Aliso Ridge Behavioral Health, LLC

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 22553 Based on record review and interview, the hospital failed to provide documented evidence that its P&P was implemented for the Master Treatment Plan Review (MTPR) for one of six sampled patients (Patient A). This failure resulted in a substandard patient care environment for hospital inpatients. Findings: During a review of the hospital’s P&P titled “Master Treatment Plan,” dated 10/2025, the P&P showed each patient admitted to the hospital shall have a written, individualized Master Treatment Plan (MTP) that identifies a plan of care addressing the patient’s needs and objectives. Treatment shall be planned, reviewed, and evaluated at regular intervals by a multidisciplinary team. Treatment planning must include communication among team members to ensure consistency and continuity of care. The Treatment Plan Review must include a patient statement and provider recertification of the level of care. Patients are to be given an opportunity to participate in treatment planning, and interventions must be explained to them. Patients shall sign the Master Treatment Plan Review in the electronic medical record after reviewing it with a treatment team member, and signatures should occur on the same day as the Treatment Team Meeting whenever possible. During a review of Patient A’s medical record on 6/3/26. The medical record showed Patient A was admitted on 3/2/26. During a review of the MTPRs dated 3/9/26, 3/11/26, and 3/16/26, the MTPRs showed the required statement for Physician Recertification of Inpatient Level of Care, which read: “I certify that this patient is inpatient psychiatric hospital admission is medically necessary for treatment which can reasonably be expected to improve the patient’s condition and/or for diagnostic study.” However, for all three dates, the fields labeled “physician who needs to confirm” and “physician signature/date/time” were blank, indicating that the required physician review and recertification were not document. During a review of the MTPR dated 3/16/26, the MTPR showed Patient A’s signature in the Patient/Guardian Statement section, which read: “I have reviewed and/or made additions to my treatment plan. I have been given the opportunity to participate in planning my care and to ask questions of the staff, and have received explanations regarding treatment.” However, the date and time fields were blank, preventing verification that the patient reviewed the plan on the day of the Treatment Team Meeting as required. During an interview with SW 1 on 6/4/26 at 1420 hours, SW 1 stated when Patient A signed the document electronically, the system should automatically populated the date and time. SW 1 stated they were responsible for entering the name of the physician assigned to the patient in the “physician who needs to confirm” field, which then routes the document to the physician’s inbox for review and signature. SW 1 stated they were unable to track whether the physician completes the review or signature but confirmed it was the SW’s responsibility to ensure the MTPR was completed.”

“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: 38660 Based on interview and record review, the hospital failed to implement their P&P for two of six sampled patients (Patients D and B) as evidenced by: 1. For Patient D, the hospital failed to ensure that medical consultation requests were followed up on and completed after Patient D’s reported genital pain and following an allegation of sexual abuse. This failure placed the patient at risk for delayed assessment and substandard clinical outcomes. 2. For Patient B, the hospital failed to implement its P&P related to safeguarding personal belongings, creating a substandard patient care environment. Findings: 1. During a review of the hospital’s P&P titled History and Physicals/Consultation Requests dated 10/2025, the P&P showed “Nursing staff from units will be responsible for notifying the medical provider of all new admits and of any consultation requests made by staff. The medical provider will check the Daily Admission Report for all H&P. Consults that need to be done. Once the exam is completed, the medical provider will initial that the consult is complete.” During a concurrent interview and review of Patient D’s medical record on 6/4/26 at 1025 hours, with the Nurse Manager 1, Patient D’s medical record showed Patient D was admitted to the hospital on 4/5/26 due to self-harm. During a review of the Consultation Request date 4/11/26 at 1508 hours, the Consultation Request showed nursing staff requested a medical consultation for Patient D. The Reason for Consultation was “Patient complaining of burning and pain in the genital area. Patient is guarding the genital area and is crouched down moaning in the dayroom on multiple occasions.” During a review of the nurse’s Progress Note dated 4/13/26 at 1651 hours, the Progress Note showed Patient D’s family member informed administration/ risk management staff that Patient D said a person named “ARK” raped him. Patient D could not identify if “ARK” was a peer or adult, nor report the perpetrator’s gender. During a review of the Consultation Request date 4/13/26 at 1510 hours, the Consultation Request showed nursing staff requested a medical consultation for Patient D. The Reason for Consultation was “Patient made accusations of sexual abuse. Please assess.” During a concurrent interview and review of Patient D’s medical record on 6/4/26 at 1336 hours, with RN 1 regarding the hospital’s process of handling sexual abuse. RN 1 stated they notified the sexual abuse case to the House Supervisor, the Nurse Manager, the social worker and the physician; requested a medical consultation and informed the family. Due to Patient D’s psychosis, RN 1 was unable to assess patient, a medical consultant was requested to evaluate the patient. The physician on call was contacted, the medical request was flagged in the chart, and RN 1 endorsed to the night shift nurse. During a concurrent interview and review of Patient D’s medical record on 6/4/26 at 1400 hours, with Nurse Manager 1, Nurse Manager 1 confirmed there was no documentation showing the medical consultant request had been followed up on or that Patient D had been assessed by the medical consultant following the patient’s report of burning and pain in the genital area on 4/11/26 and the allegation of sexual abuse on 4/13/26. 22553 2. During a review of the hospital’s P&P titled “Belongings and Valuables,” dated 10/2025, the P&P showed all providers and staff working in the hospital to include inpatient and outpatient services. The policy is to identify a system by which a patient’s belongings and valuables are appropriately inventoried and stored throughout hospitalization and safely returned to the patient at the time of discharge. A. Belongings Anytime a patient brings belongings onto the unit, they must be thoroughly searched by a staff member. Belongings Inventory After the belongings search is completed, each item is to be listed on the patient’s belongings sheet. The location of the patient’s belongings must be documented on the belongings sheet (e.g., with patient, in safe, in bin, in storeroom, in nurses’ station). Any large items must be bagged, tagged with the patient’s identification sticker, and placed in the storage room. Return of Belongings and Valuables All belongings must be returned to the patient at the time of discharge. It is the patient’s responsibility to request all items. Both the patient and staff must sign the bottom of the belongings sheet at the time items are returned. During a review of Patient’s B medical record on 6/3/26, the medical record showed Patient B was admitted on 3/5/26 and discharged on 3/13/26. During a review of Patient B’s admission surveillance footage on 6/13/26 at 1310 hours, the surveillance footage showed Patient B was escorted to the hospital on 3/5/26 at 2214 hours. The admission MHW received a black backpack and a brown paper bag from the EMT worker and brought both items into the intake room. During a review of Patient B’s Patient Valuables Form on 6/3/26 at 1104 hours, the Patient Valuables Form (Inpatient Contraband/Inventory, Intake) for both the 3/5/26 admission and 3/13/26 discharge did not list a black backpack. During an interview with Nurse Manager 2 on 6/3/26 at 1333 hours, Nurse Manager 2 stated Patient B was readmitted on 4/6/26. During that stay, Patient B reported the loss of a black backpack from the previous admission. Nurse Manager 2 located the backpack, and it was returned to the patient at discharge along with a large brown bag containing sweaters and a beanie. During an interview with RN 3 on 6/3/26 at 1424 hours, RN 3 stated on 3/13/26, the day of Patient B’s discharge, the patient inquired about the missing backpack. RN 3 searched the patient room, unit, and other units but was unable to locate it. RN 3 instructed the patient to leave contact information and reported the concern to the House Supervisor. RN 3 stated that a few days after discharge, MHW 1 informed RN 3 that the backpack had been found. RN 3 saw the backpack and notified the House Supervisor to contact the patient. RN 3 could not confirm whether follow up communication occurred. During an interview with MHW 1 on 6/3/26 at 1445 hours, MHW 1 stated that on the day of discharge, Patient B was frustrated about the missing backpack, and it was not listed on the belongings inventory. MHW 1 reported the issue to the RN overseeing the discharge. MHW 1 explained that the patient could file a grievance, which would be forwarded to Performance Improvement. Upon reviewing the Release of Property at Discharge documentation for 3/5/26 and 3/13/26, MHW 1 noted that the patient was discharged on 3/13/26 with only one black shirt and blue jeans. MHW 1 signed and dated the form but stated there was no acknowledgment or initials documenting belongings from 3/5/26. During an interview with the Executive Assistant and Communications Manager on 6/3/26 at 1519 hours, the Executive Assistant and Communications Manager confirmed that the hospital had no documentation related to Patient B’s missing personal property, no report from the patient, no record from the House Supervisor, and no nursing documentation indicating that the backpack was lost or located. During an interview with the CNO on 6/3/26 at 1610 hours, the CNO stated the hospital did not have a system in place to ensure follow up on patients’ lost-and-found belongings as required. During an interview with the Nurse Manager 1 on 6/3/26 at 1104 hours, Nurse Manager 1 also reviewed the Patient Valuable Forms for Patient B’s closed record. The Release of Responsibility for Valuables showed Patient B’s signature, but the date and time fields were left blank. Additionally, two staff signatures in Section 2: Other Valuables (Safe) did not include the required time. Nurse Manager 1 confirmed the above findings.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 38660 Based on interview and record review, the hospital failed to ensure each unit always maintained the required number of licensed nurses on 3/1, 3/7, and 4/5/26 during the PM shift as mandated by the hospital’s P&P Staffing Patterns and Patient Acuity policy, Staffing Matrix, and the California Code of Regulations (CCR) Title 9. Although the Daily Assignment sheets showed four RNs scheduled per unit in accordance with the census, the hospital did not ensure that staff remained compliant during break periods or after early departures. These failures demonstrated that the hospital did not maintain the required nurse-to-patient ratios throughout the entire shift and did not ensure continuous compliance with staffing requirements, including coverage during breaks. As a result, the hospital was not in compliance with its own P&P and Title 9 staffing requirements, placing patients at risk for substandard care. Findings: During a review of the hospital’s P&P titled “Staffing Patterns and Patient Acuity,” revised October 2025, the P&P showed all shifts on each unit, are to be staffed using the staffing matrix,” in accordance with Title 9 guidelines. During a review of the hospital’s Staffing Matrix, revised February 2025, the PM Staffing Guidelines were shown follows: 1-10 patients = 2 RNs per unit 11-15 patients = 3 RNs per unit 16-20 patients = 4 RNs per unit 21-25 patients = 5 RNs per unit 26-28 patients = 6 RNs per unit During an interview and record review with the CNO and Nurse Managers 1 and 2 on 6/2/26 at 1343 hours, Nurse Manager 1 stated all units had a nurse-to-patient ratio of 1:5 with all RNs. Resource nurses assisted with breaks in some shifts. If there were no resource nurses, the House Supervisor or Nurse Managers covered breaks. a. During a review of the Nursing Department Daily Assignment on 3/1/26, for PM shift, the Nursing Department Daily Assignment showed: The census for Unit 1 West was 20 and four RNs were on duty The census for Unit 1 East was 17 and four RNs were on duty The census for Unit 2 West was 20 and four RNs were on duty The census for Unit 2 West was 20 and four RNs were on duty The census for Specialty unit was 19 and four RNs were on duty. During a review of the PM Break Assignments on 3/1/26, the PM Break Assignments showed: * Unit 1 West: RNs recorded 30-minute meal breaks at 0230, 0330, and 0400 hours. At 0300 hours, two RNs were on their 30-minute meal break at the same time. Unit 1 East: RNs recorded 30-minute meal breaks at 0030, 0200, 0300, 0330, 0400, and 0430 hours. At 0300 hours, two RNs were on their 30-minute meal break simultaneously. Unit 2 West: RNs recorded 30-minute meal breaks at 0200 and 0300 hours. At 0230 hours, two RNs were on their 30-minute meal break simultaneously. b. During a review of the Nursing Department Daily Assignment for PM shift, on 3/7/26, the Nursing Department Daily Assignment for PM shift showed: Unit 1 West: census 20; four RNs on duty Unit 1 East: census 16; four RNs on duty Unit 