental health disorder), from a remote city around two hours away from hospital. CNO stated Patient 30 scored as a “high risk” for suicide during the intake process. CNO stated Patient 30 became highly agitated because she did not think she would be so far from home. CNO stated an intake Registered Nurse (RN) 1 and Licensed Marriage and Family Therapist (LMFT) were in the Interview Room with Patient 30 and were unable to deescalate Patient 30’s agitation. CNO stated the Director of Intake (DOI) was not in the hospital and the intake staff had been instructed to notify the Chief Executive Officer (CEO) for any issues when DOI was not available. CNO stated the intake team contacted the CEO, as instructed, and the CEO along with Director Human Resources (DHR) responded to the Interview Room and spent “quite some time” with Patient 30. CNO stated CEO made assessment notes over RN 1’s notes. CNO stated CEO’s assessment indicated Patient 30 was no longer a danger to self (DTS) and she instructed RN 1 to call Physician 1 to have Patient 30 discharged. CNO stated CEO had already informed Patient 30 that she would be able to go home prior to Physician 1 being notified. CNO stated RN 1 called Physician 1, as instructed, and Physician 1 gave orders to discharge Patient 30. CNO stated RN 1 did not feel safe discharging Patient 30 and then notified CNO. CNO stated she notified DOI of CEO’s clinical interventions, and that DOI and CEO got into a “heated conversation.” CNO stated DOI instructed RN 1 to notify Physician 1 of Patient 30’s DTS score and Physician 1 gave orders to cancel his discharge orders and admit Patient 30 on a 5150 hold status. CNO stated RN 1 asked CEO to inform Patient 30 that she would not be discharged, but CEO refused because CEO “did not feel safe” going in to speak with Patient 30. CNO stated Patient 30 was informed that she would not be discharged she began to exhibit assaultive behavior toward the staff and interventions to deescalate Patient 30’s behavior did not work. CNO stated Patient 30 required administration of emergency medications to calm her behavior. CNO stated she reviewed Patient 30’s medical record (MR) with LMFT after the event and LMFT stated the notes made in the margins of the “Intake Assessment” were made by CEO. CNO stated LMFT stated CEO’s assessment of Patient 30 “was inaccurate.” During a concurrent interview and review of Patient 30’s MR on 6/18/25 at 9:40 a.m. with CNO the “Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment” dated 5/15/25, indicated Patient 30, “Didn’t want to live anymore and that she has no purpose” after taking 180 iron pills. The “Intake Assessment” (IA), dated 5/16/25 at 12:54 p.m. indicated Patient 30 arrived at the hospital, “Pt [patient] is on a 5150 for DTS [danger to self] for overdosing on iron pills.” The IA, page 8, subheading “Step 3” indicated Patient 30 scored 25 out of 25 for “Specific questioning about Thoughts, Plans, and Suicidal Intent.” CNO stated a score of 25 indicated Patient 30 was at a “High Risk” for suicide. CNO stated the IA (page 8) handwritten documentation in the right margin (highlighted by hospital staff) was documented by CEO as a “reassessment” at 4:05 p.m. The highlighted documentation by CEO indicated “benefit of D/C [discharge] outweighs risk [of suicide].” The “Nurses Progress Notes” (NPN) dated 5/16/25, at 4:30 p.m. indicated, “Intake nurse voiced concern to the CEO that this [discharging Patient 30] is not a safe discharge as the patient has not been evaluated by a psychiatrist in person and discharging a patient on a 5150 hold [with a telephone order] is not appropriate. The CEO responded that similar patients are often discharged without a psychiatrist assessment. Following this, the CEO spoke with the patient [Patient 30] again at length and recommended to continue discharging the patient. CEO notified the patient that [the hospital] can provide transport for pt. [Physician 1] contacted and notified of nursing concerns regarding this being an unsafe discharge as the patient has not been evaluated by a psychiatrist at [the hospital]. Physician 1 agreed with nursings [sic] concerns and gave order to cancel the previous [discharge orders and] 5150 hold remained in place.” During an interview on 6/18/25 at 9:22 a.m. with Chief Medical Officer (CMO), CMO stated CEO continually tried to overrule MD orders. CMO stated CEO has tried to change “treatment plans” during interdisciplinary team meetings. During an interview on 6/19/25 at 11:43 a.m. with CEO, CEO stated she was called to the Intake Room for Patient 30 when RN 1 told her Patient 30’s behavior and agitation could not be deescalated. CEO stated she had “No clinical say-so.” CEO stated her documentation on the IA form was not an assessment but her attempt to show “two separate perspectives.” CEO stated she makes decisions to protect the hospital. During an interview on 6/18/25 at 11:05 a.m. with Regional Vice President of Operations (RVPO), RVPO stated CEO was not hired to perform any clinical work. During a review of “Chief Executive Officer Job Description” (CEOJD), the CEOJD indicated, “Principal Duties and Responsibilities: 1. Create and communicate a vision for the hospital. 2. Identify, develop and direct the implementation of business strategy. 3. Plan and direct the hospital’s activities to achieve stated/agreed targets and standards for financial and trading performance, quality, culture and legislative adherence. 4. Define measurable goals that develop and enhance processes, systems and practices and provide the means and resources needed to accomplish the goals. 5. Manage and develop key administrative team members. 6. Effectively delegate goals and responsibilities of key executive staff. 7. Direct functions and performance via the administrative team. 8. Review and monitor organizational development.” 2. During a review of Patient 13’s “Certification Review of Hearing Minutes” (CRHM), dated 5/29/25, the “CRHM” indicated, Patient 13 was willing to stay in the hospital voluntarily. During a concurrent interview and record review on 6/18/25 at 11:50 a.m. with RN 2, Patient 13’s MR, dated May 2025 was reviewed. The MR indicated, there was no voluntary admission consent. RN 2 stated staff should have had a consent signed for the voluntary admission. During a concurrent interview and record review on 6/18/25 at 11:54 a.m. with RN 2, Patient 13’s “Physician Orders” (PO), dated May 2025 was reviewed. The PO indicated, there was no physician orders made for Patient 13’s voluntary admission. RN 2 stated staff should notify the physician about the voluntary admission and get an order. During a concurrent interview and record review on 6/18/25 at 11:26 a.m. with CNO, Patient 19’s MR was reviewed. CNO stated Patient 19 was brought to the hospital on 6/6/25 on a 5150 hold for DTS. The “Notice of Certification” (NC) dated 6/9/25 indicated Patient 19 continued to be “A danger to himself or herself” at the end of the 5150 hold. The “Certification Review of Hearing Minutes” (CRHM), dated 6/9/25 indicated Patient 19 agreed to stay in the hospital as a voluntary admission. CNO stated there was no PO to admit Patient 19 as a voluntary admission and there was no signed consent for Patient 19 to stay in the hospital on a voluntary basis. The Facesheet indicated Patient 19 was discharged from the hospital on 6/14/25 at 12:31 p.m. During a concurrent interview and record review on 6/18/25 at 11:33 a.m. with CNO, Patient 20’s MR was reviewed. CNO stated Patient 20 was brought to the hospital on 5/22/25 on a 5150 72-hour hold for DTS. The CRHM, dated 5/24/25 indicated Patient 20 continued to be a “danger to self” and “Will stay voluntarily? YES” as a voluntary hospital admission. CNO stated there was no PO to admit Patient 20 as a voluntary admission and there was no signed consent for Patient 20 to stay in the hospital on a voluntary basis. The Facesheet indicated Patient 20 was discharged from the hospital on 6/2/25 at 5:48 p.m. During an interview with RN 2, RN 2 stated when a patient wins their court order to be discharged after a 5150 hold, but decides to stay as a voluntary admission, the RN must get a PO for the admission and the patient must sign a consent for voluntary admission. During a concurrent interview and record review on 6/18/25 at 12:11 p.m. with CNO, Patient 21’s MR was reviewed. CNO stated Patient 21 was brought to the hospital on 5/24/25 on a 5150 72-hour hold for DTS. The CRHM, dated 5/26/25 indicated Patient 21 continued to be a “danger to self” and “Will stay voluntarily? YES” as a voluntary hospital admission. CNO stated there was no PO to admit Patient 21 as a voluntary admission and there was no signed consent for Patient 21 to stay in the hospital on a voluntary basis. The Facesheet indicated Patient 21 was discharged from the hospital on 6/1/25 at 10:10 a.m. During a review of the hospital’s P&P titled, “72-Hour Hold for Evaluation and Treatment” dated 3/12/25, the P&P indicated, “Prior to the end of the 72 hours detention one of the following dispositions must be arranged: [1] Unconditional release.[2] The patient consents to Voluntary Treatment and signs Request for Voluntary Admission and Authorization for Treatment Form.” 3. During a concurrent interview and review of Court Liaison’s (CL) personnel file (PF) on 6/19/25 at 10:37 a.m. with DHR, the PF indicated CL did not meet qualifications for the CL position. The PF indicated CL had neither a bachelor’s degree or a master’s degree in any field of study. DHR stated applicants, for any posted hospital job, complete an electronic application on the hospital’s website. DHR stated applications are automatically rejected if the applicant does not meet the minimum requirements. DHR stated CL was hired as a “Care Coordinator” which did not involve any patient care interaction. DHR stated CL was promoted to the CL position internally. The “Personnel Action Request” (PAR), dated 3/12/25 was reviewed. The PAR indicated CL was hired on 11/4/24 and a change in status was initiated in March 2025. DHR stated CL was promoted to a new position (CL) in another department after only four months of being hired at the hospital. DHR stated there was no interview documentation in CL’s PF. DHR stated CL had no prior experience as a court liaison. DHR stated CL’s training for the CL position was “two-hour” education presentation by a county patient’s rights advocate. During a review of the hospital’s job description for the job description indicated, “Basic Purpose of Position: Attend court hearings. Track and oversee completion of holds and represent the hospital at legal hold hearings. LPS conservatorship [Lanterman-Petris-Short conservatorship, legal process that allows for the involuntary treatment and care of adults with severe mental illness who are deemed “gravely disabled” and unable to care for their basic needs] applications. Serve patients with Physician ordered legal holds and work with social workers to ensure that all legal holds are kept up to date over the weekends. Assist and train psychiatrist with writing holds and legal documents including 5250 [up to 14-day hold for involuntary psychiatric treatment following a 72-hour hold], 5270 [additional 30 days of involuntary detention], 5260 [allows for continued intensive treatment beyond the initial 5250 hold], Riese [legal process to determine if a person on an involuntary mental health hold can refuse antipsychotic medication], and WRIT [legal action that can be used to challenge the legality of someone’s detention], conservatorship paperwork. Provide prompt response to persons in crisis with the goal of stabilizing the crisis in the least restrictive way, facilitating access to mental health services, and/or performing clinical and legal investigation and evaluation for involuntary detention to psychiatric facilities. . . Job Requirements: Minimum Education Bachelors Degree in Psychology or related field or equivalent experience and education. Master’s degree in Social Work preferred. Minimum Work Experience: Three (3) years experience in mental health or related field with knowledge of Patients Rights, Court Hearings, CMS [Centers for Medicare and Medicaid Services] mental health system title 9 and Title 22 regulations along with TJC [The Joint Commission- an accreditation agency] Standards.” 47734 During a concurrent interview and record review on 6/18/25 at 3:54 p.m. with Licensed Vocational Nurse (LVN), Patient 23’s “Notice of Certification Acknowledgement” (NCA),” dated 6/8/25 was reviewed. The NCA indicated, “a certification review hearing will be held within four days of the date on which the certification was completed.” LVN stated this meant a hearing would have been scheduled for Patient 23, LVN stated there was no Court Hearing Minutes in Patient 23’s MR. During a concurrent interview and record review on 6/18/25 at 4:04 p.m. with Quality and Risk Manager (QRM), the hospital’s “Involuntary Patient Data Sheet” (IPDS- court hearing schedule), undated was reviewed. The IPDS indicated, on 6/9/25, Patient 23 had a court hearing scheduled with a decision made. QRM stated Patient 23 was on the schedule for a court hearing and was admitted voluntarily after the hearing. During an interview on 6/18/25 at 4:06 p.m. with LVN, LVN stated the CL was responsible to file the Court Hearing Minutes for Patient 23 and LVN stated the Court Hearing Minutes were not filed, and the hospital was unable to locate the missing document. During a review of the hospital’s P&P titled, “Employee Transfer,” dated 7/27/22, the P&P indicated, “TRANSFERS WITHIN THE SAME FACILITY 1. Job changes will be considered only after an employee completes six months of employment with one department.””