2 West: census 20; four RNs on duty Unit 2 East: census 15 at start of PM shift; 20 at end of shift; four RNs on duty Specialty Unit: census 20; four RNs on duty. During a review of the PM Break Assignments on 3/7/26, the PM Break Assignments showed: Unit 1 West, one RN took 30 minutes break at 0030, 0130, 0200, 0230, and 0300 hours. Unit 1 East, one RN took 30 minute break at 0330, 0400 and 0430 hours, and two RNs had their 30 minute break at 0300 hours. Unit 2 West, one RN took 30 minute break at 0100, 0300, 0330, 0400, and 0430 hours. Unit 2 East, one RN took 30 minutes break at 0300, 0330, 0400, and 0430 hours. Specialty Unit, one RN took 30 minute break at 0100, 0200, 0300, 0400, and 0430 hours, and two RNs had their 30 minute break at the same time 0330 hours. c. During a review of the Nursing Department Daily Assignment dated 4/5/26, the Nursing Department Daily Assignment for PM shift showed: Unit 1 West: census 16; four RNs on duty Unit 1 East: census 19; four RNs on duty Unit 2 West: census 18; four RNs on duty Unit 2 East: census 16 at start of PM shift; 17 at end of PM shift; four RNs on duty Specialty Unit: census 20 at start of shift; 19 at end of shift; four RNs on duty During a review of the PM Break Assignments on 4/5/26, the PM Break Assignments showed: * Unit 2 East, one RN took 30 minutes meal breaks at 0300, 0330 and 0400 hours. * Specialty Unit, one RN took 30 minute break at 0300, 0330, and 0430 hours, and two RNs took theirs 30 minutes meal break at 0400 hours. During an interview with Nurse Managers 1 and 2 on 6/3/26 at 0955 hours, Nurse Manager 1 stated the daily staffing was determined by the patient matrix, rather than acuity. On 3/1/26, 3/7/26, and 4/5/26 PM shifts, there were no resource nurses available to cover breaks in Unit 1 West, 1 East, 2 West, 2 East, and Specialty Unit; these units did not have four nurses during break periods. During a review of the Daily Staffing sheet dated 4/5/26, the Daily Staffing sheet showed RN 2 was assigned to Unit 2 East, worked from the start of the AM shift into the PM shift, and left at 2300 hours. RN 3 was assigned to Unit 2 West, worked from the start of the AM shift into the PM shift, and left at 0100 hours. After these two RNs left, Unit 2 West and 2 East had three RNs remaining on duty during PM shift. The Nurse Manager 1 and 2 verified the above findings.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the nursing staff followed the physician’s order for laboratory blood test for one of four sampled patients (Patient 1). This failure increased the risk for substandard outcomes for this patient. Findings: During a review of the hospital’s P&P titled, “Transcribing Provider Orders” dated 10/2025, the P&P showed it is the hospital’s policy to accept and carry out written and telephone orders for medication related orders and treatments. During a concurrent interview and review of Patient 1’s medical record on 4/1/26 at 1110 hours, with the CNO, Patient 1’s medical record showed Patient 1 was admitted to the hospital on 2/13/26 and was discharged on 2/20/26. During a review of the physician’s order dated 2/13/26 at 0918 hours, the physician’s order showed Patient 1 had the orders for Lipid Panel and TSH laboratory blood tests. During a review of the Progress Note dated 2/20/26 at 0648 hours, the Progress Note showed Patient 1 cooperated during the laboratory blood draw; two attempts were unsuccessful with little to no blood return. The morning shift staff would follow up to complete the laboratory blood tests. During a concurrent interview and review of Patient 1’s medical record on 4/1/26 at 1600 hours with the CNO, the CNO stated the order for TSH and Lipid were included in the admission order. The CNO confirmed there was no documentation showing the physician’s orders for Lipid Panel and TSH laboratory blood tests were carried out between 2/13 and 2/20/26, nor there was any records showing Patient 1 refused the laboratory tests.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the nursing staff implemented its P&P for managing head lice for one of four sampled patients (Patient 3) by not performing an admission assessment for lice, not reassessing Patient 3 within 24 hours after treatment, and not notifying the physician to discontinue isolation. As a result, Patient 3 remained in isolation unnecessarily, missing the Halloween celebration and multiple group therapy sessions, which negatively impacted socialization and contributed to feelings of withdrawal, depression, and anxiety. Findings: During a review of the hospital’s P&P titled Scabies or Pediculosis Management dated October 2025, the P&P showed all patient will be assessed for lice and scabies on admission. Any patient with suspected or confirmed pediculosis or scabies shall be placed on Contact Precautions automatically and reported to unit director and Infection Control Department for appropriate follow up. The patient should be placed in contact isolation until 24 hours after appropriate treatment, preferably in private room; and instructed to take a bath or shower after applying the medication according to the Manufacturer Recommendations. Review of the Elimite: Package Insert/Prescribing Info showed Elimite (permethrin) 5% cream is a topical scabicidal agent for the treatment of infestation with scabies. The Elimite Dosage and Administration section showed to thoroughly massage Elimite 5% cream into the skin from the head to the soles of the feet; the cream should be removed by washing (shower or bath) after eight to 14 hours; one application is generally curative. During a review of Patient 3’s medical record on 12/15/25 at 0900 hours, with the Director of Performance Improvement and Risk Management and Nurse Managers 1 and 2, Patient 3’s medical record showed Patient 3 was admitted to the hospital on 10/29/25, for suicidal and danger to self and discharged on 11/1/25. During a review of the Nurse Admission Assessment dated 10/29/25 from 1325 hours to 1340 hours, the Nurse Admission Assessment did not include the head lice assessment for Patient 3. During the review of the Group Note dated 10/30/25 from 1600 to 1700 hours, the Group Note showed Patient 3 actively participated in gym groups including basketball, volleyball, soccer, and yoga. Patient 3 interacted appropriately with peers and did not require verbal redirection. Patient 3 demonstrated an understanding of the group’s purpose by engaging with sports equipment and participating in activities. Review of the Group Note dated 10/30/25 from 1700 to 1800 hours, showed Patient 3 actively participated in a one-on-one quiz, discussions and group information about treatment and goals, acknowledged the benefits of attending therapeutic groups, coping skills, ADLs, meeting with therapists/psychiatrists, and collecting prizes and stamps. During a review of the Order dated 10/30/25 at 1622 hours, the Order showed the order for permethrin (same as Elimite) external 1% lotion, external use once for the treatment of lice, one bottle for one application. During a review of the nurse’s Progress Note dated 10/30/25 at 1912 hours, the Progress Note showed patient’s family member was informed Patient 3 was found to have head lice, one time treatment was ordered by the physician and completed. Patient 3 was placed on isolation precautions per facility protocol. During a review of the Psychiatric Progress Note dated 10/31/25 at 0900 hours, the Psychiatric Progress Note showed Patient 3 was withdrawn and isolated due to having lice. Patient 3 reported depression and anxiety and was unable to contract for safety. During the review of the Group Notes dated 10/31/25, the Group Notes showed the following: * From 0930 to 1030 hours, Patient 3 could not attend the group session due to isolation precautions. The therapist provided Patient 3 with the group workout. * From 1100 to 1200 hours, Patient 3 was on room restriction for active lice infection and given activities to work instead of group activities. * From 1330 to 1430 hours, Patient 3 could not join in group session due to contact precautions. Patient 3 met one on one to discuss the benefits of group participation, provided supplemental materials, and educated the benefits of participating in future groups. * From 1500 to 1600 hours, Patient 3 missed the group session due to isolation precautions. The therapist attempted to meet one-on-one to discuss friendships and healthy versus unhealthy boundaries. * From 1600 to 1700 hours, Patient 3 was on isolation due to an active lice infection and received treats and prizes from the Halloween party. * From 1700 to 1800 hours, Patient 3’s behavior showed a calm effect upon approach. Patient 3 refused discussion on the benefits of attending therapeutic group, coping skills, ADL, and meeting with therapists/ psychiatrists stating “no.” During a review of the Discharge Summary dated 11/4/25 at 0746 hours, the Discharge Summary showed Patient 3 was assessed on 11/1/25 at 1000 hours. Patient 3 was isolated to room due to lice and received group therapy paperwork. Patient 3 was stable with an improved mood, no signs of irritability or dangerousness, better sleep, motivated to get better, and satisfaction with the aftercare plan. Patient 3 could benefit from further hospitalization. Patient 1’s family member wanted to take patient AMA due to isolation. During a telephone interview with the IP on 12/15/25 at 1055 hours, the IP stated Patient 3 had head lice and was placed on contact isolation. The treatment followed manufacturer’s recommendations. The IP stated Patient 3 was instructed to shower after treatment and the linen and room were cleaned. Patient 3 was checked within 12 to 24 hours. Isolation could continue beyond 24 hours if necessary and if Patient 3 was not clear. The nurse could notify the physician to get the verbal order to discontinue the isolation. During an interview with the Therapist with the present of the Director of Performance Improvement and Risk Management and Nurse Managers 1 and 2 on 12/15/25 at 1130 hours, the Therapist stated she helped with morning and afternoon group therapy for seven hours. The Therapist stated when patients were in contact isolation, the therapist would not go into patient’s room, but meet patients at their door to provide activities schedule, group worksheet and drawings. Discontinuation of isolation was discussed every morning in the treatment team meetings. During an interview with the Director of Performance Improvement and Risk Management, Nurse Manager 1 and 2 on 12/15/25 at 1138 hours, the Director of Performance Improvement and Risk Management confirmed no head lice assessment was conducted on admission and 24 hours post treatment to clear the patient from isolation. The Director of Risk Management confirmed the nurse did not inform the physician to discontinue isolation as per their P&P, causing Patient 3 to miss the Halloween celebration and group sessions.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure one of seven sampled patients (Patient 2) grievance was promptly processed according to the hospital’s P&P. This failure created the risk of unresolved safety and quality concerns and substandard patient care for patients. Findings: During a review of the hospital’s P&P titled, “Grievances and Complaints” dated 1/20/25, the P&P showed: * Grievance is defined as the written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights, hospital compliance with regulatory agencies, or if the patient requests a formal written response to their concern. * All internal complaints and grievances are to be submitted verbally or in writing to the hospital staff, either by the patient, the patient’s representative, or a staff member if a patient is unable to execute a written complaint. * Follow-up will begin with the Court Liaison Quality Department Coordinator/Designee upon receipt of the complaint. The Court Liaison Quality Department Coordinator/Designee will interview all individuals with knowledge of events surrounding the complaint. * Based on the results of the investigation, the Court Liaison Quality Department Coordinator/Designee will take immediate steps to resolve or rectify the situation or refer the issue to the appropriate department head for further analysis and appropriate action. The Court Liaison Quality Department Coordinator/Designee will respond, verbally and in writing to the person about the action being taken on his/her complaint within seven days of receipt of the complaint for significant issues. The written response must include hospital name, name of contact person, steps taken to investigate the complaint, results of complaint process, and date of completion. During a review of the Grievance Log for August 2025, the Grievance Log showed no grievance was filed. During a review of Patients 2 and Patient 3’s closed medical records on 9/29/25 starting at 1100 hours, Patients 2 and 3’s medical records showed the following: * Patient 2’s medical record showed Patient 2 was admitted to the hospital on 8/3/25 and discharged on 8/19/25. * Patient 3’s medical record showed Patient 3 was admitted to the hospital on 8/4/25 and discharged on 9/11/25. - During a review of Patient 3’s Progress Note dated 8/9/25 at 1638 hours, the Progress Notes showed Patient 3 was sexually acting out with peers. - During a review of Patient 3’s Psychiatric Progress Note dated 8/9/25 at 1928 hours, the Psychiatric Note showed Patient 3 was sexually acting out by touching another patient’s private part and was not on 1:1 observation. During an interview with RN 1 in the presence of the CNO on 9/29/25 at 1408 hours, RN 1 stated Patient 3 touched Patient 2’s private part during group therapy on 8/9/25 and RN 1 reported the incident to the house supervisor. During an interview with the Director of Quality on 9/30/25 at 0852 hours, the Director of Quality stated Patient 2 reported the incident on 8/12/25. The Director of Quality did not consider it a grievance and verified the grievance process was not followed.”

“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: 35310 Based on interview and observation, the hospital failed to ensure the master treatment plans (MTP) were updated as per the hospital’s P&P for one of seven sampled patients (Patient 3). These failures created the risk of substandard healthcare outcomes to the patients in the hospital. Findings: Review of the hospital’s P&P titled, “Master Treatment Plan,” dated October 2024 showed within 72 hours of admission, members of the treatment team shall further develop the MTP that is based on a comprehensive assessment of the patient’s presenting problems, physical health, and emotional and behavioral status. The Team will consist of the provider, nursing staff, social services staff, adjunctive therapy staff, and other clinical disciplines, as appropriate. The master treatment plan review shall be reviewed within seven days of completion, with the exception of significant events which should be updated within 24 hours. The treatment plan review shall include new issues, updates to problems/goals as identified in the master treatment plan form. During a review of Patient 3’s closed medical record on 9/29/25 starting at 1100 hours, the medical record showed Patient 3 was admitted to the hospital on 8/4/25 and discharged on 9/11/25. Review of the Master Treatment Plan dated 8/5/25, showed “sexual acting out” was identified as initial problem #1. The Psychiatric Problem Sheet for problem #1 dated 8/5/25, documented interventions for attending psychiatrist, nursing, social services, and activity therapy. During a review of the Progress Note for Patient 3 dated 8/9/25 at 1638 hours, the Progress Note showed Patient 3 was sexually acting out with peers. After the incident, Patient 3 was directed to their room and educated about appropriate behavior. The NP was notified, and one-to-one supervision was ordered. During a review of the Psychiatric Progress Note for Patient 3 dated 8/9/25 at 1928 hours, the Psychiatric Progress Note showed Patient 3 was sexually acting out by touching another patient’s private part and was now on 1:1 observation. During an interview with RN 1 in the presence of the CNO on 9/29/25 at 1408 hours, RN 1 stated Patient 3 touched Patient 2’s private part during the group therapy on 8/9/25. During an interview and concurrent medical record review with the CNO on 9/30/25 at 0920 hours, the CNO stated the MTP review was to be done every seven days after the initial MTP or after any event. The CNO further stated there was no updated MTP review after the event and no regular MTP review every seven days. The CNO verified the findings.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure one of seven sampled patients (Patient 2) sexual assault was reported to the CDPH within 24 hours after the detection. This failure had a risk of delaying the investigation of the event and of violating the patient’s rights. Findings: During a review of the hospital’s P&P titled, “Incident Reports: Classification System,” revised 3/12/25, the P&P showed the following: VI. Reporting: Pursuant to Health and Safety Code sections 1279.1 and 1279.3, adverse events shall be reported by the hospital through a secure internet website maintained by the Department pursuant to the following timelines: * Adverse events that are ongoing, urgent or emergent, threatening the welfare, health, or safety of patients, personnel, or visitors, shall be reported within 24 hours after the adverse event is detected. * Sexual assault of a patient, including allegations of sexual assault of a patient, provided for under Health and Safety Code section 1279.1 (b)(6)(C), shall be reported within 24 hours after the detection. During a review of Patients 2 and Patient 3’s closed medical records on 9/29/25 starting at 1100 hours, Patients 2 and 3s medical records showed the following: * Patient 2’s medical record showed Patient 2 was admitted to the hospital on 8/3/25 and discharged on 8/19/25. * Patient 3’s medical record showed Patient 3 was admitted to the hospital on 8/4/25 and discharged on 9/11/25. - During a review of the Progress Note for Patient 3 dated 8/9/25 at 1638 hours, Patient 3 was documented as sexually acting out with peers. - During a review of the Psychiatric Progress Note for Patient 3 dated 8/9/25 at 1928 hours, Patient 3 was documented as sexually acting out by touching another patient’s private part. During an interview with RN 1 in the presence of the CNO on 9/29/25 at 1408 hours, RN 1 stated Patient 3 touched Patient 2’s private part during the group therapy on 8/9/25. RN 1 further stated after the incident, he reported to the house supervisor. During an interview with the Director of Quality on 9/30/25 at 0852 hours, the Director of Quality stated Patient 2 reported the incident on 8/12/25, and the incident was reported to the CDPH on the same day. When asked about the reporting system, the Director of Quality stated front line staff reported to the supervisors, the supervisors reported to Quality Department, then the Quality Department reported to the CDPH. The Director of Quality verified the house supervisor did not report the incident.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure one of seven sampled patients (Patient 6) was monitored while in seclusion as per the hospital’s P&P. This failure posed a risk to patient safety due to the lack of timely monitoring and clinical evaluation during seclusion. Findings: During a review of the hospital’s P&P titled Seclusion/Restraint revised 2/25, the P&P showed the RN will assign a trained staff person to monitor the patient face-to-face and document the patient’s condition and response at least every fifteen minutes on the restraint/seclusion record. The patient in restraint/seclusion will be monitored continuously after being placed in physical restraints/seclusion by a team of staff members. The RN will continually assess the patient for release from restraints/seclusion. Assess the Patient’s need for food and fluids: Offer patient food/fluid at mealtimes, offer supplemental fluids every fifteen minutes...Assess the patient’s toileting needs: Offer the patient opportunities to use the toilet facilities at least every fifteen minutes and on patient’s request. Observation Record includes: continue to document every fifteen minutes, or as ordered by provider noted; and all nursing care and interventions, i.e. fluids, toileting, skin and circulation checks, ROM, meals and vital signs. During a review of Patient 6’s closed medical record on 9/29/25, Patient 6’s medical record showed Patient 6 was admitted to the hospital on 8/16/25 and discharged on 9/3/25. During the review of the document titled “(Standardized) Seclusion/Restraint,” the document showed Patient 6 was ordered to place in seclusion for four hours due to being an imminent danger to others on 9/1/25 at 1205 hours. The document showed Patient 6 was placed in seclusion from 9/1/25 at 1200 hours to 9/1/25 at 1305 hours (1 hour and 5 minutes). During an interview and on 9/30/25 at 0945 hours with the CNO, a request was made for Patient 6’s Seclusion/Restraint Flowsheet from the time Patient 6 was in seclusion on 9/1/25 from 1200 to 1305 hours (1 hour and 5 minutes). The CNO was unable to provide the document and was unable to show Patient 6 was monitored while in seclusion as per the hospital’s P&P. On 9/30/25 at 1025 hours, the CNO was notified and acknowledged the above findings.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure an adequate number of licensed nurses was maintained for Unit A on 9/2/25 PM shift as per the hospital’s Staffing Matrix. This failure had the potential for poor patient outcomes. Findings: Review of the hospital’s P&P titled Staffing Patterns and Patient Acuity revised March 2025 showed all shifts on each unit, are to be staffed using the staffing matrix, in accordance with title IX guidelines. Review of the hospital’s document titled Staffing Matrix revised August 2025 showed PM Staffing Guidelines as follows: * 1-10 patients = 2 RNs per unit * 11-15 patients = 3 RNs per unit * 16-20 patients = 4 RNs per unit * 21-25 patients = 5 RNs per unit * 26-28 patients = 6 RNs per unit During a record review on 9/29/25 at 1100 hours, the Nursing Department Daily Assignment dated 9/2/25 was reviewed. The Nursing Department Daily Assignment showed the census for Unit A at the start of the PM shift was 19. The census of Unit A at the end of the PM shift was 20. The document showed four RNs were on duty on the AM and PM shifts; RN 9 was on duty in Unit A from the start of the AM shift and worked into the PM shift. Review of Patient 5’s Progress Note dated 9/2/25 at 2153 hours, showed RN 9 transferred care of Patient 5 to remaining unit staff on 9/2/25 at 2153 hours. During an interview on 9/23/25 at 1330 hours, with the CNO, the CNO stated the PM shift for Unit A on 9/2/25 was short and RN 9 had stayed over from dayshift to help pass medications. The CNO stated that the administration was made aware by the house supervisor and came in early at around 0400-0500 on the morning of 9/3/25 to help. The CNO acknowledged Unit A did not have four RNs to be on duty as per the hospital’s P&P, from approximately 2153 hours on 9/2/25 to 0400 hours on 9/3/25. On 9/30/25 at 1025 hours, the CNO was notified and acknowledged the above findings.