“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: 40516 Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, “Discharge Planning” for one of 30 sampled patients (Patient 23). This failure had the potential for an interruption in provision of care and unmonitored patient treatment progress. Findings: During an interview on 6/17/25 at 11:54 a.m. with Chief Nursing Officer (CNO), CNO stated discharge planning was completed by the hospital’s Case Managers (healthcare professionals who coordinate and manage patient care, acting as a liaison between patients, families, and the healthcare team). CNO stated discharge planning starts within 24 hours of the patient’s admission. During a concurrent interview and review of Patient 23’s medical Record (MR), on 6/18/23, at 2:37 p.m. with CNO, the “Facesheet” indicated Patient 23 was admitted to the hospital on 6/5/25 at 9:30 p.m. The “Social Service Progress Note” dated 6/7/25 at 8:23 a.m. indicated Case Manager 1 made the initial case management note. CNO stated the case management note was more than 24 hours after Patient 23’s admission. During a review of the hospital’s P&P titled, “Discharge Planning” dated 3/25/22, the P&P indicated, “Discharge planning is intended to maintain continuity of care, maintain progress achieved during treatment, and minimize the risk of relapse or readmission . . . PROCEDURE: 1. The Case Manager will see every patient within the first twenty-four hours of admission.” 47734”

“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: 47444 Based on interview and record review the hospital failed to ensure four of 30 sampled patients (Patient 16, Patient 17, Patient 1, and Patient 30) were provided safe discharge (D/C) planning when: 1.a. Patient 16’s Master Treatment Plan (MTP) was not reviewed after change in Patient 16’s behavior (on 3/23/25 night shift). 1.b. Patient 16’s family member (FM) 1 was not notified of Patient 16’s D/C plan. 1.c. Patient 16’s order for cancellation of D/C was not followed. 1.d. Patient 16’s intake assessment was not completed and provider was not consulted before Patient 16 was returned to the locked unit. 1.e. Patient 16 was D/C’d to FM 2’s home (Patient 16’s identified trigger for suicidal ideation [SI - thoughts about ending one’s own life]). 2. Patient 17 was D/C’d home without a plan for ensuring safe self care. 3. There was no documentation from physician indicating Patient 1 was no longer a danger to self before D/C from the hospital. 4. Patient 30 was D/C’d to FM 5 without confirmation of legal documentation for guardianship. These failures had the potential to result in Patient 16, Patient 17, Patient 1, Patient 30 and Patient 3 to have unsafe D/Cs and negative physical and mental health outcomes. Findings: 1.a. During a review of Patient 16’s “Discharge Summary (DS),” dated 3/27/25, the DS indicated, “History of Present Illness: Patient [16] was a 14-year-old. . . currently was brought in here [hospital] on 5150 hold for being danger to self and for having suicidal ideation with plan to run into the traffic. . . Admission Diagnoses: 1. Major depressive disorder, recurrent, severe, with psychotic features. 2. Posttraumatic stress disorder. . . Course of Hospitalization: Patient . . . was admitted to Adolescent Psychiatric Unit, on 03/16/2025, involuntarily [against will].” During a review of Patient 16’s “Physician Orders (PO),” dated 3/24/25 at 9 a.m., the PO indicated, “D/C Home.” During a concurrent interview and record review on 5/7/25 at 8:20 a.m. with Medical Doctor (MD) 1, Patient 16’s “Master Treatment Plan Review (MTPR),” dated 3/21/25 was reviewed. The MTPR indicated Patient 16 had an incident on 3/20/25 of severe agitation, claiming to hear music and was given an emergency medication injection. MD 1 stated there was no MTPR for Monday 3/24/25 after Patient 16 had an incident on 3/23/25 at 7:25 p.m. and was given an emergency medication injection. MD 1 stated a MTPR should have been done on 3/24/25 after Patient 16’s change in behavior on 3/23/25. During a concurrent interview and record review on 5/7/25 at 8:33 a.m. with MD 1, Patient 16’s “Nursing Night Shift Notes (NNSN),” dated 3/23/25 were reviewed. The NNSN indicated Patient 16 was scratching at her arms, was not redirectable, was anxious, trying to harm herself and emergency medication injection was given on 3/23/25 at 7:25 p.m. During a review of the hospital’s policy and procedure (P&P) titled, “Multidisciplinary Treatment Planning,” dated 3/25/25. The P&P indicated, “2. A Master Treatment Plan is required for all patients within 72 hours of admission to guide individualized care, establish measurable treatment goals, and ensure a coordinated, patient centered approach to recovery. Including functional status in the treatment plan ensures that care strategies address cognitive, behavioral, emotional, and social capabilities, optimizing patient outcomes and discharge readiness. The Master Treatment Plan is fluid and should be reviewed and updated based on the patient’s progress or changes in behavior or mental status. . . 4. Discharge Planning & Continuity of Care Identification of discharge criteria and readiness indicators. . . The discharge plan and goals shall address the living situation, continuing treatment/aftercare, medication, safety, and support.” 1.b. During an interview on 5/5/25 at 4:23 p.m. with Patient 16’s Family Member (FM) 1, FM 1 stated the hospital did not contact her regarding Patient 16’s discharge plan. FM 1 stated she informed Case Manager (CM) 2, the morning of 3/24/25 that she had not been contacted about Patient 16’s D/C plan. CM 2 stated she would call FM 1 back. CM 2 called FM 1 back and stated Patient 16 had been D/C’d and was in route to FM 1’s home. FM 1 stated the nurse had called the night prior (3/23/25) to report that Patient 16 had an incident of self harm and was given medications to calm the behavior. FM 1 stated she was concerned that Patient 16 was not ready to be discharged and was still a danger to herself. FM 1 requested that CM 2 have Patient 16 return to the hospital. FM 1 stated CM 2 called and stated the Nurse Practitioner (NP) gave an order to cancel the D/C and he would see Patient 16 the next morning (3/25/25). FM 1 stated she received a call from Licensed Marriage and Family Therapist (LMFT) stating that Patient 16 had returned to the hospital but did not meet criteria for readmission and threatened to call Child Protective Services (CPS) if FM 1 did not accept Patient 16 home. FM 1 stated Patient 16 was D/C’d to FM 2 on 3/24/25. FM 1 stated one week later Patient 16 was admitted to another behavior hospital for self harm behaviors. During an interview on 5/7/25 at 8:38 a.m. with MD 1, MD 1 stated patients with SI were at highest risk of suicide within the first 15 days after D/C. During a concurrent interview and record review on 5/7/25 at 9:04 a.m. with Interim Chief Nursing Officer (ICNO), Patient 16’s “Social Services Progress Notes (SSPN),” dated 3/17/25 through 3/24/25 were reviewed. ICNO stated there was no note indicating FM 1 was notified of Patient 16’s D/C plan details and follow up appointments. During a concurrent interview and record review on 5/7/25 at 9:12 a.m. with MD 1, Patient 16’s “SSPN,” dated 3/24/25 at 10 a.m. was reviewed. The SSPN indicated FM 1 found out Patient 16 was D/C’d the morning of 3/24/25 after Patient 16 was already in transport van on her way to FM 1’s home. The SSPN indicated FM 1 was upset and could not receive Patient 16 home at that time due to safety concerns. MD 1 stated the team needed to collaborate with FM 1 for Patient 16’s safe D/C and document the discussions. During a review of the hospital’s P&P titled, “Discharge of Patients,” dated 4/10/25. The P&P indicated, “If the patient is a minor, the case manager and/or nursing staff will communicate and coordinate the discharge time with the legal guardian.” During a review of the hospital’s P&P titled, “Discharge Planning,” dated 3/25/25. The P&P indicated, “6. The Case Manager, with the patient’s consent, engages family or caregivers in planning to ensure they are prepared to support the patient post-discharge.” 1.c. During a concurrent interview and record review on 5/7/25 at 4:40 p.m. with CM 2, Patient 16’s “SSPN,” dated 3/24/25 at 10 a.m. was reviewed. CM 2 stated she called FM 1 regarding D/C of Patient 16 and FM 1 expressed concern about the D/C and stated Patient 16 had threatened to kill herself when she returned home. CM 2 stated she called NP who gave an order to cancel Patient 16’s D/C and keep her until 3/26/25. CM 2 stated she went to inform Registered Nurse (RN) 3 of the NP order, but Patient 16 was already in route to FM 1’s home via the hospital transport van. During a concurrent interview and record review on 5/8/25 at 2:54 p.m. with RN 3, Patient 16’s “Nursing Progress Notes (NPN),” dated 3/24/25 was reviewed. RN 3 stated she was assigned care of Patient 16 on 3/24/25. RN 3 stated she D/C’d Patient 16 at approximately 10 a.m. RN 3 stated she became aware that Patient 16 was returning to the hospital when CM 2 informed her that NP canceled Patient 16’s D/C. RN 3 stated she did not contact the Physician or NP regarding the canceled D/C. During an interview on 5/8/25 at 8:22 a.m. with NP, NP stated CM 2 notified him that Patient 16 was having SI while in route to FM 1’s home. NP stated he gave a verbal order to cancel Patient 16’s D/C but did not speak to an RN. NP stated he was waiting for a RN to contact him for the order. 1.d. During a concurrent interview and record review on 5/7/25 at 9:35 a.m. with MD 1, Patient 16’s medical record (MR) was reviewed. There was no Intake Assessment (IA) in the MR for Patient 16’s return to hospital on 3/24/25. MD 1 stated Patient 16 needed to be reassessed by a physician or NP to determine if criteria for readmission was met. During a concurrent interview and record review on 5/7/25 at 9:40 a.m. with MD 1, Patient 16’s “SSPN,” dated 3/24/25 at 1:09 p.m. was reviewed. The SSPN indicated LMFT contacted FM 1 and explained that Patient 16 did not meet criteria for admission. MD 1 stated LMFT was not able to make the determination if Patient 16 did not meet criteria for readmission. MD 1 stated intake RN should have assessed Patient 16 and contacted a physician or NP. During an interview on 5/7/25 at 2:35 p.m. with RN 2, RN 2 stated she was the RN in the intake area (where patients are assessed for admission to the hospital) on 3/24/25. RN 2 stated she was not informed that Patient 16 was returning to the hospital, did not complete an intake assessment and did not communicate with the physician or NP regarding Patient 16. During an interview on 5/8/25 at 2:54 p.m. with RN 3, RN 3 stated Patient 16 was taken to the locked unit by CM 2 at approximately 2 p.m. RN 3 stated an intake assessment was not completed. RN 3 stated she did not communicate with NP or physician when Patient 16 returned to the locked unit. During an interview on 5/7/25 at 9:45 a.m. with ICNO, ICNO stated when Patient 16 returned to the hospital on 3/24/25 a new patient packet should have been completed including contraband screening, belongings list and intake assessment by therapist, RN, and psychological evaluation by physician. ICNO stated a physician or NP should have been notified of Patient 16’s return to the hospital and assessed Patient 16 for readmission. During an interview on 5/7/25 at 2:35 p.m. with RN 2, RN 2 stated a skin assessment, contraband search, and face to face patient handoff was not done on 3/24/25 when Patient 16 returned to the locked unit. During an interview on 5/8/25 at 8:22 a.m. with NP, NP stated it was expected that a provider would have seen Patient 16 and done a new intake assessment and evaluation. NP stated the process would be the intake RN would call the on-call NP or physician to accept the admission. NP stated it was not acceptable to take Patient 16 back to the locked unit without any assessment. NP stated he would expect the RN on the unit to contact NP or physician to get orders for medications and monitoring. NP stated returning Patient 16 to the locked unit without a physician order could be considered being held against her will. During an interview on 5/8/25 at 2 p.m. with LMFT, LMFT stated CM 2 informed her that Patient 16 was returning to the hospital. LMFT stated she assessed Patient 16 upon return to the hospital and determined Patient 16 did not meet criteria for readmission. LMFT stated she did not notify the intake RN, physician or NP. During a review of the hospital’s P&P titled, “Admission Protocol,” dated 8/24/22. The P&P indicated, “When admission is deemed appropriate, the Intake staff will call the physician, submitting the information gathered in the intake process. The physician makes the final determination regarding admission of the patient. The procedure for voluntary admission is as follows: . . . 4. Intake RN meets with patient and conducts medical triage. . . 6. Intake RN or clinician completes the Intake assessment. . . 8. When patient is medically appropriate a psychiatrist is notified and presented with the patient’s symptoms. The patient is admitted per the psychiatrist’s assessment of presenting symptoms. . . 10. Intake then obtains consents. 11. Once the consent for admission has been signed, the patient will be escorted to the nursing floor. In the event that consents cannot be obtained at the time of admission, intake will make up to three additional attempts to secure consent. If, after these attempts, consent remains unobtainable or the patient or family refuses to sign, the consent documentation will be marked accordingly to reflect that consent was not obtained. . . If the patient is admitted, they will receive a contraband search, which will include wanding patient’s belongings that will go with them to the unit. The patient will then be taken to the exam room for the skin check and body check.” 1.e. During a concurrent interview and record review on 5/7/25 at 8:41 a.m. with MD 1, Patient 16’s “Application for up to 72 hour Assessment, Evaluation and Crisis Intervention (5150),” dated 3/16/25 was reviewed. The 5150 indicated, “. . . youth [Patient 16] expressed suicidal ideation [SI] with no plan and an increase in urges to self-harm. . . Youth noted that there was not specific trigger to this recent increase but did note over the past week she has been having conflict with her father [FM 2]. Youth reported feeling misunderstood by him and that she does not feel that he is receptive to her when she tries to having [sic] conversations about how she is feeling. Youth stated that her father. . . continued to bring up her diet and exercise which was triggering to the youth. Youth acknowledged overall she does not feel “stable with my mental health” and that any triggering conversation would “put me over the edge.” MD 1 stated Patient 16 identified FM 2 as a trigger for her SI. During a concurrent interview and record review on 5/7/25 at 8:45 a.m. with MD 1, Patient 16’s “Master Treatment Plan (MTP),” dated 3/17/25 was reviewed. The MTP indicated, “Post-Discharge Goal(s) (Patient’s own words) To not go back to my dads.” MD 1 stated Patient 16’s therapist and CM should have explored the reasons that Patient 16 did not want to go to FM 2’s home. MD 1 stated there was no documentation that the reasons were explored with Patient 16. During an interview on 5/7/25 at 9:51 a.m. with MD 1, MD 1 stated psychosocially the hospital team “dropped the ball” for Patient 16 by not ensuring a safe D/C to FM 1’s house and ultimately D/C’d to FM 2’s home, who Patient 16 identified was a trigger for her SI. During a review of the hospital’s P&P titled, “Discharge Planning,” dated 4/10/25. The P&P indicated, “Discharge planning begins at the time of admission. Based on input from the patient, family/significant other, physician and members of the multidisciplinary team, a discharge plan is developed. . . Patient will be discharged to the least restrictive environment, taking the patient’s choices into consideration and complying with that choice when possible.” 2. During a review of Patient 17’s “5150,” dated 6/10/24, the 5150 indicated, “[Patient 17] was gravely disabled [GD - unable to provide basic personal needs for food, clothing, or shelter] . . . refused to eat a complete meal, she refuses to adhere to her prescribed medication and she is urinating in a bucket as opposed to using the toilet. . . presents as paranoid, guarded and uncooperative. . . unable to formulate a viable plan for food and refused third party assistance. . . was observed drinking contaminated water from a bucket. . . Per [FM 3] [Patient 17] gives away the food they provide her. She stopped taking her psych meds [medications] and she refuses to complete activities of daily living. . . showering, changing into clean clothes and using the bathroom in an appropriate manner. [Patient 17] refuses to have food in the house.” During a review of Patient 17’s “Intake Assessment (IA),” dated 6/11/24, the IA indicated, “Patient Designated Family Caregiver to Assist in Aftercare Plan: [FM 3 and FM 4].” During an interview on 5/7/25 at 3:31 p.m. with ICNO, ICNO stated when Patient 17 was identified as GD. During a concurrent interview and record review on 5/8/25 at 9:35 a.m. with MD 2, Patient 17’s “Riese Petition [determines a person’s ability to refuse medication to treat mental disorder] - Medication Capacity Petition (RP),” dated 6/12/24 was reviewed. The RP indicated Patient 17 suffers from Schizoaffective disorder (mental illness including paranoid thoughts, depression, mania and unable to care for self). The RP indicated Patient 17 was not aware of her mental disorder and was not able to understand the behaviors that led to involuntary hospitalization. The RP indicated Patient 17 was not able to understand the risks and benefits of medications, was not able to rationally understand and evaluate information regarding informed consent and had minimal participation in treatment decisions. MD 2 stated Patient 17 was refusing medications to treat her mental disorder. MD 2 stated the court authorized the facility to administer the medications to Patient 17. During a concurrent interview and record review on 5/8/25 at 9:38 a.m. with MD 2, Patient 17’s “PPN,” dated 6/16/24 was reviewed. The PPN indicated, Patient 17 had “poor discharge planning, no viable safety plan and poor participation in treatment.” MD 2 stated Patient 17 was considered gravely disabled meaning she was unable to secure food, clothing and shelter for self. MD 2 stated Patient 17 needed assistance with activities of daily living. MD 2 stated decisions about patient care and D/C planning were made as a collective team with input from CM, therapist, RN, and physician. During a concurrent interview and record review on 5/8/25 at 9:42 a.m. with MD 2, Patient 17’s “Interdisciplinary Team (IDT - group of health care providers),” dated 6/14/24, was reviewed. The IDT indicated Patient 17 would be monitored for improvement over weekend and tentative D/C based on improvement. MD 2 stated there was no IDT completed before Patient 17’s D/C on 6/17/24. MD 2 stated IDT should have been done to decide if Patient 17 had improved over the weekend and had a safe plan for D/C. During a concurrent interview and record review on 5/8/25 at 9:45 a.m. with ICNO, Patient 17’s “SSPN,” dated 6/13/24 through 6/17/24 were reviewed. ICNO stated there was no plan to ensure Patient 17 was able to care for herself after D/C. ICNO stated FM 3 and FM 4 were not notified of Patient 17’s D/C plan. During a review of Patient 17’s “Nursing Progress Notes (NPN),” dated 6/17/25 at 11:36 a.m., the NPN indicated Patient 17 was D/C’d via hospital transport. During a review of the hospital’s P&P titled, “Multidisciplinary Treatment Planning,” dated 3/25/25. The P&P indicated, “2. A Master Treatment Plan is required for all patients within 72 hours of admission to guide individualized care, establish measurable treatment goals, and ensure a coordinated, patient centered approach to recovery. Including functional status in the treatment plan ensures that care strategies address cognitive, behavioral, emotional, and social capabilities, optimizing patient outcomes and discharge readiness. The Master Treatment Plan is fluid and should be reviewed and updated based on the patient’s progress or changes in behavior or mental status. . . 4. Discharge Planning & Continuity of Care Identification of discharge criteria and readiness indicators. . . The discharge plan and goals shall address the living situation, continuing treatment/aftercare, medication, safety, and support.” 51320 3. During a review of Patient 1’s “5150,” date 3/19/25, the 5150 indicated Patient 1 was on an involuntary (against their will) hold for SI. During a review of Patient 1’s “IA,” dated 3/19/25, the IA indicated Patient 1 stated “I am going to hang myself.” During a review of Patient 1’s “Nursing Admission Assessment (NAA),” dated 3/19/25, the NAA indicated Patient 1 was banging her head against the wall and tried to strangle herself with her shirt. Patient 1 was unable to be redirected, was placed on a one-to-one observation and received emergency medication for danger to self. During a review of Patient 1’s “PO”, the PO indicated emergency medications administered to Patient 1 on: 3/19/25 at 7:06 p.m. - Ativan (medication for relaxation) 2 mg (milligrams) and Benadryl (medication for relaxation) 50 mg IM (Intramuscular injection - medication that goes into a muscle for absorption) for severe agitation. 3/20/25 at 11:40 a.m. - Seroquel (medication for psychosis) 20 mg po (by mouth) for agitation, Ativan 2 mg and Benadryl 50 mg po for severe agitation. 3/20/25 at 11:45 a.m. - Benadryl 50 and Ativan 2 mg IM now for severe agitation. During a review of Patient 1’s “Nursing Day shift note (NDSN),” dated 3/20/25, the NDSN indicated Patient 1 was on a one to one observation for SI. During a review of Patient 1’s “Psychiatric Evaluation (PE),” dated 3/20/25, the PE indicated Patient 1’s estimated length of stay was one to three days, prognosis (outcome) was poor and plan of care to address aggressive/violent behaviors. During a review of Patient 1’s “Discharge Aftercare Plan (DAP),” dated 3/20/25, the DAP indicated Patient 1 was D/C’s from the facility at 5 p.m. During a concurrent interview and record review on 5/7/24 at 9:47 a.m. with MD 1, Patient 1’s MR was reviewed. MD 1 stated there was no physician progress note documentation regarding Patient 1’s change in behavior and no determination that she was not a danger to self prior to D/C. During a review of the hospital’s P&P tilted, “Discharge Planning,” dated 3/25/25, the P&P indicated, “Discharge Planning is intended to maintain continuity of care, maintain progress achieved during treatment, and minimize the risk of relapse or readmission.” 4. During a review of Patient 30’s “5150,” dated 4/28/25, the 5150 indicated Patient 30 was on an involuntary hold for SI. During a concurrent interview and record review on 5/8/25 at 4:48 p.m. with Licensed Case Social Worker (LCSW) 1, Patient 30’s “Psychosocial Assessment (PA),” dated 4/29/25 was reviewed. PA indicated Patient 30’s mother had passed away and Patient 30 was living with FM 5. The PA indicated Patient 30 felt FM 5 did not want her anymore and had started drinking again. LCSW stated there was no documentation in the MR indicating FM 5 had legal guardianship of Patient 30. During a concurrent interview and record review on 5/8/25 at 3:21 p.m. with CM 1, Patient 30’s MR was reviewed. CM 1 stated there was no documentation that she addressed Patient 30’s request for alternative living arrangements. CM 1 stated she assumed FM 5 was the legal guardian of Patient 30 as he had signed the treatment consents. During a review of Patient 30’s “DAP,” dated 4/6/25, the DAP indicated Patient 30 was D/C’d to FM 5. During an interview on 5/8/25 at 5:02 p.m. with ICNO, the ICNO stated staff needed to verify legal guardianship before signing consents for treatment of adolescent patients and to ensure safe D/C of patient. During a review of the hospital’s P&P tilted, “Discharge of Patients,” dated 4/10/25, the P&P indicated, “If the patient is a minor, the case manager and/or nursing staff will communicate and coordinate the discharge time with the legal guardian.””

“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: 35649 Based on interview and record review, the hospital failed to: 1. Obtain informed consents (process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) from the family members (FM 2 and FM 3) for two of two minor sampled patients (Patient 4 and Patient 5) prior to administration of psychotropic medications (medications that affect the mind, emotions, and behavior). This failure resulted in Patient 4 and Patient 5 receiving medications without knowing the risks, benefits, and alternatives of the drugs and without FM 2 and FM 3 being aware of the medications prescribed and administered to their minor children. 2. Obtain informed consent for Condition of Admissions and Treatment for one of 10 sampled patients (Patient 6). This failure had the potential for patients’ wishes to not be honored, and for patients to not receive the opportunity to exercise their rights to make decisions over their health. Findings: 1. During a concurrent interview and record review on 9/18/24 at 2:51 p.m. with Quality/Risk Registered Nurse (QRRN), Patient 4’s Physician’s Orders (PO), dated 9/13/24, were reviewed. The PO indicated, “Abilify (medication to decrease hallucinations [false perception of objects or events])15 mg (milligrams) one tablet at bedtime for bipolar (a mental illness that causes unusual shifts in a person’s mood, energy), Trileptal (medication to treat seizures) 300 mg one tablet daily in the morning and 600 mg one tablet at bedtime for bipolar, Vistaril (medication used to help control anxiety and tension) 25 mg one tablet three times a day PRN (as needed) for anxiety, and Wellbutrin (medication to treat depression) SR (slow release) 100 mg one tablet at bedtime.” QRRN stated Patient 4 came in with suicidal ideation (thinking about killing one’s self) with a plan. During a concurrent interview and record review on 9/18/24 at 2:55 p.m. with Interim Chief Nursing Officer (ICNO), Patient 4’s Informed Consent for Abilify, dated 9/13/24, was reviewed. The informed consent form for Abilify 15 mg did not indicate the name of FM 2 as giving the consent to administer Abilify 15 mg one tablet orally at bedtime. The informed consent form for Ability 15 mg indicated two healthcare workers, a physician, and a registered nurse signed Patient 4’s informed consent form on 9/13/24. ICNO stated she was unable to find documentation FM 2 had been contacted to give consent to administer Abilify 15 mg orally at bedtime to Patient 4. During a concurrent interview and record review on 9/18/24 at 3 p.m. with ICNO, Patient 4’s Informed Consent for Trileptal 300 mg and Trileptal 600 mg, dated 9/13/24, were reviewed. The informed consent form for Trileptal 300 mg and Trileptal 600 mg did not indicate the name of Patient 4’s FM 2 as giving the consent to administer Trileptal 300 mg one tablet daily in the morning and Trileptal 600 mg one tablet at bedtime. The informed consent form for Trileptal 300 mg and Trileptal 600 mg indicated two healthcare workers, a physician, and a registered nurse signed the informed consent form on 9/13/24. ICNO stated she was unable to find documentation FM 2 had been contacted to give consent to administer Trileptal 300 mg in the morning and Trileptal 600 mg at bedtime to Patient 4. During a concurrent interview and record review on 9/18/24 at 3:05 p.m. with ICNO, Patient 4’s Informed Consent for Wellbutrin SR 100 mg, dated 9/13/24, was reviewed. The informed consent form for Wellbutrin SR 100 mg did not indicate the name of Patient 4’s FM 2 as giving the consent to administer Wellbutrin SR 100 mg one tablet every morning. The informed consent form for Wellbutrin SR 100 mg indicated two healthcare workers, a physician, and a registered nurse signed the informed consent form on 9/13/24. ICNO stated she was unable to find documentation FM 2 had been contacted to give consent to administer Wellbutrin SR 100 mg one tablet in the morning to Patient 4. During a concurrent interview and record review on 9/18/24 at 3:10 p.m. with ICNO, Patient 4’s Informed Consent for Vistaril 25 mg, dated 9/13/24, was reviewed. The informed consent form for Vistaril 25 mg tablet did not indicate the name of Patient 4’s FM 2 as giving the consent to administer Vistaril 25 mg tablet orally three times a day PRN for anxiety. The informed consent form for Vistaril 25 mg indicated two healthcare workers, a physician, and a registered nurse signed the informed consent form on 9/13/24. ICNO stated she was unable to find documentation FM 2 had been contacted to give consent to administer Vistaril 25 mg three times a day as needed for anxiety to Patient 4. During a review of Patient 4’s Medication Administration Record (MAR), dated 9/13/24 and 9/14/24, the MAR indicated the following: Abilify 15 mg PO (orally) given on 9/13/24 at 9 p.m. Trileptal 600 mg PO given on 9/13/24 at 9 p.m. Trileptal 300 mg PO given on 9/14/24 at 9 a.m. Wellbutrin SR 100 mg PO given on 9/14/24 at 9 a.m. During a concurrent interview and record review on 9/18/24 at 3:20 p.m. with ICNO, Patient 5’s Physician’s Orders, dated 9/12/24, were reviewed. The Physician’s Orders indicated the following psychotropic medications: Prozac (treats major depressive disorder [MDD-a mental health disorder characterized by persistently depressed mood or loss of interest in activities]) 40 mg by mouth every day, Latuda (treats MDD) 60 mg one tablet by mouth at bedtime, Hydroxyzine (treats anxiety) 25 mg by mouth three times a day PRN for anxiety, and Trazodone (used to treat depression) 50 mg by mouth every HS (at bedtime) PRN for insomnia. During a concurrent interview and record review on 9/18/24 at 3:25 p.m. with ICNO, Patient 5’s Informed Consent for Prozac 40 mg, dated 9/12/24, was reviewed. The informed consent form for Prozac 40 mg tablet did not indicate the name of Patient 5’s FM 3 as giving the consent to administer Prozac 40 mg by mouth every day for MDD. The informed consent form for Prozac 40 mg indicated two healthcare workers, a physician, and a registered nurse signed the informed consent form on 9/12/24. ICNO stated she was unable to find documentation FM 3 had been contacted to give consent to administer Prozac 40 mg by mouth daily to Patient 5. During a concurrent interview and record review on 9/18/24 at 3:30 p.m. with ICNO, Patient 5’s Informed Consent for Latuda 60 mg, dated 9/12/24, was reviewed. The informed consent form for Latuda 60 mg tablet did not indicate the name of FM 3 as giving the consent to administer Latuda 60 mg by mouth at bedtime. The informed consent form for Latuda 60 mg indicated two healthcare workers, a physician, and a registered nurse signed the informed consent form on 9/12/24. ICNO stated she was unable to find documentation FM 3 had been contacted to give consent to administer Latuda 60 mg by mouth at bedtime to Patient 5. During a concurrent interview and record review on 9/18/24 at 3:35 p.m. with ICNO, Patient 5’s Informed Consent for Hydroxyzine 25 mg, dated 9/12/24, was reviewed. The informed consent form for Hydroxyzine 25 mg tablet did not indicate the name of Patient 5’s FM 3 as giving the consent to administer Hydroxyzine 25 mg by mouth three times a day PRN for anxiety. The informed consent form for Hydroxyzine 25 mg indicated two healthcare workers, a physician, and a registered nurse signed the informed consent form on 9/12/24. ICNO stated she was unable to find documentation FM 3 had been contacted to give consent to administer Hydroxyzine 25 mg by mouth three times a day PRN for anxiety to Patient 5. During a concurrent interview and record review on 9/18/24 at 3:40 p.m. with ICNO, Patient 5’s Informed Consent for Trazodone 50 mg, dated 9/12/24, was reviewed. The informed consent form for Trazodone 50 mg tablet did not indicate the name of Patient 5’s FM 3 as giving the consent to administer Trazodone 50 mg by mouth every HS PRN for insomnia (difficulty sleeping). The informed consent form for Trazodone 50 mg indicated two healthcare workers, a physician, and a registered nurse signed the informed consent form on 9/12/24. ICNO stated she was unable to find documentation FM 3 had been contacted to give consent to administer Trazodone 50 mg by mouth every HS PRN for insomnia to Patient 5. During an interview on 9/19/24 at 10:22 a.m. with Physician (MD) 2, MD 2 stated he called Patient 4’s FM 2 and Patient 5’s FM 3, MD stated he did not document the family member’s names. MD 2 stated the FM’s were not entered on the informed consent forms of the prescribed antipsychotic medications. During a review of the facility’s policy and procedure (P&P) titled, “Consent to Psychotropic Medications,” dated 9/5/23, the P&P indicated, “1. On admission and prior to administration of medication, the provider who orders the medication obtains consent ...8. Nurses may not administer psychotropic medication to any patient without a signed consent form ...” During a review of the facility’s “Clinical Documentation Training Manual,” dated 2024-2025, the Training Manual indicated, “Informed Consent: Psychotropic medications treatment is not one of the sensitive services that a minor can consent to. Parent/guardian consent is required if psychotropic medications are prescribed.” 2. During a concurrent interview and record review on 9/18/24 at 3:40 p.m. with ICNO, Patient 6’s Condition for Admission and Consent for Treatment, dated 9/16/24, were reviewed. The Condition for Admission and Condition for Treatment consent forms for Patient 6’s consents were not signed. ICNO stated there were no attempts by staff to obtain Patient 6’s consent for admission and treatment. During a review of the facility’s “Clinical Documentation Training Manual,” dated 2024-2025, the Training Manual indicated, “Adults, including those receiving behavioral health treatments have the right to give or refuse consent to medical diagnostic or treatment procedures. California Health and Safety Code 7185.5(a) states that ‘legislature finds that adult persons have the fundamental right to control the decisions relating to the rendering of their own medical care. California Code of Regulations Title 22 70707(b)(6) provides that a person has a right to participate actively to decisions regarding medical care.””