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 26756 Based on observation, interview, and record review, the GB failed to ensure the safe and effective operation of the hospital as evidenced by: 1. The GB did not ensure the RN conducted ongoing hourly assessments during approximately 17 episodes of seclusion for Patient 2, who remained in seclusion for a cumulative total of 125 hours and 21 minutes between 8/4/25 and 8/19/25. Cross reference to A175, example # 1. 2.The GB did not ensure Patient 2 received care in a safe, sanitary, and therapeutic environment when the patient was placed in seclusion. Cross-reference to 144. 3. The GB did not ensure Patient 3 was assessed for vital signs, nutrition need, hydration need, hygiene need, and elimination need as per the Order and the hospital’s P&P. In addition, the hospital failed to ensure the nursing staff completed a timely assessment and evaluation of Patient 3’s readiness to discontinue seclusion despite the patient remaining in seclusion beyond the initial order duration. Cross reference to A175, example # 2. 4. The GB did not ensure a P&P developed specifying what personnel should be present when a full skin assessment was performed on an adolescent patient and failed to protect the dignity, privacy, and patient rights for one of seven sampled patients (Patient 1) when it conducted an invasive intake skin assessment using two male staff members of the opposite sex, without offering a same-sex alternative or obtaining informed consent. Cross reference to A142. 5. The GB did not ensure the Order for seclusion to manage violent behavior was renewed when the order exceeded four hours for Patient 3 as required by the hospital’s P&P. Cross reference to A171. 6. The GB did not ensure the development, implementation, and maintenance of an effective, ongoing, hospital-wide, data driven QAPI program. Cross reference to A263. The cumulative effect of these systemic failures resulted in the GB’s inability to ensure provision of quality healthcare in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 26756 Based on observation, interview, and record review, the hospital failed to protect and promote the rights of each patient as evidenced by: 1. The hospital failed to ensure the RN conducted ongoing hourly assessments during approximately 17 episodes of seclusion for Patient 2, who remained in seclusion for a cumulative total of 125 hours and 21 minutes between 8/4/25 and 8/19/25. Cross reference to A175, example # 1. 2. The hospital failed to ensure Patient 2 received care in a safe, sanitary, and therapeutic environment when the patient placed in seclusion. Cross-reference to 144. 3. The hospital failed to ensure Patient 3 was assessed for vital signs, nutrition need, hydration need, hygiene need, and elimination need as per the Order and the hospital’s P&P. In addition, the hospital failed to ensure the nursing staff completed a timely assessment and evaluation of Patient 3’s readiness to discontinue seclusion despite the patient remaining in seclusion beyond the initial order duration. Cross reference to A175, example # 2. 4. The hospital failed to develop a P&P specifying what personnel should be present when a full skin assessment was performed on an adolescent patient and failed to protect the dignity, privacy, and patient rights for one of seven sampled patients (Patient 1) when it conducted an invasive intake skin assessment using two male staff members of the opposite sex, without offering a same-sex alternative or obtaining informed consent. Cross reference to A142. 5. The hospital failed to ensure the Order for seclusion to manage violent behavior was renewed when the order exceeded four hours for Patient 3 as required by the hospital’s P&P. Cross reference to A171. The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision and protection of patient rights.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 26756 Based on observation, interview, and record review, the hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven QAPI program as evidenced by: The hospital failed to collect and analyze detailed, patient-specific restraint/seclusion data limits, the hospital’s ability to identify patterns or high-risk patients, prevented accurate evaluation of the appropriateness and safety of interventions. Cross reference to A273. The cumulative effects of these systemic problems resulted in failure to ensure hospital services were delivering care in the safest and most effective manner.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to protect the dignity, privacy, and patient rights for one of seven sampled patients (Patient 1) when it conducted an invasive intake skin assessment using two male staff members of the opposite sex, without offering a same-sex alternative or obtaining informed consent. The procedure included genital exposure and a cough-and-squat maneuver, actions that were not part of a standard clinical skin assessment and lacking clinical justification. In addition, the leadership and clinical staff also failed to ensure that appropriate protocols and P&Ps were available and failed to protect Patient 1’s rights and emotional well-being. This failure had the potential to affect Patient 1’s psychosocial well-being and could lead to allegations of child abuse against the staff. Findings: During a review of the hospital’s document titled “ARBH Skin Assessment Method (SAM) “(undated), indicated the outlined procedure included steps that exceed the scope of a standard clinical skin assessment. The guidelines directed staff to: 1. Have the patient remove their clothing while providing a paper gown for them to change into. 2. Once gowned, inspect every area of the body (including hair, nape of neck, mouth, palms, and soles of feet), keeping accurate notes of any abnormalities of the skin for documentation. 3. Have the patient reveal their back and buttocks for assessment. 4. Have the patient face you and reveal their upper body above the waist. Patients with pendulous breasts and heavier patients with skin folds will lift them so staff can assess for injuries or contraband. 5. Have patient reveal their lower body from waist down. All skin folds and genitals must be viewed to ensure no injuries or objects are present. a. Males must life their scrotum and penis individually to ensure no contraband has been hidden, then have them squat and cough forcefully three times. b. Females must squat and cough and cough forcefully three times to ensure no contraband has been hidden. The ARBH Skin Assessment Method (SAM) did not distinguish between a clinical skin assessment and a contraband search and did not provide clinical justification for these invasive steps. There was no mention of obtaining informed consent or offering patients the option to have the assessment conducted by staff of the same sex. During an interview on 8/19/25 at 1125 hours with RN 1, RN 1 stated that during admission skin assessments, the goal was to have two staff members of the same sex as the patient. RN 1 stated if having two staff members of the same sex was not possible, at least one same-sex staff member performed the assessment while an opposite-sex staff member remained in the room with their back turned to the patient for privacy. During an interview on 8/19/25 at 1120 hours with RN 2, RN 2 stated he was an intake nurse, and it was his job to assess the new arrivals and complete a full body, head-to-toe skin check on all newly admitted patients. RN 2 stated the staff assigned to perform the assessments depended on the sex/gender of the patient. RN 2 stated if the patient was a female adolescent, they had a female staff member completing the assessment and if possible, another female staff in the room. RN 2 also stated for an adolescent female, they did not assign two male RNs to perform the head-to-toe skin assessment. RN 2 confirmed that during the full body, head-to-toe assessment, the cough-and-squat evaluation was conducted for safety. RN 2 stated the purpose was to ensure there was no contraband hidden inside a body cavity. RN 2 did not recall the skin assessment performed on Patient 1 on 2/14/25. During a review of Patient 1’s medical record, conducted on 8/19/25 at 1405 hours, indicated Patient 1 was an adolescent female who was admitted to the hospital on 2/14/25 and discharged on 2/20/25. During a review of Patient 1’s “Nursing Admission Assessments” dated 2/14/25, the Nursing Admission Assessments indicated Patient 1’s admission skin assessment was completed by RN 2 and MHW 1 (both males). During a review of Patient 1’s “Intake Assessment” dated 2/14/25 at 1145 hours, did not indicate that Patient 1 was offered a female staff member to perform the admission skin assessment. The document also did not reflect that Patient 1 or Patient 1’s parent or legal guardian provided explicit consent for the skin assessment to be conducted by two staff members of the opposite sex. During an interview on 8/20/25 at 1120 hours with the CNO, the CNO acknowledged the hospital did not have a P&P showing what staff would be present when a skin assessment was performed. The CNO was also notified of and acknowledged the above findings. During an interview on 8/21/25 with Family Member 1, Family Member 1 stated Patient 1 had recently begun experiencing nightmares related to an event that occurred during Patient 1’s admission skin assessment. Family Member 1 stated Patient 1 alleged being touched inappropriately by a male staff member during the skin assessment.”

“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: 26756 Based on observation, interview, and record review, the hospital failed to ensure the patient received care in a safe, sanitary, and therapeutic environment when the patient placed in seclusion. This deficient practice was identified for one of seven sampled patients (Patient 2) and resulted in prolonged seclusion under inhumane conditions, including lack of access to restroom facilities and evidence of physical injury. These unsafe seclusion conditions placed Patient 2 at risk for both physical harm and psychological harm. Findings: During a review of the hospital’s P&P titled, “Seclusion/Restraint,” dated June 2025, the hospital’s P&P indicated, “Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members, or others as imminent risk has been identified ... Discontinuation of restraint and seclusion occurs as soon as possible, based on an individualized patient assessment and reevaluation, regardless of the scheduled expiration of the order ... A provider or registered nurse will assess the need for Seclusion and/or Restraints only after less restrictive measures have failed... B. Applying Restraint or Initiating Seclusion....Maintain a clean, safe and comfortable environment ... C. Monitoring ... Qualified staff members do the following: ... Evaluate the patient for safety and comfort at the initiation of the restraint or seclusion and minimally every 15 minutes unless otherwise noted ... The evaluation includes any of the following, as appropriate to the patient and the type of restraint or seclusion... Nutrition and hydration are offered at least hourly, offer meals and snacks per hospital schedule. ... Vital signs... Hygiene and elimination are offered toileting at least hourly or as needed...Readiness for discontinuation of restraint or seclusion.” On 8/19/25, a review of Patient 2’s medical record was initiated. Patient 2’s medical record indicated the patient was admitted to the hospital on 8/3/25. During a review of Patient 2’s “Psychiatric Evaluation,” dated 8/3/25, the Psychiatric Evaluation indicated Patient 2 was admitted to the hospital with history pf psychosis. On exam, the patient reported not taking his psychiatric medications in two weeks because the patient felt the patient did not need to. The patient reported difficulty with auditory hallucinations. The patient reported ongoing paranoia and reported that people were after him and trying to harm him. The patient reported difficulty with voices telling him not to take medications. The patient was admitted on a 5150-hold. Review of the “Seclusion/Restraint Flowsheet” indicated Patient 2 was placed in seclusion on multiple occasions (approximately 17 occasions) from 8/4/25 to 8/19/25. The total cumulative duration of the seclusion was approximately 125 hours and 21 minutes between 8/4/25 and 8/19/25. The individual seclusion episode ranged from 2 hours and 5 minutes to 18 hours and 21 minutes. For each seclusion episode, the “Seclusion/Restraint Flowsheet” documented behavioral observations every 15 minutes. Cross reference to A175, example # 1. During an observation of the seclusion room on 8/19/25 at 0900 hours, the following was observed: - The seclusion room had multiple disposable paper cups on the floor, one of which contained a yellow liquid with a strong odor of urine. - Food and snack wrappers were scattered across the floor. - The mattress was observed with dark reddish-brown, blood-like stains and was dirty, with a strong odor of urine. - The seclusion room had no bathroom, toilet, or running water. The only patient bathroom available was located outside, across the seclusion area. - The floor of the seclusion room contained urine puddles, and the walls were marked with graffiti drawings. During a review of the “Seclusion/Restraint Flowsheet,” dated 8/19/25, the “Seclusion/Restraint Flowsheet” indicated Patient 2 was placed in seclusion from 8/18/25 at 1258 hours, and out of Seclusion on 8/19/25 at 0058 hours (a total duration of 12 hours). During a review of the “Face to Face Evaluation” dated 8/18/25 at 2058 hours, the “Face to Face Evaluation” indicated under Patient Injuries: “Bruised and scabbed knuckles on bilateral knuckles from punching walls, the door, attacking staff.” During an interview on 8/19/25 at 0900 hours with the CNO, the CNO stated Patient 2 was aggressive, and there had been situations where they attempted to let him out of seclusion to use the bathroom, and Patient 2 attacked staff. The CNO stated Patient 2 was a danger to others, he was bleeding because he punched the walls out of frustration and threatened to hurt staff. The CNO stated they had a few staff members out due to being hit a few times in their face and head all unprovoked. The CNO stated Patient 2 was the last patient that had used the seclusion room. During a concurrent observation and interview on 8/19/25 at 0930 hours with Patient 2, Patient 2 was observed wearing a T-shirt with visible blood stains on the collar. Patient 2 had dry scabbed wounds on the knuckles of both hands. Patient 2 stated if remaining compliant while in seclusion, he would be discharged, and that all he needed was snacks and a paper cup to urinate. During a concurrent video surveillance review, from the inside seclusion room, and interview on 8/20/25 at 1100 hours with the CNO, the CNO reviewed the video surveillance recording dated 8/18/25 at 2033 hours, which captured Patient 2 urinating into a paper cup, without privacy, while in seclusion. On 8/20/25 at 2149 hours, the nursing staff allowed Patient 2 to go out to the bathroom, located across the restraint rooms. The CNO stated the hospital’s policy only allowed physical holds and did not permit the use of mechanical restraints. The CNO stated the hospital was trying to protect other patients and staff from Patient 2. The CNO verified and acknowledged the above findings. During an interview on 8/21/25 at 1100 hours with the hospital’s Medical Director, the Medical Director stated aside from administering medication and initiating seclusion, there were no additional interventions available when Patient 2 began hitting the door and sustained bleeding, behavior that constituted a danger to self. The Medical Director acknowledged that the appropriate clinical response would have been to initiate mechanical restraints, but this intervention was not implemented due to the hospital’s policy, which permits only physical holds and seclusion.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 38660 Based on interview and record review, the hospital failed to ensure the physician’s order for seclusion to manage violent behavior was renewed when the order exceeded four hours for one of seven sampled patients (Patient 3) as required by the hospital’s P&P. This failure could lead to the unnecessary use of restraint for the patient. Findings: During a review of the hospital’s P&P titled, “Seclusion and Restraints,” dated June 2025, the hospital’s P&P indicated, “Authorizing/Ordering Restraint or Seclusion...Order the use of restraint or seclusion when determined to be clinically necessary ... Duration or anticipated ending time (as soon as possible, based on an individualized patient assessment and reevaluation) .... Adults - maximum of 4-hour duration...Seclusion or restraint must be discontinued at the earliest possible time once the patient has met criteria for release and no longer poses an imminent threat to him/ herself or others ... If the patient has not met release criteria and cannot safely be released from seclusion or restraint by the end of the initial order, a new order must be obtained from the psychiatrist or LIP to continue the restrictive measure. ... The clinical justification for continued use of restraint or seclusion at the time of the order’s expiration.” During a review of Patient 3’s medical record on 8/19/25, Patient 3’s medical record indicated Patient 3 was admitted to the hospital on 7/25/25 and discharged on 8/1/25. During the review of the “Seclusion/Restraint” dated 7/26/25 at 0448 hours, the Seclusion/Restraint indicated on 7/25/25 at 2057 hours, Patient 3 told RN that he “wanted to wind down” because the dayroom was getting loud. The RN asked other patients to quiet down. Patient 3 went up to nursing station and started banging on the window and asking the staff to put on “god or religious movies on the TV”, but the staff told Patient 3 that other patients were still watching the movie. Patient 3 stated he was feeling “anxious” and the RN offered patient a Vistaril (a medication used as a sedative to treat anxiety and tension). The patient stated, “I do not have anxiety” and refused Vistaril. Patient 3 was sitting next to another patient and started washing their feet. MHW 2 asked Patient 3 to stop and Patient 3 became agitated and started swinging and attacking MHW 2. MHW 2 attempted to use MAB technique, but Patient 3 continued to attack MHW 2. Patient 3 pulled MHW 2 over dayroom tables and a few tables were knocked over. Patient 3 then grabbed MHW 2’s hair and would not let go. An RN attempted to intervene and help MHW 2, but Patient 3 was too strong and continued to attack MHW 2. Patient 3 then “dislocated MHW’s right shoulder.” Code Grey was called and several RNs and MHWs responded to the code, holding Patient 3 down using four-point restraint at 2101 hours. Review of the RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated seclusion started on 7/25/25 at 2109 hours and ended at 0416 hours and the restraint was started at 2100 hours and ended at 2107 hours. The Type of Restrictive Intervention Implemented section indicated the boxes of “Seclusion” and “Physical Hold (restraint)” were checked. The Type of Behavior Warranting Restraint/Seclusion section indicated the box of “Imminent danger to others” was checked and the patient attacked the MHW and dislocated the MHW’s shoulder. The Event Description section indicated the NP approved renewal for seclusion in advance because Patient 3 was extremely violent and unpredictable. At that time, staff did not feel comfortable releasing the patient from seclusion due to his violent behavior. Review of the Order for Restrain/Seclusion indicated a telephone order dated 7/25/25 at 2121 hours, for seclusion and physical restraint of the upper right limb, upper left limb, lower right limb and lower left limb. The duration of seclusion was four hours for patients over 18-year-old. The specific measures for ensuring patient’s health and wellbeing included to continuous visual observation of patient, obtain vital signs every hour, assess skin integrity, RN reassess patient hourly, offer fluids hourly, offer toilet hourly, offer food per unit routine. The Criteria for Discontinuation section indicated the boxes of “No longer presents an imminent danger to self” and “No longer presents as an imminent danger to others” were left blank. There was no clinical justification documented for the continued use of seclusion, and the seclusion order was not renewed after Patient 3 remained in seclusion for more than four hours. During a concurrent interview and review of Patient 3’s medical record on 8/20/25 at 1333 hours with the CNO, the CNO reviewed the medical record and acknowledged the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 26756 Based on observation, interview, and record review, the hospital failed to ensure two of seven sampled patients (Patients 2 and 3) were monitored when were placed in seclusion as per the hospital’s P&P as evidenced by: 1. The hospital failed to ensure the RN conducted ongoing hourly assessments during approximately 17 episodes of seclusion for Patient 2, who remained in seclusion for a cumulative total of 125 hours and 21 minutes between 8/4/25 and 8/19/25. 2. The hospital failed to ensure Patient 3 was assessed for vital signs, nutrition need, hydration need, hygiene need, and elimination need as per the Order and the hospital’s P&P. In addition, the hospital failed to ensure the nursing staff completed a timely assessment and evaluation of Patient 3’s readiness to discontinue seclusion despite the patient remaining in seclusion beyond the initial order duration. These failures posed a risk to patient safety due to the lack of timely monitoring and clinical evaluation during seclusion. Findings: During a review of the hospital’s P&P titled, “Seclusion/Restraint,” dated June 2025, the hospital’s P&P indicated, “Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members, or others as imminent risk has been identified ... Discontinuation of restraint and seclusion occurs as soon as possible, based on an individualized patient assessment and reevaluation, regardless of the scheduled expiration of the order ... A provider or registered nurse will assess the need for Seclusion and/or Restraints only after less restrictive measures have failed...” “Monitoring ...Qualified staff members do the following: ... Evaluate the patient for safety and comfort at the initiation of the restraint or seclusion and minimally every 15 minutes unless otherwise noted...The evaluation includes any of the following, as appropriate to the patient and the type of restraint or seclusion: ... Nutrition and hydration are offered at least hourly; offer meals and snacks per hospital schedule. ... Vital signs... Hygiene and elimination are offered toileting at least hourly or as needed...Readiness for discontinuation of restraint or seclusion.” “Release from Restraint or Seclusion...The Psychiatrist/Provider or Registered Nurse will:...Assess the patient’s vital signs at regular intervals that ensure the patient’s safety ... Assess the patient for readiness to discontinue restraint or seclusion at regular intervals that ensure the patient’s safety and meet the hospital’s requirements ... Document the assessments in the patient’s medical records... Documentation...The attending/on call psychiatrist, provider or RN will document:...each in-person evaluation and reevaluation of the patient.” 