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 45654 Based on observation, interview, and record review, the hospital failed to provide direct observation and supervision for two of two sampled patients (Patient 21 and Patient 22) in the adolescent unit, when Patient 22 was seen exiting Patient 21’s room. This failure had the potential for staff being unaware if Patient 21 was in distress or danger. Findings: During an interview on 9/18/24 at 10:35 a.m. with Chief Executive Officer (CEO), CEO stated Patient 22 snuck out of her room and entered Patient 21’s room and hid behind a door. CEO stated she stressed to the patients the goal was to keep them safe while in the hospital. CEO stated Patient 21 was getting ready for bed. CEO stated Patient 21 told Patient 22 to leave the room. During a concurrent interview and review of hospital’s video hallway recording at 11:20 a.m. on 9/18/24 with CEO and Interim Chief Nursing Officer (ICNO), the video recording dated 9/6/24, indicated, Patient 21 went to his room. Patient 22 entered into Patient’s 21 room at 7:43 p.m.. At 7:52 p.m. Mental Health Worker (MHW) 4 was doing observation rounds to check on Patient 21’s room, and without entering room closed Patient 21’s and Patient 22’s door. At 8:10 p.m. MHW 4 without entering the room, opened and closed Patient 22’s door. At 8:17 p.m. Patient 22 left Patient 21’s room. ICNO stated Patient 22 went into Patient 21’s room in-between every-five-minute observation rounds. During an interview on 9/18/24 at 11:25 p.m. with ICNO, ICNO stated MHW 4 did not monitor Patient 22. During an interview on 9/18/24 at 2:10 p.m. with MHW 3, MHW 3 stated the process for direct observation monitoring a patient in the bathroom with the door closed was to call out to the patient and have the patient respond to the staff. During a review of Patient 22’s, “Observation Rounding Precautions (ORP),” dated 9/6/24, the ORP indicated, Patient 22’s location was in the bathroom. During a review of Patient 22’s “Signed Statement (SS),” dated 9/6/24, the SS indicated, “[Patient 21 and Patient 22] went into the shower for 20 minutes.” During a review of the facility’s policy and procedure (P&P) titled, “Rounds of Patient Observation,” approved 7/27/22, the P&P indicated, “Every 5 minute Observations. Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress. Staff will be vigilant for potential risk factors identified for specific patients (levels of precautions).””