1. On 8/19/25, a review of Patient 2’s medical record was initiated. Patient 2’s medical record indicated the patient was admitted to the hospital on 8/3/25. During a review of Patient 2’s “Psychiatric Evaluation,” dated 8/3/25, the Psychiatric Evaluation indicated Patient 2 was admitted to the hospital with history pf psychosis. On exam, the patient reported not taking his psychiatric medications in two weeks because the patient felt the patient did not need to. The patient reported difficulty with auditory hallucinations. The patient reported ongoing paranoia and reported that people were after him and trying to harm him. The patient reported difficulty with voices telling him not to take medications. The patient was admitted on a 5150-hold. During an observation of the Seclusion Room on 8/19/25 at 0900 hours, the seclusion room mattress was observed stained and dirty, with a strong odor of urine. The floor of the seclusion room contained urine puddles, and the walls were marked with graffiti. Inside the room, the floor was observed with bags of snacks, a paper cup full of yellow liquid with smelling-like urine. The seclusion room had no bathroom, toilet, or running water. The only patient bathroom was located outside across the seclusion area. During an interview with Patient 2 on 8/19/25 at 1115 hours, Patient 2 stated he wanted to be discharged from the hospital. Patient 2 stated...as long he had snacks and a paper cup, he could stay in seclusion. Patient 2 stated the paper cup was to pee because staff did not let him go to the bathroom. A concurrent video surveillance review, from the inside seclusion room, and interview with the CNO was conducted on 8/20/25 at 1100 hours. Review of the video surveillance recording dated 8/18/25 at 2033 hours, captured Patient 2 was urinating into a paper cup, without privacy, while in seclusion. On 8/20/25 at 2149 hours, the nursing staff allowed Patient 2 to go out to the bathroom, located across the seclusion rooms. During a review of the Seclusion/Restraint and the Seclusion/Restraint Flowsheets for Patient 2 from 8/4/25 to 8/19/25, the Seclusion/Restraint and the Seclusion/Restraint Flowsheets indicated Patient 2 was placed in seclusion for approximately 17 episodes between 8/4/25 to 8/19/25. Each episode of the seclusion was initiated under the pre-printed Order for Restraint/Seclusion that contained identical directives, including: * Order Type: Seclusion * Specific Measures for Ensuring Patient Safety - Continuous visual observation - Obtain vital signs every hour - Assess skin integrity - RN reassess the patient hourly - Offer fluids hourly - Offer toilet hourly - Offer food per unit routine - Criteria for Discontinuation: “No longer presents an imminent danger to others” The hospital’s Seclusion/Restraint Flowsheets included the printed instructions requiring that “Staff observed patient continuously with documentation minimally every 15 minutes...registered nurse must perform assessment at least once every hour during the course of restraint or seclusion.” Documentation on the Seclusion/Restraint Flowsheet included vital signs every hour; fluid, food, elimination every hour; and describe patient behavior every 15 minutes. Review of the Seclusion/Restraint and the Seclusion/Restraint Flowsheets for Patient 2 from 8/4/25 to 8/19/25, indicated the following: * On 8/4/25, Patient 2 was placed in seclusion from 1312 hours to 1517 hours (2 hours and 5 minutes). No RN assessment was documented at least once every hour during the course of seclusion. The only RN entry was at the time of the release of the patient from seclusion. * On 8/5/25, seclusion occurred from 1527 hours to 1948 hours (4 hours and 21 minutes). The Seclusion/Restraint Flowsheet noted the repeated entries of “laying on bed” or “lying on floor,” with no escalation in behavior. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/6/25, seclusion was initiated at 0735 hours and ended at 1537 hours (8 hours and 2 minutes). No RN assessment was documented at least once every hour during the course of seclusion. * On 8/6/25, the second episode of seclusion occurred from 1548 hours to 1952 hours (4 hours and 4 minutes). The Restraint/Seclusion Flowsheet did not indicate any behavioral escalation from 1815 to 1930 hours. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/7/25, seclusion occurred from 1221 hours to 2021 hours (8 hours). On 8/7/25 at 1621 hours, the RN came to the patient’s room to reassess the patient; the seclusion order was renewed; and the patient was currently in locked seclusion room. The patient was sitting on the floor, lying on the floor, or lying on the bed from 1715 to 2015 hours. No RN assessment was documented at least once every hour during the course of seclusion. No evaluation for readiness to discontinue was noted. * On 8/9/25, seclusion was documented from 1138 hours to 2119 hours (9 hours and 41 minutes). No RN assessment was documented at least once every hour during the course of seclusion. * On 8/9/25 at 2219 hours to 8/10/25 at 0258 hours (4 hours and 39 minutes), the patient was placed in seclusion. The patient was asleep from 0000 to 0300 hours. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/11/25, seclusion lasted from 0921 hours to 2110 hours (11 hours and 49 minutes). The patient’s behavior was alternated between sleeping and verbal threats. No RN assessment was documented at least once every hour during the course of seclusion. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated the RN signed and dated this section on 8/11/25 at 1321 and 1720 hours. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/12/25, seclusion occurred from 1130 hours to 2155 hours (10 hours and 25 minutes). The patient’s behavior alternated between aggression and sleep. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated the RN signed and dated this section on 8/12/25 at 1530 and 1935 hours. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/13/25, the patient was placed in seclusion at 0934 hours. The patient was sleeping, lying in bed, pacing, or resting from 0945 to 1300 hours. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section dated 8/13/25 at 1457 hours, indicated the patient was assessed in the seclusion room; the provider was notified about the patient’s current status and provided an order for lock seclusion at this time; the seclusion was started at 1334 hours and ended at 1705 hours. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint dated 8/13/25 at 1705 hours, indicated the EMT transport arrived to transport the patient to an acute care hospital. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/14/25, a seclusion episode initiated at 1256 hours as per physician’s order. The duration of the seclusion episode was not specified in the documentation. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/15/25, a seclusion episode started at 1022 hours and ended on 8/16/25 at 0443 hours (18 hours and 21 minutes). The patient was documented as asleep or lying quietly from 1245 hours to 1345 hours, 1430 hours to 1500 hours, and from 2000 hours to 0200 hours. On 8/16/25 at 0215 hours, the RN attempted to give the patient a gown; the patient refused, remaining withdrawn in the corner of the room. At 0440 hours, staff unlocked the seclusion room. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated the RN signed and dated this section on 8/15/25 at 1123, 1544, and 1835 hours; and on 8/16/25 at 0220 hours. Despite extended periods of inactivity, no reassessment or consideration for release was documented. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/16/25, the patient was placed in seclusion at 1201 hours. At 2001 hours, the patient was escorted back to the patient’s room from the seclusion room. At 2018 hours, the patient punched a mental health worker. The patient was restrained from 2018 to 2022 hours. At 2023 hours, the patient was in locked seclusion room. On 8/17/25 at 0023 hours, the door of the seclusion room was open, and the patient was escorted back to the patient room. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated the RN signed and dated this section on 8/16/25 at 2354 hours. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/17/25, a seclusion episode was started at 1624 hours and ended on 8/18/25 at 0022 hours (7 hours and 58 minutes). The flowsheet indicated the patient was restless. The flowsheet did not indicate any escalation in behavior. No RN assessment was documented at least once every hour during the course of seclusion. * On 8/18/25, Patient 2 was placed in seclusion from 0828 to 1248 hours (4 hours and 24 minutes). The patient was lying in bed, eating, sitting in bed, or sleeping from 0830 to 1245 hours. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section indicated the RN signed and dated this section on 8/18/25 at 1022 hours. No RN assessment was documented at least once every hour during the course of seclusion. * The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section dated 8/18/25 at 1505 hours, indicated at 1248 hours, staff unlocked the seclusion room door and attempted to let the patient out into the unit after the patient contracted for safety; the patient came to the seclusion doorway and attacked staff member unprovoked, striking staff member in the jaw with a closed fist. Code Grey was called, and staff members intervened, escorting the patient to seclusion room bed. The door of the seclusion room was locked at 1258 hours. The Seclusion/Restraint Flowsheet dated 8/18 and 8/19/25, indicated Patient 2 was placed in seclusion from 8/18/25 at 1258 hours to 8/19/25 at 0058 hours (12 hours). The patient was sleeping from 1325 to 1545 hours. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section indicated the RN signed and dated this section on 8/18/25 at 1433, 1505, 1800, 2210 hours. No RN assessment was documented at least once every hour during the course of seclusion. During a review of the “Seclusion/Restraint Flowsheets,” the “Seclusion/Restraint Flowsheets” indicated Patient 2 was placed in seclusion on approximately 17 occasions or approximately a total of 125 hours and 21 minutes between 8/4/25 to 8/19/25. The shortest episode occurred on 8/4/25, lasting 2 hours and 5 minutes, while the longest episode was from 8/15/25 to 8/16/25, lasting 18 hours and 21 minutes. During a review of the “Seclusion/Restraint Flowsheets,” the “Seclusion/Restraint Flowsheets” documented the behavioral observations at 15-minute intervals. A review of Patient 2’s medical record failed to show documented evidence the RN assessments conducted at least once every hour during any of the seclusion periods as required by the orders and hospital’s P&P. A review of Patient 2’s medical record failed to show documented evidence of evaluations regarding Patient 2’s readiness for release from seclusion, even when the Flowsheets indicated the patient had calm behavior, was sleeping, or lack of aggression. During an interview on 8/21/25 at 0835 hours with RN 5, RN 5 stated the RN assessments were conducted after an emergency situation, where the patients were placed in restraint/seclusion. RN 5 stated there was no specific hourly RN assessment requirement. During an interview on 8/21/25 at 1000 hours with the CNO, the CNO stated the restraint P&P needed to be reviewed, the hospital’s P&P indicated to assess the patients in restraints/seclusion at regular intervals. The CNO acknowledged the above findings. 