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 42344 Based on interview and record review, the facility failed to reevaluate the discharge plan for one of 10 sampled patients, (Patient 11), when the facility was informed that Patient 11 was not welcome to return to family member (FM) 1’s home at discharge. This failure resulted in the facility attempting to discharge Patient 11 to a shelter with no available beds, and discharging to an unsafe location. Findings: During an interview on 9/16/24 at 9:40 a.m. with Director of Clinical Services (DCS), DCS stated when the facility discharges a patient that is homeless, the staff must make sure it is a safe discharge. DCS stated a safe discharge would be to a homeless shelter (HS). During an interview on 9/17/24 at 8:38 a.m. with FM 1, FM 1 stated he pleaded with the facility not to discharge Patient 11 to his residence. FM 1 stated he told the facility that he was not a safe discharge plan; that he worked two jobs and could not ensure Patient 11 to be safe. FM 1 stated on the day Patient 11 was discharged, he was at work when he got a call from someone at the facility who told him he had to accept Patient 11 into his home. FM 1 stated he had to leave his job and go to his residence to accept Patient 11. FM 1 stated he had to take Patient 11 to the emergency department (ED) where she was placed on a 5150 hold (a temporary involuntary hospitalization for a person experiencing a mental health crisis). FM 1 stated Patient 11 was transferred from the ED and admitted to another psychiatric hospital. During an interview on 9/18/24 at 8:35 a.m. with DCS, DCS stated there was a multidisciplinary team (MDT a group of people from different disciplines who work together to achieve a common goal) discussion about Patient 11’s discharge plan. DCS stated they knew FM 1 did not want Patient 11 to be discharged to his home and was asking the facility about a discharge to a Board and Care or another facility. The facility did not have a confirmed bed at a shelter. DCS stated when medical doctor (MD) 2 discharged Patient 11, MD 2 was adamant about discharging Patient 11 on 8/26/24. DCS stated the MDT did not believe Patient 11 was ready for discharge. During a concurrent interview and record review on 9/18/24 at 9:45 a.m. with Case Manager (CM) 2, Patient 11’s “Social Service Progress Notes (SSPN),” dated 8/26/24, were reviewed. The first “SSPN” indicated, “8/26/24 4:30 pm (CM) met with patient [11] to go over discharge plan ...CM informed [Patient 11] that she was being discharge [sic] today and her two options are to discharge back to [FM 1] home, but [FM 1] does not welcome you back into the home or the [HS]. Patient 11 stated that she would go to the HS. CM informed Patient 11 that [transport company (TC)] will be transporting her to [HS 1].” The second “SSPN” indicated, “8/26/24 4:41 pm [CM] spoke to [MD 2] to inform him that HS was full and no viable placement was available for Patient 11. [MD 2] stated that Patient 11 needs to be discharged today to the HS. CM agreed to arrange the transportation.” The third “SSPN” indicated, “8/26/24 6 pm [CM] messaged [TC] to change Patient 11’s discharge address to home address [address in Santa Maria] as it is patients last home address. HS are full, and no viable placement was found.” CM 2 stated she met with Patient 11 to discuss the discharge plan. CM 2 stated the patient told her she would go to the shelter. CM 2 stated she called HS 1 and was told, “there may be a bed.” CM 2 stated she called TC to transport Patient 11 to Santa Maria. CM 2 stated she called HS 1 at 3 p.m. and was told they did not have any available beds. CM 2 stated she notified MD 2 of the bed situation and MD 2 told her patient [11] had to be discharged to her home address. CM 2 stated she notified TC to change the discharge address from HS 1 to Patient 11’s home. During a concurrent interview and record review on 9/18/24 at 9:54 a.m. with CM 1, an email sent by CM 1 to the CM group, [undated], was reviewed. The email indicated, “[Patient 11] was estimated for [discharge] on 8/23, but was canceled. [FM 1] had major concerns over the stability of [Patient 11] and did not feel safe [with] her return. [FM 1] expresses that he does not have the means to take care of [Patient 11] and feels that she will decompensate further if discharged .CM l stated he sent out this email to the CM group in case [Patient 11] was discharged while he was on time off. CM 1 stated FM 1 was very clear that he could not take care of Patient 11. During an interview on 9/18/24 at 10:26 a.m. with MD 2, MD 2 stated, “This was a very difficult placement issue.” MD 2 stated he had to discharge Patient 11 because she did not meet the criteria for a hold, Patient 11 was not a danger to self (DTS), not a danger to others (DTO), and not gravely disabled (GD) because Patient 11 was willing to accept placement in a shelter. MD 2 stated the facility was required to use the least restrictive environment and a “psych hospital” is extremely restrictive. MD 2 stated FM 1 was required to let Patient 11 return to her place of residence because FM 1 had not legally “evicted” (move out of one’s home) Patient 11. During an interview on 9/18/24 at 12:05 p.m. with Director of Utilization Review (DUR), DUR stated she received a call from the facility on 8/26/24, that Patient 11 had been discharged and transported to a shelter in Santa Maria and there were no available beds. DUR called FM 1 and asked him to go to his residence and receive Patient 11. DUR stated FM 1 agreed and said, “O.K., but I’m just gonna take her to the ER.” During a review of Patient 11’s “Face Sheet (FS),” dated 8/18/24, the FS indicated Patient 11’s address was a residence in Santa Maria. During a review of Patient 11’s “Discharge Summary (DS).” dictated 8/30/24, the “DS” indicated, “Patient was homeless ...patient was discharged to [HS 1] at Santa Maria.” During a review of Patient 11’s “Discharge Aftercare Plan (DAP).” dated 8/26/24, the DAP indicated, “Discharge Address: [address of HS 1].” During a review of Patient 11’s “Physician Progress Note (PPN),” [undated], the “PPN” indicated, “[Discharge] failed due to family refuse to pick up pt [patient] ...Although pt is delusional [a fixed false belief that a person holds despite evidence to the contrary] willing to accept shelter [FM 1] refuse [sic] to pick her up.” During a review of the facility’s policy and procedure (P&P) titled, “Discharge of Patients,” approved date 7/27/22, the P&P indicated, “PURPOSE: To ensure a smooth transition to the next level of care ...and to ensure continuity of the treatment modalities selected for the patient.” During a review of the facility’s P&P titled, “Discharge Planning,” Approved 4/27/22, the P&P indicated, “2. To aid in the achievement of maximum post hospital adjustment through the identification of the etiology of environmental stressors past and present and to offer recommendations for resolution or at least lessening of these stressors. 3. To preserve and or strengthen family relationships by providing emotional support and interpretation to family members so that they will become more accepting and aware about the patient’s problems and goals. 4. To involve the relatives in planning for the patients current and ongoing care and recognition of the necessity for change in their living patterns. 5. To assist patients and their families in making the transition and adjustments from hospital to home or to another facility.””

“DISCHARGE PLANNING-QUALIFIED PERSONNEL CFR(s): Any discharge planning evaluation or discharge plan under this paragraph must be developed by or under the supervision of a registered nurse, social worker, or other appropriately qualified personnel. This Standard is not met as evidenced by: 35649 Based on interview and record review, the hospital failed to ensure the Director of Competency Restoration Program (DCRP) provided oversight for a Doctoral Student (DS) in the discharge planning/transfer request documentation for one of one sampled patient (Patient 1), who was under the care of DCRP. This failure had the potential for insufficient planning and inadequate information, which could result in Patient 1’s discharge to be incomplete and ineffective for continuity of care. Findings: During the initial tour of the Competency Restoration Unit (Incompetent To Stand Trial (IST) Unit in units 500, 600, and 700) on 9/16/24 at 10:07 a.m. with Program Coordinator (PC) and Medical Doctor (MD) 1, PC stated Patient 1 was discharged/transferred to another Department of State Hospital (DSH). PC stated Patient 1 failed to complete the 90-120-day competency evaluation to stand trial. PC stated Patient 1 was discharged at 5:30 a.m. and picked up by the transportation DSH arranged and designated. During a concurrent interview and record review on 9/16/24 at 10:30 a.m. with PC, Patient 1’s discharge planning documents were not in Patient 1’s medical records (MR). PC stated the documentation was in a secured electronic mail. During a concurrent interview and record review on 9/16/24 at 11:06 a.m. with Registered Nurse (RN) 3, Patient 1’s “Redirect Request (RR-a transfer request to the program management unit responsible for all DSH transfers),” dated 9/5/24 was reviewed. The RR indicated, “Patient 1 has been unable to demonstrate a complete knowledge of his charges or an ability to assist his counsel in a rational manner.” RN 3 stated the DS completed the RR. RN 3 was unable to provide documentation of the DCRP in Patient 1’s MR to verify DS documentation and demonstrate supervision of DS discharge planning/transfer request. During an interview on 9/16/24 at 2:42 p.m. with DCRP and Interim Chief Nursing Officer (ICNO), DCRP stated the hospital had doctoral students in psychology completing their clinical rotation. DCRP stated the doctoral students were working “under my license.” DCRP stated she reviewed their documentation, met with the students weekly, and conducted face-to-face sessions with the students to go over their documentation. DCRP stated she did not document she reviewed and co-signed DS documentation nor wrote a progress note of approval of DS RR for Patient 1. During a review of the facility’s “Clinical Documentation Training Manual,” dated 2024-2025, the Training Manual indicated, “Staff shall provide all services within the scope of practice of the individual delivering the service. Clinicians will follow the specific scope of practice requirements determined by regulations, including those of the governing boards of the applicable licenses . . . Notes requiring co-signatures must be submitted to a supervisor within two business days for review and authorization. Upon authorization, the staff requiring the co-signature must finalize the note to claim the service. If the supervisor is not available, the providing staff must coordinate with the program director or other designated supervisors to review notes and other clinical documents for co-signatures.””

“Staffing Requirements CFR(s): [Psychiatric hospitals must] Meet the staffing requirements specified in §482.62. This Standard is not met as evidenced by: 35649 Based on interview and record review, the hospital failed to: 1. Ensure the Program Coordinator (PC) had the competency and the qualification to manage the Incompetent to Stand Trial [IST] Unit in Units 500, 600, and 700 designed to train and educate the patients regarding processes in court proceedings. This failure had the potential to result in the PC not being able to provide the necessary leadership and management skills necessary to run an efficient and effective IST Unit. 2. Ensure nine of 10 employees (Quality Risk Registered Nurse [QRRN], PC, two MHW, ( MHW 1 and MHW 2), and five Registered Nurses (RN 1, RN 2, RN 3, RN 4, and RN 5) received training on Emergency Preparedness. This failure had the potential for patients and staff to be unsafe in the event of an emergency. 3. Ensure three of 10 employees (PC, MHW 1 and MHW 2) received training on Infection Control. This failure had the potential for patients and staff to be exposed to infections and transmit infectious diseases. Findings: 1. During a concurrent interview and record review on 9/18/24 at 3 p.m. with Interim Chief Nursing Officer (ICNO), the IST Case Manager’s Personnel File (CMPF), was reviewed. The CMPF indicated, “IST Case Manager (CM) was hired as case manager for the IST Unit. The Job Description/Performance Appraisal and Competency Evaluation Form (JDPACEF), dated 6/7/24, was reviewed. The JDPACEF indicated, CM was evaluated based on the job description, performance, and competency of a program coordinator. ICNO stated she was not aware the IST CM was promoted to a PC. During an interview on 9/18/24 at 3:20 p.m. with Human Resources Coordinator (HRC), HRC stated Human Resources did not have a record of the IST unit CM being promoted to a PC. During an interview on 9/19/24 at 11:15 a.m. with PC, in the presence of the Chief Executive Officer (CEO), PC stated her official title was Program Coordinator. PC stated, “I am a Program Coordinator. I help the Director of Competency Restoration Program [DCRP] in the IST Unit.” PC stated,” I was the case manager but there was not much case management duties in IST, not so much with finding placements.” PC stated she held a Degree in Psychology from the University of Phoenix in 2017, one of the qualifications for the position of Program Coordinator.” At 12:15 p.m. PC presented herself with DCRP and stated, “I am sorry I did not finish school.” During a concurrent interview and record review on 9/19/24 at 12 p.m. with HRC and ICNO, PC’s educational background check, dated 5/24/17, was reviewed. The educational background check from the University of Phoenix indicated, “No degree. Only attendance confirmed.” The JDPACEF, dated 6/7/24, was reviewed. JDPACEF indicated,” Job requirement- Minimum Education: Bachelor’s degree in psychology, Healthcare Administration, Business or a related field and/or a combination of education and experience determined acceptable by regulatory compliance requirements and Hospital Administration.” ICNO stated the IST Competency Training record indicated PC did not have the IST competency training. HRC and ICNO stated PC did not meet the requirements of the position of a Program Coordinator. During a review of the facility’s policy and procedure (P&P) titled, “Job Evaluation Policy,” the P&P indicated, “3. All existing jobs that require reevaluation due to changes in task and responsibility will be evaluated using the current job description and the completed Job Evaluation Request Form. 4. All new positions must be evaluated and have a written job description before the position is posted or filled.” 2. During a concurrent interview and review of employee personnel files on 9/18/24 at 2:25 p.m. with ICNO, the employee personnel files for QRRN, PC, MHW 1, MHW 2, RN 1, RN 2, RN 3, RN 4, and RN 5 were reviewed. The personnel files for the 9 employees indicated, no emergency preparedness training. ICNO confirmed the above employees did not have emergency preparedness training in their orientation . 3. During a concurrent interview and review of employee personnel files on 9/18/24 at 2:35 p.m. with ICNO, the employee personnel files for PC, MHW 1, and MHW 2, were reviewed. The personnel files for PC, MHW 1 and MHW 2 indicated, no infection control training. ICNO confirmed MHW 1 and MHW 2 did not have infection control training in their orientation. During a review of the facility’s P&P titled, “Inservice Education and Training,” dated 5/2/22, the P&P indicated, “1 ...All new employees are required to attend orientation. Included in new employee orientation are safety training, infection control procedures, corporate compliance, and communication regarding hazardous materials. All employees with patient care responsibilities are required to attend additional departmental orientation.” During a review of the facility’s P&P titled, “Orientation,” dated 5/2/22, the P&P indicated, “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.””