38660 2. During a review of Patient 3’s closed medical record on 8/19/25, Patient 3’s medical record indicated Patient 3 was admitted to the hospital on 7/25/25 and discharged on 8/1/25. During the review of the “Order for Restrain/Seclusion,” the “Order for Restrain/Seclusion” indicated, a telephone order dated 7/25/25 at 2121 hours, was received for a physical restraint on upper right limb, upper left limb, lower right limb, and lower left limb and for seclusion with the duration of seclusion was four hours for patient over 18-year-old. Specific measures for ensuring patient’s health and wellbeing included to continuous visual observation of patient, obtain vital signs every hour, assess skin integrity, RN reassess patient hourly, offer fluids hourly, offer toilet hourly, offer food per unit routine. a. During the review of the “Seclusion/Restraint Flowsheet” dated 7/25/25, indicated the form instructions indicated staff observed patient continuously with documentation minimally every 15 minutes, registered nurse must perform assessment at least once every hour during the course of restraint or seclusion. Documentation on the Seclusion/Restraint Flowsheet included vital signs every hour; fluid, food, elimination every hour; and describe patient behavior every 15 minutes. Further review of the Seclusion/Restraint Flowsheet indicated the following: * Patient 3 was placed in Physical Hold from 2100 hours, and out of Physical Hold at 2107 hours (seven minutes). * Patient 3 was placed in seclusion from 2109 hours, and out of Seclusion at 0416 hours. * Patient 3 refused vital sign measurements from 2100 to 2300 hours. There was no documented evidence showing attempts to obtain the patient’s vital signs every hour from 0000 to 0416 hours. There was no documented evidence showing the patient’s needs were assessed and recorded as per the hospital’s P&P, specifically for nutrition, hydration, hygiene, and elimination needs, from 0000 to 0416 hours. b. Review of the Seclusion/Restraint for Patient 3 indicated the seclusion was started on 7/25/25 at 2109 hours and ended at 0416 hours. The Order for Restraint/Seclusion section of the Seclusion/Restraint indicated the Criteria for Discontinuation section showing the boxes of “No longer present as an imminent danger to self” and “No longer presents as an imminent danger to others” were left blank. There was no RN assessment or evaluation Patient 3 for readiness to discontinue seclusion. During an interview and concurrent review of Patient 3’s medical record on 8/21/25 at 0907 hours, with the CNO, the CNO verified the above findings.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 26756 Based on observation, interview, and record review, the hospital failed to ensure its QAPI program collected and analyzed data related to the use of restraints/seclusion. The hospital was unable to demonstrate that restraint and seclusion use was being monitored and evaluated, and could not produce any restraint data for July and August 2025. This lack of documentation and analysis impaired the hospital’s ability to identify patterns, recognize high-risk patients, and evaluate the appropriateness and safety of interventions. Findings: During a review of the hospital’s “Performance Improvement Plan 2025,” indicated, ... “The Performance Improvement Plan for the Hospital has the following objectives: ... To support and review, on an ongoing basis, processes that objectively and systematically monitor and evaluate the quality and appropriateness of the aspects of patient care that directly or indirectly affect patient outcomes and that improve efficiency of patient care...Through the Performance Improvement Program, information on important aspects of patient care is collected routinely though the following mechanisms: ... medical records review and patient satisfaction, complaints and clinical outcomes used ... safety/risk management program (high risk procedures, incident reporting, untoward occurrences)...” During an observation, interview, and record review on 8/19, 8/20, and 8/21/25, the following deficient practices related to the use of seclusion were identified: * The hospital failed to ensure the RNs conducted ongoing hourly assessments during approximately 17 episodes of seclusion for Patient 2, who remained in seclusion for a cumulative total of 125 hours and 21 minutes between 8/4/25 and 8/19/25. Cross reference to A175, example # 1. * The hospital failed to ensure Patient 2 received care in a safe, sanitary, and therapeutic environment while in seclusion. Cross reference to 144. * The hospital failed to ensure Patient 3 was assessed for vital signs, nutrition need, hydration need, hygiene need, and elimination need as per the Order and the hospital’s P&P. In addition, the hospital failed to ensure the nursing staff completed a timely assessment and evaluation of Patient 3’s readiness to discontinue seclusion despite the patient remaining in seclusion beyond the initial order duration. Cross reference to A175, example # 2. * The hospital failed to ensure the Order for seclusion to manage violent behavior was renewed when the order exceeded four hours for Patient 3, as required by the hospital’s P&P. Cross reference to A171. During a review of the “2025 Clinical Benchmarking Report” from January to June 2025, indicated the hospital only tracked aggregate monthly totals for mechanical restraint, physical restraint, and seclusion. The report lacked the following: 1. Identification of the individual patients restrained/secluded. Duration of each episode (number of hours). Type of intervention used (emergency vs. planned). Unit or location of each episode. Documentation of whether release occurred at the earliest possible time. 2. Lack of Rate Calculations: The data was presented as raw counts. There were no rates per 1,000 patient days or percentage of patients restrained/secluded, preventing valid comparisons over time or against benchmarks. 3. No Trend or Root Cause Analysis: Large month-to-month fluctuations (e.g., Physical Restraint - Adult: March = 56; April = 11) had no documented explanation or analysis to determine causative factors. During an interview on 8/21/25 at 1100 hours, with the Director of Quality, the Director of Quality was not able to produce documentation to show a system to collect or analyze patient-level data related to restraint or seclusion use. There were no logs, rate-based metrics, or trend analyses available for review. The Director of Quality stated the QAPI only received aggregate totals.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the staff monitored the vital signs, nutrition, hydration, hygiene, and elimination needs as per the hospital’s P&P for one of 18 sampled patients (Patient 6) when the patient was restrained or secluded. This failure had the potential to result in unsafe care and poor clinical outcomes to the patient. Findings: Review of the hospital’s P&P titled Seclusion and Restraints dated October 2024 showed seclusion is the involuntary confinement and isolation of a person, alone in a room or an area, where the patient is physically prevented from leaving. * The LIP/Trained RN section showed when less restrictive interventions fail, initiates the seclusion and restraints process when emergency situation continues: - Places patient in seclusion or restraints and obtains telephone or written order from physician/provider/or LIP who is responsible for the care of the patient immediately following initiation of S and R or seclusion only. PRN or standing orders are not acceptable. - Order includes the following information: date and time of order; specific behavior that led to S or R (Reason for seclusion or restraints). - If order not immediately obtained from patient’s attending physician or provider, continues to attempt to reach physician or provider follows escalation chain as necessary to obtain order as soon as possible. Escalation chain as follows: If attending physician or provider cannot be reached after two attempts (no more than 10 minutes apart), then the nurse will phone the physician or provider-on call for order; If physician or provider on-call cannot be reached after two attempts (no more than 10 minutes apart) nurse will call the facility medical director for order. * The Clinical Staff section showed the following: - MAB trained staff provides direct observation in close proximity to the patient for any patient in locked seclusion only (not restraints). - Completes documentation on the S and R flow sheet. The following patient needs will be assessed on a continuous 1:1 basis and documented in the medical record every 15 minutes: vital signs every 15 minutes or as ordered; any signs of injury and over all skin integrity; nutrition and hydration need every 15 minutes; hygiene and elimination every 15 minutes. On 1/21/25 at 1407 hours, an interview and concurrent review of Patient 6’s medical record was conducted with the CNO. Patient 6’s medical record showed Patient 6 was admitted to the hospital on 12/3/24. Review of Patient 6’s Seclusion/Restraint Record showed Patient 6 was placed in seclusion on 12/8/24 at 0043 hours and ended on 12/8/24 at 0443 hours. There was no documentation in the Seclusion/Restraint Record to show the following patient needs were assessed and documented every 15 minutes as per the hospital’s P&P: vital signs, nutrition, hydration, hygiene, and elimination needs. The CNO was asked for the physician’s order for seclusion. The CNO verified the physician’s order for seclusion was dated 12/9/24 at 0535 hours. The CNO was asked for the monitoring of the patient’s vital signs, nutrition, hydration, hygiene, and elimination needs every 15 minutes as per the hospital’s P&P. The CNO stated there was no section on the Seclusion/Restraint Record for staff to document the assessment of patient needs (nutrition, hydration, hygiene, and elimination) every 15 minutes. The CNO also stated the patient refused for the vital signs to be taken. However, there was no documented evidence the patient refused for the vital signs to be taken. The CNO verified the findings.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the care plans were developed for eight of 18 sampled patients (Patients 1, 2, 3, 5, 8, 11, 12, and 13) as per the hospital’s P&P. These failures created the increased risk of poor health outcomes to the patients in the hospital. Findings: Review of the hospital’s P&P titled Master Treatment Plan dated October 2024 showed the following: * Policy: Each patient admitted to the hospital shall have a written, individualized master treatment plan (MTP) that formulates a plan of care that meets the patient’s objectives and needs. Treatment shall be planned, reviewed, and evaluated at regular intervals by a multidisciplinary treatment team. This team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. Treatment planning will provide appropriate communication between team members that fosters consistency and continuity in the care of the patient. Ultimate responsibility for the development and implementation of the master treatment plan shall rest with the provider. * Procedure: - Within eight hours of admission, the RN will initiate the master treatment plan. This initial plan shall include high risk and critical medical problems, and appropriate physician and nursing interventions as determined by the initial assessments, the provider’s treatment plan, and the provider’s order. - Within 72 hours of admission, member of the treatment team shall further develop the master treatment plan that is based on a comprehensive assessment of the patient’s presenting problems, physical health, emotional and behavioral status. The team will consist of the provider, nursing staff, social services staff, adjunctive therapy staff, and other clinical disciplines, as appropriate. - The treatment plan is developed and reviewed on the same day as the treatment team meeting. - The Master Treatment Plan Review shall be reviewed within 7 days of completion with the exception of significant events which should be updated within 24 hours. This includes episodes of seclusion and restraints. The Treatment Plan review shall include treatment and discharge changes, modality or intervention change, new issues, updates to problems or goals as identified in Mater Treatment Plan Form. - Additional Treatment Plan Components includes Active Problems. For each problem to be addressed during treatment, the treatment plan status will be deemed “active “ , and a problem sheet will be completed. The problem statement will be in behavioral, medical, observable terminology, etc. Only medical problems should be stated in diagnostic terms (example hypertension) but should also include statement of current status of condition. 1. On 1/14/25 at 1425 hours, Patient 1’s closed medical record was reviewed with the CNO. Patient 1’s medical record showed the patient was admitted to the hospital on 12/2/24, and discharged on 12/16/24. On 1/21/25 at 1315 hours, Patient 1’s medical record was reviewed with RN 7. Review of the MAR showed the patient was given Flonase (a nasal steroid) one nasal spray on 12/12/24 at 1308 hours, for nasal congestion; and Bentyl (an anticholinergic) 20 mg po on 12/11 at 1418 hours and 12/12/24 at 1810 hours, for intestinal spasm. Review of the MTP did not show a care plan for the use of the Flonase and Bentyl. On 1/21/25 at 1315 hours, during an interview and concurrent review of Patient 1’s medical record with RN 7, RN 7 verified the care plan was not updated. 