“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: 42148 Based on observation, interview, and record review, the hospital failed to adequately supervise and provide a safe environment for one of eight sampled patients (Patient 1) who had aggressive behaviors. This failure resulted in Patient 1 barricading himself in the dayroom causing harm to himself, staff, and destruction of hospital property. Findings: During a concurrent observation and interview on 8/14/24 at 9:29 a.m. with Director of Plant Operations (DPO) in Unit 200 dayroom, there were large pieces of paper covering all the windows and door of the dayroom. There were eight chairs in the patient hallway. DOP stated, “Dayroom is requiring some maintenance and cannot be used by patients. Patio is also closed because you can only access it through the dayroom.” During an interview on 8/14/24 at 9:45 a.m. with Patient 13, Patient 13 stated patients have not been able to use the dayroom because “a patient destroyed it.” During an interview on 8/14/24 at 3 p.m. with Chief Executive Officer (CEO), CEO stated on 8/4/24, around 9:30 p.m., Patient 1 barricaded himself in the dayroom in unit 200. CEO stated Patient 1 was telling staff he couldn’t sleep in his room and asked staff if he could hang out in the dayroom. CEO stated, “At some point, the staff walked away for a minute and [Patient 1] barricaded himself in the dayroom.” CEO stated Patient 1 put chairs up against the door so staff couldn’t come in and more staff were called in to assist. CEO stated, “within an hour he [Patient 1] had torn down the camera, ceiling tiles, some wiring, and broke glass in the main dayroom door.” CEO stated local police were called, and took the Patient 1 into custody around 10:30 p.m. During an interview on 8/18/24 at 10:30 p.m. with Registered Nurse (RN) 4, RN 4 stated, “I was the primary nurse taking care of [Patient 1] on 8/4/24 and right before 9 p.m., [Patient 1] was in the dayroom demanding food and stating he wanted to sleep in the dayroom. I told [Patient 1] the dayroom closes at 9 p.m. and patients must go to their rooms for the night.” RN 4 stated, Patient 1 became upset and barricaded himself in the dayroom by putting chairs and a table in front of the door. RN 4 stated Patient 1 broke ceiling tiles, the camera, wires, a television, boxes on the wall, and broke glass out of the door. RN 4 stated the hospital called 911. RN 4 stated Patient 1 tried to cut himself with a piece of metal and was bleeding. RN 4 stated, “I’ve never seen anything like this, staff was scared, and one of our maintenance guys got punched in the face twice by [Patient 1] after he was called to try and get the door open.” RN 4 stated Patient 1’s provider was notified, and medications were ordered, but Patient 1 refused to let staff in the dayroom to give them. RN 4 stated local police eventually came in with force and arrested Patient 1. RN 1 stated the Administrator on call (AOC) came to the facility and was aware of the incident. RN 4 stated Patient 1 was considered a “harm to himself.” RN 4 stated the dayroom and the patio has been closed ever since and patients are not allowed to use dayroom/patio. During an interview on 8/19/24 at 9:48 a.m. with Plant Operations Maintenance Technician (POMT), POMT stated, on 8/4/24 around 9:30 p.m. he was asked by staff to help open a door where a patient had barricaded himself in the dayroom of unit 200. POMT stated Patient 1 had chairs and a table up against the door. POMT stated he pushed the door open a “little bit” and Patient 1 hit him in the face twice with his hand on the left side of his cheek. POMT stated he was scared of Patient 1 at this point and did not attempt to open the door anymore. During a concurrent review of video surveillance and interview on 8/18/24 at 2 p.m. with Risk Manager (RM), CEO, and Chief Nursing Officer (CNO), the video surveillance dated 8/4/24 indicated, at: 9:15 p.m. - Patient closes the dayroom door and puts two chairs in front of the door. Staff seen at the door on the other side. 9: 28 p.m.- Seven staff members are gathered outside of the dayroom door. Patient 1 has four chairs and a table against the door inside the dayroom. Patient 1 is pacing the room and yelling at staff through the windows. 9:31 p.m.- Nine staff members are gathered outside of the dayroom door. Patient 1 is turning the lights on and off in the day room, yelling, and pacing the room. 9:45 p.m.- Eight local police officers arrive and gather outside dayroom door. One officer is seen trying to negotiate with Patient 1 through the windows. 9:47 p.m.- PMOT tries to open the door. Patient 1 hits PMOT in the face twice. 9: 52 p.m.- The dayroom camera is broken by Patient 1, only camera seen is outside of dayroom of staff and the police officers. 10:49 p.m.- Local police goes in dayroom and comes out with patient in handcuffs. CEO stated she was made aware of this incident while it was happening. During a review of Patient 1’s, “Intake Assessment (IA),” dated 8/2/24, the “IA” indicated, Patient 1 was a moderate suicide risk. “[Patient 1] came on a 5150 [72 hour involuntary hold] stating he wanted to drive off a cliff.” During a review of Patient 1’s, “High Risk Alert (HRA),” dated 8/2/24, the “HRA” indicated, Patient 1 was a high risk for suicide. During a review of Patient 1’s, “Physician Order (PO),” dated 8/3/24, the “PO” indicated, Patient 1 was on Suicide Precautions. During a review of Patient 1’s, “PO” dated 8/4/24, the “PO” indicated, Patient 1 was on Suicide Precautions. During a review of Patient 1’s, “Master Treatment Plan (MTP),” the “MTP” indicated, “Legal Status: Involuntary. Danger to self. Date Established 8/2/24.” During a review of Patient 1’s “Nursing Progress Notes (NPN),” dated 8/4/24, the “NPN” indicated, “Around 21:00 [9 p.m.] during round time, staff request to all the patient’s time to bed, we should close the dayroom [sic]. When staff members try to close the door and let’s go to your room and take a rest then patient shut the door on staff [sic]. Staff told the patient [Patient 1] that you could not be in the dayroom passed 21:00 [9:00 p.m.] and explained to the patient that it is the policy of hospital. Patient [Patient 1] started yelling to the staff and he put all the furniture in front of the door. When staff try open to the door and patient keep yelling, staff tried to redirect him and, but he still barricaded himself in a dayroom [sic]. Around 21:10 [9:10 p.m.] NP called, and situation made aware. NP ordered Throazine 50 mg IM. Order carried by staff, patient refused to take medication [sic]. Patient [Patient 1] was violent, start punching wall. Pt [Patient 1] was hyperverbal, loud. For safety purpose Code Grey was announced at 2112 [ 9:12 p.m.]. Patient [Patient 1] still barricaded in the dayroom. Patient [Patient 1] was yelling [I wanted my discharge letter and I also want to listen to music and sleep in a dayroom. If I didn’t get it, I will start hurting staff]. Staff began to start pushing dayroom door open. Patient [Patient 1] punched on the staff x 2. Patient was in very dangerous situation. He starts destroying hospital property. Pt [Patient 1] hit the window and broke the glasses and camera, also broke the grievance box and fire alarm box and also attempted cut self with metal piece. Pt [Patient 1] was barricaded in the room. Staff was not able to open the door. Situation was made aware to AOC and also NP as per ordered. At 2145 [9:45 p.m.] called to 911 for safety purpose for staff and also patient [Patient 1] was in dangerous situation inside the room. Patient [Patient 1] got on top of the table and began ripped ceiling out, camera and wires. Patient [Patient 1] took the camera out and attempted to brake [sic] the window again. Pt [Patient 1] also used metal panel to brake in dayroom gallery. Once the window was broken, He [Patient 1] reached into the broken window to open inside. Patient [Patient 1] then proceeded to take fridge out, water dispenser and cabinet door out of gallery and destroying property, Pt [Patient 1] was bleeding and licked it and put it on face [sic]. For follow up called 911 again because pt [Patient 1] was in a dangerous situation. Emergency staff states they are on the way to help him out. Patient [Patient 1] was still yelling on staff. Patient [Patient 1] was yelling out he did not care to die if cops got involved. He was going to go down with fight. Patient [Patient 1] continue destroying property, screaming and throwing item to door and windows until cops showed up. Cops showed up 2220 [10:22 p.m.] and cops were redirecting the patient but patient [Patient 1] was not cooperative and was saying on the cops and also yelling on the cops. For safety purpose cops broken off the door window reached inside the dayroom and patient escape in the gallery. Cops escort the patient at 2238 [10:38 p.m.] Patient was still aggressive towards staff and yelling on cops and staff.” During a review of the Hospital’s Policy and Procedure (P&P) titled, “Rights & Responsibilities of Patient’s and/or Parents”, dated 2/22/22, the P&P indicated, “The rights and responsibilities delineated below apply to patients. . . All hospital personnel shall observe these patient rights. Patient Safety: The patient has the right to expect reasonable safety insofar [sic] as the hospital’s practices and environment are concerned.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 46958 Based on interview and record review, the hospital failed to ensure that the face-to-face assessment for two of 30 sampled patients (Patient 3 and Patient 6) were completed within 1 hour of the initiation of the restraint (involuntary restricting the movement of arms or legs or the whole body) and seclusion (patient place alone in a quiet room being monitored by staff) for patients with violent and self-destructive behaviors. This failure resulted in patients’ not receiving a comprehensive physical and behavioral assessment. Findings: During a concurrent interview and record review on 8/14/24 at 3 p.m. with Chief Nursing Officer (CNO), Patient 6’s, “Restraint/Seclusion Orders for Violent Behavior (RSOVB),” dated 8/11/24 was reviewed. The RSOVB indicated Patient 6 was in seclusion on 8/11/24 at 2:15 p.m. and the face to face assessment was not documented. CNO stated the face to face assessment should be completed within one hour. During a concurrent interview and record review on 8/15/24 at 10:40 a.m. with Registered Nurse (RN) 1, Patient 3’s “RSOVB,” dated 7/30/24 was reviewed. The RSOVB indicated, Patient 3 was in seclusion on 7/30/24 at 4:45 p.m. and the face to face assessment was not documented. RN 1 stated the face to face assessment should be completed within one hour. During a concurrent interview and record review on 8/15/24 at 11 a.m. with RN 1, Patient 3’s “RSOVB”, dated 7/30/24 was reviewed. The RSOVB indicated, Patient 3 was in seclusion on 7/30/24 at 5:50 p.m. and the face to face assessment was not documented. RN 1 stated the face to face assessment should be completed within one hour. During a review of the hospital’s policy and procedure (P&P) titled, “Seclusion and Restraint,” dated 9/25/23, the P&P indicated, “The patient must be evaluated [face-to-face] as to the appropriateness of seclusion and restraint as an intervention within one (1) hour of the initiation of the intervention.””

“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: 42148 Based on interview and record review, the hospital failed to complete an admission assessment for one of 30 sampled patients (Patient 3). This failure had the potential to not meet Patient 3’s mental health needs. Findings: During a concurrent interview and record review on 8/15/24 at 1:40 p.m. with Registered Nurse (RN) 1, Patient 3’s “Nursing Admission Assessment (NAA),” dated 7/30/24 was reviewed. The NAA indicated all sections of the assessment were not completed. RN 1 stated the NAA was blank, and it should be completed after admission when the patient goes on the unit. During a review of the hospital’s policy and procedure (P&P) titled, “Nursing Service-Inpatient Mental Health Unit,” dated 7/27/2022, the P&P indicated, “a. The Nursing Assessment shall be started in the first 8-hours of admission, and completed in 24-hours on cooperative patients. If the patient is uncooperative, the assessment shall be completed as soon as possible, and daily attempts to complete data areas should be made following admission. b. If patient remains uncooperative during the entire period, the assessment may be completed to the extent possible.””

“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: 42148 Based on observation, interview, and record review, the hospital failed to follow their Policy and Procedure (P&P) titled, “Occurrence Reporting & Adverse Event Determination” after one of eight sampled patients (Patient 1) was barricaded in a dayroom causing harm to himself and hospital staff. This failure resulted in the proper authorities not being notified of the incident and not being made aware of potential negative outcomes. Findings: During an interview on 8/14/24 at 11:47 a.m. with Risk Manager (RM), RM stated, the incident on 8/4/24 that involved Patient 1 barricading himself in the dayroom was not reported to the California Department of Public Health (CDPH). RM stated, “It is up to the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) what gets reported to CDPH. RM stated “They [CEO and CNO] let me know to report, then I send the paperwork to CDPH.” RM stated she was aware of the incident and had also seen the video surveillance of the incident. During a review of Patient 1’s “Nursing Progress Notes (NPN),” dated 8/4/24, the “NPN” indicated, “. . . Staff told the patient [Patient 1] that you could not be in the dayroom passed 21:00 [9:00 p.m.] and explained to the patient that it is the policy of hospital. Patient [Patient 1] started yelling to the staff and he put all the furniture in front of the door. When staff try open to the door and patient keep yelling, staff tried to redirect him and, but he still barricaded himself in a dayroom [sic]. . . .Staff began to start pushing dayroom door open. Patient [Patient 1] punched on the staff x 2. Patient was in very dangerous situation. . . .Pt [Patient 1] also used metal panel to brake in dayroom gallery. Once the window was broken, He [Patient 1] reached into the broken window to open inside. . . Pt [Patient 1] was bleeding and licked it and put it on face [sic]. . .” During an interview on 8/14/24 at 3 p.m. with CEO, CEO stated she did not report the incident to CDPH because “I didn’t think it was reportable since nobody was injured, including patients, staff, or visitors and it isn’t unusual for police officers to come onsite at our facility.” During an interview on 8/14/24 at 4:15 p.m. with CNO, CNO stated the incident on 8/4/24 with Patient 1 was not reported to CDPH. CNO stated, “we didn’t think it needed to be reported.” During a concurrent interview and record review on 8/15/24 at 8:30 a.m. with RM, “Occurrence Summary Report (OSR),” dated 8/5/24 was reviewed. The OSR indicated, “[Patient 1] barricaded himself with multiple weighted table and chairs in the unit dayroom. The patient was yelling, threatening staff demanding to be discharged. Staff called a code Grey [patient escalation incident] to which additional staff members attended and provided verbal de-escalation and redirection. Despite staff’s efforts, [Patient 1] began pulling down ceiling tiles which exposed wires he tugged on and broke off the surveillance camera. In addition, he [Patient 1] broke off the unit grievance box and hit the dayroom door windows causing them to break. Multiple attempts were made to de-escalate the patient [Patient 1] and contract for safety. [Local Police] was contacted to further assist in de-escalating the situation and prevent further property destruction caused by the patient [Patient 1]. The patient [Patient 1] was detained and taken into custody by local law enforcement.” RM stated, “This [OSR] was done last night even though it is dated 8/5/24,” RM stated, “it should have been done right after the incident occurred.” During a concurrent review of video surveillance and interview on 8/18/24 at 2 p.m. with RM, CEO, and CNO, the video surveillance dated 8/4/24 indicated, at: 9:15 p.m. - Patient closes the dayroom door and puts two chairs in front of the door. Staff seen at the door on the other side. 9: 28 p.m.- Seven staff members are gathered outside of the dayroom door. Patient 1 has four chairs and a table against the door inside the dayroom. Patient 1 is pacing the room and yelling at staff through the windows. 9:31 p.m.- Nine staff members are gathered outside of the dayroom door. Patient 1 is turning the lights on and off in the day room, yelling, and pacing the room. 9:45 p.m.- Eight local police officers arrive and gather outside dayroom door. One officer is seen trying to negotiate with Patient 1 through the windows. 9:47 p.m.- PMOT tries to open the door. Patient 1 hits PMOT in the face twice. 9: 52 p.m.- The dayroom camera is broken by Patient 1, only camera seen is outside of dayroom of staff and the police officers. 10:49 p.m.- Local police goes in dayroom and comes out with patient in handcuffs. During an interview on 8/19/24 at 2:22 p.m. with CEO, CEO stated, after watching the video surveillance of the incident on 8/4/24, “an Unusual Occurrence Report should have been filed with CDPH.” During a review of the hospital’s P&P titled, “Occurrence Reporting & Adverse Event Determination,” dated 1/22/22, the P&P indicated, “Purpose: An effective Quality and Patient Safety Program requires optimal reporting of medical/healthcare occurrences. [Hospital] encourage recognition of risks to patient safety, the initiation of actions to reduce these risks, the internal reporting of what has been found and the actions taken to avoid reoccurrence. The focus is to be on improving processes and systems and to discourage individual blame or retribution for involvement in a medical/healthcare care occurrence. The Director of Quality/Risk/compliance has been designated by the Governing Board to ensure ongoing compliance with required notifications to the Office of Licensing and Certification, State of California. . . Policy: 1. Under the direction of the Chief Executive Officer, The Director of Quality/Risk/Compliance is responsible to ensure prompt notification to CDPH, when indicated, as required by applicable regulations related to the hospital license. 4. It is the responsibility of all hospital staff to report occurrences. . . In the event that an occurrence meets the self-reporting provision in title 22. . . the Director of Quality/Risk/Compliance or their designee will report no later than 5 days after the event has been detected; or, if the event is on ongoing urgent or emergent threat to the welfare, health, or safety of patients, personnel, or visitors, no later than twenty-four [24] hours after the adverse event has been detected. Unusual Occurrences may include but is not limited to: Epidemic outbreak, poisoning, fire, major accident, disaster, and other catastrophe or other unusual occurrence which threatens the welfare, safety, or health of patients, personnel, or visitors.””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 42148 Based on interview and record review, the hospital failed to ensure prescriptions were sent to a pharmacy after discharge from the facility for one of 30 sampled patients (Patient 2). This failure resulted in Patient 2 not having medications he required daily which had the potential for adverse affects and withdrawals. Findings: During a concurrent interview and record review on 8/19/24 at 10 a.m. with Risk Manager (RM), Patient 2’s, “Discharge Aftercare Plan (DAP),” dated 7/8/24 was reviewed. The DAP indicated, “Pharmacy [Patient 2’s Pharmacy], Pharmacy Contact: E [Electronic]-Prescriptions, Signature by Patient 2, Signature by two Registered Nurse’s.” RM stated this form is filled out to indicate that medications Patient 2 will take after discharge will be sent electronically to the pharmacy listed. During a concurrent interview and record review on 8/19/24 at 10:15 a.m. with RM, Patient 2’s, “Discharge Medication Summary for Patient (DMS),” (undated) was reviewed. The DMS indicated, no medications were electronically sent to Patient 2’s pharmacy after discharge. RM stated two different medications were supposed to be sent to Patient 2’s pharmacy for continued use after discharge from the facility. During a concurrent interview and record review on 8/19/24 at 10:23 a.m. with RM, Patient 2’s, “Medication Administration Report (MAR),” dated 7/8/24 was reviewed. The MAR indicated, Abilify [medication used to treat mental health disorders] 10 mg [milligram] take one tablet at bedtime. Depakote [medication used to treat mood disorders] 500 mg take one tablet at bedtime. Physician wrote “continue” beside each medication and signed the bottom of the MAR. RM stated this is what the facility reviews to see what medications should be electronically sent to Patient 2’s pharmacy upon discharge from our facility. RM stated this did not happen and Patient 2 did not have any medications sent electronically to the pharmacy. During a review of the hospital’s policy and procedure (P&P) titled, “Discharge of Patients,” dated 7/27/22, the P&P indicated, “Purpose: To ensure a smooth transition to the next level of care and to ensure continuity of the treatment modalities selected for the patient. Documentation: Ask physician if they wish to have medications called to the pharmacy for the patient.””

“Therapeutic Activities CFR(s): Standard: Therapeutic Activities The hospital must provide a therapeutic activities program. This Standard is not met as evidenced by: 46958 Based on observation, interview, and record review, the hospital failed to ensure patient centered therapeutic activities were followed per posted “Weekly Activities Schedule (WAS)” for nine of 30 sampled patients (Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This failure had potential to negatively impact patient’s psychosocial well-being and not meet psychological needs. Findings: During a concurrent observation and interview on 8/14/24 at 9:30 a.m. with Risk Manager (RM) in unit 200, dayroom was closed and there were eight chairs in the hallway and no therapy/activity happening. RM stated, there is no activity going on at this time. During a concurrent observation and interview on 8/14/24 at 10:25 a.m. with RM in unit 200, there was no therapy group happening. Patients were observed sleeping in their rooms and walking in the hallway. RM stated there is no therapy group going on at this time. During an interview on 8/14/24 at 10:40 a.m. with Patient 4, Patient 4 stated since she has been at the facility, she has not been offered any activities. During a concurrent observation and interview on 8/14/24 at 11 a.m. with Registered Nurse (RN) 2 in Unit 200 hallway, there was no therapy group happening with the patients. RN 2 stated therapy group did not happen this morning. During an interview on 8/14/24 at 11:10 a.m. with RN 3, RN 3 stated patients have not been doing patio time for the last six days. RN 3 stated “Not having therapy is affecting mental health, but I am not sure how.” During an interview on 8/14/24 at 11:20 a.m. with Social Service Director (SSD), SSD stated the therapist who was supposed to be doing therapy group in unit 200 today, scheduled herself for another training and did not update him on the schedule conflict. SSD stated his expectations are for the activity schedule to be followed. SSD stated, “Recreational therapy should be offered. No Fresh air is being done. It is detrimental.” During a review of the unit’s “Adult Activity Schedule (AAS),” (undated), the “AAS” indicated, “Activity Group is from 9 a.m.-10 a.m., Therapy Group is from 10 a.m. - 11 a.m., 2nd Activity Group is from 1 p.m.- 2 p.m., and 2nd Therapy Group is 2 p.m.- 3 p.m.” During a concurrent observation and interview on 8/14/24 at 2:20 p.m. with Mental Health Worker (MHW) 1, in Unit 200, group therapy was not happening. MHW 1 stated patients did not get their fresh air break, activity group from 1 p.m.-2 p.m., and no therapy group from 2 p.m.-3 p.m. During a concurrent interview and record review on 8/15/24 at 8:30 a.m. with RM, Patient 11’s, “Group Notes (GN)”, 7/31/24- 8/5/24 was reviewed. The GN indicated, Patient 11 did not receive group therapy/activities on: 7-31-24 at 2 p.m.- 3 p.m. 8-1-24 at 10 a.m.- 11 a.m. 8-5-24 at 9 a.m.- 10 a.m. 8-5-24 at 10 a.m.- 11 a.m. 8-5-24 at 1 p.m.- 2 p.m. RM stated, “that means he [Patient 11] didn’t get any activities or therapy during those times.” During a concurrent observation and interview on 8/15/24 at 8:40 a.m. with RM in unit 200, chairs were being moved from hallway to dayroom. No activities were happening. RM stated dayroom should be open within the one hour. RM stated patients will miss activities until 10 a.m. During a concurrent interview and record review on 8/15/24 at 11:50 a.m. with RN 1, Patient 3’s “GN,” dated 8/5/24 was reviewed. The GN indicated, Patient 3 did not receive therapy or activities from 8:30 a.m.- 2 p.m. RN 1 stated there is no documentation confirming Patient 3 received therapy or activities 8:30-2 p.m. RN 1 stated “If it is not documented it is not done.” During a concurrent interview and record review on 8/15/24 at 2:50 p.m. with RN 1, Patient 7’s “GN,” dated 8/7/24-8/12/24 was reviewed. The GN indicated, Patient 7 did not receive group therapy/activities on: 8/7/24 at 1 p.m. - 2 p.m. and 2 p.m. - 3 p.m., 8/8/24 at 2 p.m.- 3 p.m., 8/9/24 at 1 p.m. - 2 p.m. 8/10/24 at 2 p.m. - 3 p.m. RN 1 stated there is no documentation that Patient 7 had group therapy/activities for the above dates and times. During a concurrent interview and record review on 8/15/24 at 3:10 p.m. with RN 1, Patient 8’s, “GN”, dated 8/1/24-8/7/24 were reviewed. The GN indicated, Patient 8 did not receive group therapy/activities on: 8/5/24 at 9a.m. -10 a.m., 10 a.m.-11 a.m., 12 p.m.-1 p.m., 1 p.m.-2 p.m. 8/6/24 at 2 p.m. - 3 p.m. RN 1 stated there is no documentation that Patient 8 had group therapy/activities for the above dates and times. During a current interview and record review on 8/19/24 at 10:06 a.m. with Chief Nursing Officer (CNO), Patient 4’s, “GN”, dated 8/14/24 was reviewed. The GN indicated, Patient 4 did not receive group therapy/activities on: 8/14/24 at 9 a.m.-10 a.m., 10 a.m.- 11 a.m. CNO stated there is no documentation that Patient 4 had group therapy/activities for the above date and times. During a current interview and record review on 8/19/24 at 10:30 a.m. with CNO, Patient 9’s, “GN”, dated 8/14/24 was reviewed. The GN indicated, Patient 9 did not receive group therapy/activities on: 8/14/24 at 9 a.m.-10 a.m., 1 p.m.-2 p.m. CNO stated there is no documentation that Patient 9 had group therapy/activities for the above date and time. During a current interview and record review on 8/19/24 at 10:40 a.m. with CNO, Patient 10’s, “GN,” dated 8/18/24 was reviewed. The GN indicated, Patient 10 did not receive group therapy/activities on: 8/18/24 at 9 a.m.-10 a.m., 10 a.m.-11 a.m., and 1 p.m.-2 p.m. CNO stated there is no documentation that Patient 10 had group therapy/activities for the above date and times. 42148 During a concurrent interview and record review on 8/19/24 at 10:47 a.m. with RM, Patient 5’s, “GN”, dated 8/14/24-8/15/24 was reviewed. The GN indicated, Patient 5 did not receive group therapy/activities on: 8-14-24 at 9 a.m.-10 a.m., 10 a.m.- 11 a.m., and 2 p.m.-3 p.m. 8-15-24 at 2 p.m.- 3 p.m.. RM stated there is no documentation that Patient 5 had group therapy/activities for the above dates and times. During a concurrent interview and record review on 8/19/24 at 11 a.m. with RM, Patient 12’s, “GN”, dated 8/13/24-8/14/24 was reviewed. The GN indicated, Patient 12 did not receive group therapy/activities on: 8-13-24 at 1 p.m.- 2 p.m. 8-14-24 at 10 a.m., 1 p.m. - 2 p.m., 2 p.m. - 3 p.m. RM stated there is no documentation that Patient 12 had group therapy/activities for above dates and times. During a review of the hospital’s policy and procedure (P&P) titled, “Therapeutic Group Intervention,” dated 4/27/22, the P&P indicated, “A formalized group schedule has been developed and is posted in each of the units for staff to follow. Each discipline is scheduled and required to provide group sessions at a designated time throughout the day.””

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 45654 The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.41 Physical Environment as evidenced by: 1. Based on observation, interview, and record review, the facility failed to maintain 1 of 3 portable air units (on unit 400) in proper working condition. (Refer to A 701, item 1). 2. Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature for patient rooms when the temperatures reached higher then acceptable ranges. (Refer to A 701, item 2). These failures resulted in placing patients at risk for heat related illnesses and mental distress. 3. Based on observation, interview, and record review, the facility failed to maintain a safe environment for two of seven units (unit 200 and unit 600) in the facility when walls had cracked and missing wall boards and loose ceiling tiles. This failure resulted in placing patients at risk for injury to self and others. (Refer to A 722). The cumulative effect of these systemic problems resulted in the hospitals inability to ensure quality health care in a safe and comfortable physical environment, in compliance with Conditions of Participation for Physical Environment.”

“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: 45654 Based on interview and record review the facility failed to ensure unit 500 (a locked secure unit patients found to be incompetent to stand trial) had completed contraband searches. This failure had the potential to endanger and physically harm patients and staff on the unit. Findings: During a concurrent interview and record review on 7/16/24 at 3:00 p.m. with Director of Quality (DOQ), the facility’s “Contraband Search Results (CSR), for unit 500 “dated 7/2/24 and 7/6/24 at 5:30 p.m., and dated 7/10/24 at 5:00 a.m. were reviewed. DOQ stated staff should be completing a contraband search each shift and documenting. During a concurrent interview and record review on 7/16/24 at 3:08 p.m. with Registered Nurse (RN) 2, facility’s CSR, dated 7/2/24, 7/6/24 and 7/10/24 was reviewed. The CSR indicated there were no contraband searches on: 7/2/24 no shift times, 7/6/24 no am night shift documentation, and 7/10/24 no day shift documentation. RN 2 confirmed the missing dates of documentation. RN 2 stated no staff had checked the unit for contraband on the dates reviewed. During a concurrent interview and record review on 7/16/24 at 3:24 p.m. with RN 1, facility’s CSR dated 7/2/24, 7/6/24, and 7/10/24 was reviewed. The CSR indicated there was no completed contraband searches on: 7/2/24 no shift times, 7/6/24 no am night shift documentation, and 7/10/24 no day shift documentation. RN 1 stated the normal process is to do a contraband check every shift. RN 1 stated she could not explain the missing documentation on contraband dates. During an interview on 7/16/24 at 3:55 p.m. with Chief Nursing Officer (CNO), CNO stated the process for contraband search for every shift was not followed. During a review of the facility policy and procedure (P&P) titled, “Contraband and Restricted Articles,” dated 7/27/22, the P&P indicated, “to ensure a safe environment. To provide a monitoring system for patients who are utilizing sharps or items designated as contraband.” During a review of “2024 Nursing Clinical Indicators (NCI),” dated 2024, the NCI indicated, “Compliance with Contraband Checks, Completed daily/shift.””

“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: 46958 Based on interview and record review, the facility failed to develop and evaluate a comprehensive care plan for two of 30 sampled patients (Patient 16 and Patient 25). This failure had the potential for unmet patients care needs. Findings: During a concurrent interview and record review on 7/16/24 at 1:20 p.m. with Chief Nursing Officer (CNO), the “Master Treatment Plan (MTP),” for Patient 19 dated 7/8/24 was reviewed. Patient 19 was in a manual hold (seclusion) on 7/11/24. The MTP for Patient 19 indicated, a treatment plan dated 7/15/24. CNO stated that MTP should’ve been reviewed within 24 hours. During a concurrent interview and record review on 7/16/24 at 2:05 p.m. with CNO, the “MTP,” for Patient 25 dated 7/5/24 was reviewed. The chart indicated, Patient 25 was in seclusion on 7/11/24. The MTP was not updated for seclusion. CNO stated that MTP should’ve been reviewed within 24 hours and documented. During the review of the facility’s policy and procedure (P&P) titled “Multidisciplinary Treatment Planning” dated 3/25/2022, the P&P indicated, “To provide a process and guidelines for implementation of a comprehensive, individualized multidisciplinary treatment plan for every patient. . .The plan shall be revised as soon as possible, but no later than 24 hours, following any major event such as a physical hold, suicide gesture or attempt or any clinical change in the patient’s presentation/status.””

“VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(i) If verbal orders are used, they are to be used infrequently. This Standard is not met as evidenced by: 46958 Based on interview and record review, the facility failed to ensure verbal order were signed by the physician with date and time according to the facility’s policy and procedure for one of 30 sampled patients (Patient 30). This failure had the potential for miscommunication that could result in errors and in unmet care needs. Findings: During a concurrent interview and record review on 7/16/24 at 3:20 p.m. with Chief Nursing Officer (CNO), Patient 30’s “Restraint/Seclusion orders for Violent Behavior (RS),” dated 7/9/24, was reviewed. The RS indicated, “Restraint Manual Hold 2 hours children ages 9-17.” The nurse obtained the order by telephone and the order was not signed by the physician. CNO stated the physician did not sign the order. During a review of the facility’s policy and procedure (P&P) titled, “Verbal Orders,” dated 10/28/2022, the P&P indicated, “Verbal/telephone orders must be co-signed/verified by a practitioner who is responsible for the care of the patient and is authorized to prescribe in accordance with state law and hospital policy. Verbal orders must be authenticated within the time-frame defined in the medical staff rules and regulations and as required by state law and regulations. (e.g. within 24 hours).””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 45654 Based on observation, interview, and record review, the facility failed to: 1. Maintain 1 of 3 portable air units (on unit 400) in proper working condition. 2. Maintain a safe and comfortable temperature for patient rooms when the temperatures reached higher then acceptable ranges. These failures resulted in placing patients at risk for heat related illnesses and mental distress. Findings: 1. During a concurrent observation and interview on 7/12/24 at 11:59 a.m. with Director of Quality (DOQ) in unit 400, portable air unit Air Rex Model # AHSE 14 temperature read “80.4 Fahrenheit (F) EK” on display screen. The unit was blowing warm air. DOQ stated water needs to be removed from the unit and then it will run cool air. DOQ stated no one dumped the water from the machine. During a concurrent observation and interview on 7/12/24 at 5:07 p.m. with Director of Plant Operation (DPO) on unit 400 was outside room 409, the portable air unit was off, no air blowing from unit. DPO stated,” the breaker is tripping and we can not get the air unit back up.” During a review of the facility’s policy and procedure (P&P) titled “Emergency Management & Disaster Plan,” dated 2024. The P & P indicated, “The hospital maintains a plan of care for patient’s during disruption of services to efficiently respond to a disaster that would require displacement of all or most patients at the hospital,” 2. During a concurrent observation and interview on 7/12/24 at 2:24 p.m. with DOQ in unit 300, with temperature infrared (thermometer which measures the temperature by radiation emitted) gun (model number 4th century), the following temperatures were reflected: Middle of hallway 84.7 F on unit 300. Back of hallway 85.6 F on unit 300. The DOQ made no statement. During an interview on 7/12/24 at 2:26 p.m. with Patient 16 in room 314, Patient 16 stated, “it’s hot.” During an interview on 7/12/24 at 2:27 p.m. with Patient 19 in room 315, Patient 19 stated, “It’s hot. I’m dying.” During a concurrent observation and interview on 7/12/24 at 2:28 p.m. with DOQ in unit 400 with temperature infrared gun, the following temperatures were reflected: Middle of hallway 80.0 F on unit 400. Back of hallway 86.7 F on unit 400. During a concurrent observation and interview on 7/12/24 at 2:45 p.m. with DOQ and Chief Nursing Officer (CNO) in unit 300, with temperature infrared gun, the following temperatures were reflected: Room 307, 86.3 F. Room 309, 86.1 F. Room 310, 86.0 F. Room 311, 86.5 F. Room 312, 87.0 F. Room 313, 89.0 F. Room 314, 89.0 F. Room 316, 94.0 F. Room 315, 88.0 F. During a concurrent observation and interview on 7/12/24 at 3:01 p.m. with DOQ and CNO in unit 400, with temperature infrared gun, the following temperatures were reflected: Room 407, 87.0 F. Room 408, 82.0 F. Room 409, 87.0 F. Room 410, 83.0 F. Room 411, 88.0 F. Room 412, 88.0 F. Room 413, 89.0 F. Room 414, 87.0 F. Room 415, 90.0 F. Room 416, 88.0 F. During an interview on 7/12/24 at 3:55 p.m. with Patient 9, Patient 9 stated it is very hot in here and being on the unit, makes me confused. During an interview on 7/12/24 at 3:56 p.m. with Patient 31, Patient 31 stated the heat on unit 300 makes me feel sleepy. During an interview on 7/12/24 at 3:58 p.m. with Patient 15, Patient 15 stated, “It’s so hot I could die.” During an interview on 7/12/24 at 3:59 p.m. with Patient 13, Patient 13 stated,”I can’t sleep on the unit.” During an interview on 7/12/24 at 4:00 p.m. with Patient 32, Patient 32 stated “It’s hot.” During an interview on 7/12/24 at 4:02 p.m. with Patient 19, Patient 19 stated “It’s hot,” on the unit. During an interview on 7/12/24 at 4:07 p.m. with Patient 33, Patient 33 stated she has depression and the heat could make me overdose. During an interview on 7/12/24 at 4:09 p.m. with Patient 16, Patient 16 stated, “It’s hot,” on the unit and it’s hard to sleep. 46958 During an interview on 7/12/24 at 4:10 p.m. with Patient 4, Patient 4 stated it is very hot here. During an interview on 7/12/24 at 4:35 p.m. with Patient 34, Patient 34 stated it is hot here the heat is making me mad, and I can’t sleep at night. During an interview on 7/12/24 at 4:55 p.m. with Patient 35, Patient 35 stated the heat is making me frustrated and making me dehydrated. During a concurrent observation and interview on 7/12/24 at 5:05 p.m. with DPO in unit 400, with temperature infrared gun the following temperatures were reflected: Hallway on unit 400 temperature was 86.1 F. Room 407, 86.5 F. Room 408, 82.5 F. Room 409, 87.0 F. Room 410, 83.0 F. Room 412, 86.0 F. Room 411, 88.0 F. Room 414, 87.0 F. Room 413, 88.0 F. Room 415, 91.0 F. Room 416, 85.0 F. End of the hallway on unit 400 90.0 F. Seclusion room on unit 300 86.0 F with door open. Seclusion room on unit 400 86.0 F with door open. During a concurrent observation and interview on 7/12/24 at 5:20 p.m. with DPO in unit 300, with temperature infrared gun, the following temperatures were reflected: Room 307, 85.0 F. Room 310, 87.0 F. Room 309, 85.0 F. Room 312, 85.0 F. Room 307, 85.0 F. Room 311, 85.0 F. Room 314, 85.0 F. Room 316, 89.0 F. Room 313, 86.0 F. Room 315, 84.0 F. During a review of the facility’s policy and procedure (P&P) titled, “Temperature and Humidity Monitoring,” dated 5/2021, the P&P indicated, “The purpose of this policy is to provide guidelines for an optimal environment for patient care areas. 2. Any variances in temperatures and/or humidity trends that fall outside the accepted range requires prompt action.” During a review of the facility’s P &P titled, “Indoor Air Quality,” dated 4/28/23, the P& P indicated, [facility] has a preferred range from 68 to 78 degrees.””

“FACILITIES CFR(s): 482.41(c) (d) Standard: Facilities. The hospital must maintain adequate facilities for its services. This Standard is not met as evidenced by: 45654 Based on observation, interview, and record review the facility failed to maintain a safe environment in the facility when walls had cracked and missing wall boards, and loose ceiling tiles. This failure resulted in placing patients and staff at risk for injury to self and others. Findings: During a concurrent observation and interview on 7/15/24 at 8:56 a.m. with Plant Operations (PO) 1 in unit 200, the wall baseboard had a 1 inch by 2 ¼ inch crack. PO 1 stated it was a hazard, and patients and can stick their fingers in it. During a concurrent observation and interview on 7/15/24 at 9:04 a.m. with PO 1 in unit 600 (a locked secure unit for patients found incompetent to stand trial ), ceiling tile lifted out of place to the left of the wall. There was a cracked ceiling tile above patient door entry. PO 1 stated the younger patients tend to jump and knock the ceiling tile out of place. PO 1 stated it was a safety issue. During an interview on 7/15/24 at 9:06 a.m. with Registered Nurse (RN) 1, RN 1 stated no one reported the cracked ceiling tiles on the unit. During a record review of the facility’s policy and procedure (P &P) titled, “Plant Operations (Wall Penetrations),” dated 10/29/15, the P&P indicated, “Plant Operation craft workers are to repair penetrations they may find in the immediate area where they may be working.” During a record review of the facility’s policy and procedure (P&P) titled, “Plant Operations,” dated 10/29/15, the P&P indicated, “The plant operations department shall maintain all equipment in a safe condition so that it will minimize all health hazards in the hospital for the protection of patients, visitors, and employees.””