2. On 1/15/25 at 0938 hours, Patient 2’s closed medical record was reviewed with the CNO. Patient 2’s closed medical record showed the patient was admitted to the hospital on 11/30/24, and discharged on 12/12/24. Review of Patient 2’s Medical History & Physical Examination dated 12/2/24 at 0930 hours, showed the patient had a medical history of HTN. Review of Patient 2’s MAR showed amlodipine (a medication to treat high blood pressure) 5 mg 1 tablet po once a day at 0900, hold for SBP less than 100 mmHg, for HTN. The MAR showed Patient 2 received amlodipine daily from 12/2/24 to 12/12/24. On 1/21/25 at 1530 hours, the CNO was interviewed. When asked about the care plan for HTN, the CNO verified there was no care plan for HTN. 3. On 1/15/25 at 1006 hours, Patient 3’s closed medical record was reviewed with the CNO. Patient 3’s closed medical record showed the patient was admitted to the hospital on 12/2/24, and discharged on 12/17/24. Review of the RN’s Progress Note dated 12/6/24 at 0216 hours, showed Patient 3 complained of nausea and vomiting earlier during the day and was given Zofran (a medication to prevent nausea and vomiting) as needed. Review of Patient 3’s MAR showed the patient received Zofran 4 mg po on 12/5/24 at 2344 hours and 12/6/24 at 1251 hours as needed for nausea and vomiting. On 1/21/25 at 1530 hours, the CNO was interviewed. When asked about the care plan for the use of Zofran, the CNO verified there no plan of care for the use of Zofran. 4. On 1/15/25 at 1107 hours, Patient 5’s closed medical record was reviewed with the CNO. Patient 5’s closed medical record showed the patient was admitted to the hospital on 11/23/24, and discharged on 12/12/24. Review of the Consultation Request to NP 1 dated 12/6/24 at 0043 hours, showed Patient 5 complained of nausea and vomiting since earlier during the day. NP 1’s Consultation Reply dated 12/6/24 at 0748 hours, showed to give Zofran as needed for nausea and vomiting and recommended a liquid diet. The diagnosis was nausea and vomiting. Review of Patient 5’s Order showed an order for loperamide (a medication used to treat diarrhea) 2 mg 1capsule every 6 hours as needed for 3 days, for diarrhea. Review of Patient 5’s MAR showed the patient received Zofran 4 mg po as needed for nausea and vomiting on 12/5/24 at 1743 and 2300 hours, on 12/6/24 at 1152 hours, and on 12/7/24 at 0750, 0938, and 1628 hours. Patient 5 also received loperamide 2 mg po as needed for diarrhea on 12/6/24 at 1507 and 2130 hours, and on 12/7/24 at 0750, 0937, and 1631 hours. On 1/21/25 at 1343 hours, the CNO was interviewed. When asked about the care plan for the use of Zofran and loperamide for nausea, vomiting and diarrhea, the CNO verified there was no care plan for the use of Zofran and loperamide. 5. On 1/22/25 at 0845 hours, Patient 8’s closed medical record was reviewed with the Nurse Educator. Patient 8’s closed medical record showed Patient 8 was admitted to the hospital on 11/28/24, and discharged on 12/11/24. Review of Patient 8’s Medical History & Physical Examination dated 11/29/24 at 0000 hours, showed the patient had a history of HIV, fibromyalgia, scoliosis, rhabdomyolysis and was on multiple pain medication. Review of Orders showed a written order for CIWA-B (Clinical Institute for Withdrawal Assessment for Benzodiazepine). Review of the Patient 8’s MTP did not show a care plan for CIWA and HIV. The Nurse Educator verified there was no care plan for CIWA and HIV. 6. On 1/22/25 at 1103 hours, Patient 11’s closed medical record was reviewed with the Nurse Educator. Patient 11’s closed medical record showed Patient 11 was admitted to the hospital on 12/2/24, and discharged on 12/11/24. Review of RN’s Progress Note dated 12/5/24 at 1045 hours, showed Patient 11 complained of nausea and vomiting. The patient at first wanted to take Zofran but changed her mind. The patient stated that the patient vomited after taking Zofran yesterday. The patient was offered warm water and crackers for nausea. Review of RN’s Consultation Request to IM showed the patient complained of constipation, not relieved by Colace (stool softener). Review of Patient 11’s MAR showed the patient received Zofran 4 mg po on 12/3/24 at 1807 hours and 12/4/24 at 1234 hours, for nausea and vomiting as needed. Patient 11 also received Colace 100 mg po on 12/3/24 at 1305 hours, and 12/4/24 at 1241 hours as needed for constipation. Review of Patient 11’s MTP did not show a care plan for constipation, nausea, and vomiting. The Nurse Educator verified the findings. 7. On 1/22/25 at 1103 hours, Patient 12’s closed medical record was reviewed with the Nurse Educator. Patient 12’s closed medical record showed Patient 12 was admitted to the hospital on 11/30/24, and discharged on 12/9/24. Review of the RN’s Progress Note dated 12/8/24 at 0914 hours, showed the patient refused gabapentin (a medication to relieve pain or treat seizures) and Lexapro (a medication that treats depression and anxiety) due to nausea and diarrhea. Review of Patient 12’s MAR showed the patient received Zofran 4 mg po on 12/7/24 at 1422 hours and 12/8/24 at 0912 hours for nausea and vomiting as needed. Review of Patient 12’s MTP did not show a care plan for nausea and vomiting. The Nurse Educator verified the findings. 8. On 1/22/25 at 1345 hours, Patient 13’s closed medical record was reviewed with the Nurse Educator. Patient 13’s closed medical record showed Patient 13 was admitted to the hospital on 12/1/24, and discharged on 12/9/24. Review of the RN’s Consultation Request to NP 1 dated 12/5/24 at 1819 hours, showed Patient 13 complained of mild diarrhea. NP 1’s Consultation Reply dated 12/6/24 at 0752 hours, showed to give Imodium (same as loperamide) every 6 hours as needed and recommended clear liquid diet. The diagnosis was acute diarrhea. Review of the Acute Nursing Progress Note (evening) dated 12/6/24 at 0556 hours, showed on the narrative update the patient was complaining of nausea and diarrhea and stated he had 3 to 4 stools today. Review of the Orders showed an order dated 12/6/24 at 0752 hours, for loperamide 2 mg capsule every 6 hours as needed for 3 days for diarrhea. Review of Patient 13’s MAR showed the patient received loperamide 2 mg capsule po for diarrhea as needed. Review of Patient 13’s MTP did not show a care plan for diarrhea.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff implemented the hospital’s P&P for eight of 18 sampled patients (Patients 1, 3, 5, 6, 9, 10, 13, and 14) as evidenced by: 1. For Patient 1, there was no written physician’s order to transfer the patient to the acute hospital ED. In addition, there was no attending physician’s order was obtained to consult with the IM provider for Patient 1’s medical problem. 2. For Patient 6, there was no physician’s order was written when placing the patient in contact isolation and when discontinuing the contact isolation for the patient. 3. For Patient 3, the diet recommendation was not clarified and was not transcribed as the order for the patient. 4. For Patient 5, the diet recommendation was not clarified and was not transcribed as the order for the patient. 5. For Patient 13, the diet recommendation was not clarified and was not transcribed as the order for the patient. 6. For Patient 9, there was no transcribed order for tiotropium (anticholinergic bronchodilator, a medication used to prevent the narrowing of the airways in the lungs). 7. For Patient 10, there was no transcribed order to transfer the patient to the ED for further evaluation. 8. For Patient 14, there was no transcribed order for a BRAT diet for the patient. These failures had the potential to result in unsafe care and poor clinical outcomes to the patients. Findings: Review of the hospital’s P&P titled Transcribing Provider Orders dated October 2024 showed in part: * It is the policy to accept and carry out written and telephone orders for medication related orders and treatments. * Telephone Orders: - Telephone orders will be accepted only if the ordering provider is not present on the unit for admissions, unplanned, AMA discharges, STAT and emergency medications or treatments, denial of rights, or in response to an emergent situation. - All telephone orders will be received by a licensed member of the nursing staff and written order as a Provider’s Order. - The licensed staff receiving a telephone order is to read the complete order back to the provider once it has been written for verification. After the order has been read back to the ordering provider the licensed staff will then complete the order. -Telephone orders must be authenticated by the provider signature within 48 hours. Review of the hospital’s P&P titled Transcribing Provider Orders reviewed date 10/24 showed the following: * Clarification of Orders: - If the provider is present, the licensed staff will ask the provider to clarify the order. The provider will write the clarifications such as a provider’s order. - If the provider is not present, the licensed staff will call the provider for clarification if the order does not contain the listed requirement, anytime there is a question regarding any of the content of the order. - The licensed staff calling the provider will write the clarification order as such as a provider’s order. - The provider will authenticate each clarification by signature within 48 hours. * Transcribing other orders: - Consults - notify the appropriate consultant or department by phone and/or on notification boards; indicate the time of the notification on the order (example notified date or time by name). - Diet Orders - notify the dietary department and or registered dietician by phone and consult request; indicate the date and time of notification on the order. Review of the hospital’s Medical Staff Rules and Regulation (undated) showed in part: * Consultations: - Consultations must be requested by the attending provider by a written or telephone order. - Medical Staff who are functioning as consulting may write orders for medication and treatment. - Emergency Consultation must be requested by the attending provider directly to the consulting provider. A telephone order may be dictated in the case of emergency. A telephone order must be transcribed, dated, timed, and signed by the authorized recipient in the patient’s medical record within the shift, whenever possible. Telephone order must be countersigned by the attending provider within 24 hours. * Nursing Standards of Practice: A RN shall be considered to be competent when he or she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows: - Formulates a nursing assessment through observation of the client’s physical condition and behavior, and through interpretation of information obtained from the client and others, including the health team. - Formulates a plan of care in collaboration with the client, which ensures that direct and indirect nursing care services provide for the client’s safety, comfort, hygiene, and protection, and for disease prevention and restorative measures. - Acts as the client’s advocate as circumstances require by initiating action to improve health care or to change decisions or activities which are against the interest or wishes of the client, and by giving the opportunity to make informed decisions about health care before it is provided. 1. On 1/14/25 at 1425 hours, Patient 1’s closed medical record was reviewed with the CNO. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 12/2/24, and discharged on 12/16/24. Review of the Nursing Progress Notes dated 12/4/24 at 1859 hours, showed Patient 1 had several episodes of watery light brown foul-smelling diarrhea during the late afternoon, Imodium was given with little effect. Patient 1 also complained of generalized abdominal pain, bloating, and some mild nausea. Patient 1’s abdomen was distended but soft. NP 1 (IM provider) was notified, and Patient 1 would be sent out for medical evaluation. The Call Center was notified and BLS transportation would be arranged to the nearest ER. a. Review of the Acute Nursing Progress Note dated 12/4/24 at 2000 hours, showed Patient 1 would be sent out to a hospital for assessment of uncontrolled diarrhea. The CNO was asked about Patient 1’s transfer to the hospital on 12/4/24. The CNO stated Patient 1 was sent out to the hospital’s ED for several hours and came back to their hospital. The CNO was asked for the physician’s order to transfer the patient to the hospital’s ED. The CNO stated the RN wrote on her progress note. On 1/16/25 at 1400 hours, an interview and concurrent review of Patient 1’s closed medical record was conducted with the Nurse Manager. The Nurse Manager was asked for the order to transfer Patient 1 to the hospital on 12/4/24. The Nurse Manager stated the verbal order was written on the RN’s progress note. However, when asked for the physician’s written order, the Nurse Manager stated generally the order had to be written as a telephone order. The Nurse Manager verified there was no written physician’s order for the patient to be transferred to the nearest hospital ED. b. On 1/15/25 at 0900 hours, an interview was conducted with the Medical Director, CNO, and Director of Quality. The Medical Director was asked about the Medical Consultants. The Medical Director stated the Medical Consults were the IM physicians who would do the patient’s H&P on admission. The IM physician would have NPs under their supervision. The H&P could be done by the NPs or IM physicians within 24 hours of the patient’s admission. On 1/16/25 at 0948 hours, an interview and concurrent review of Patient 1’s closed medical record review was conducted with the Director of Quality. The Director of Quality was asked about Patient 1’s H&P examination. The Director of Quality stated the NP who performed Patient 1’s H&P examination was not the psychiatrist. The IM provider was consulted to do the H&P examination; and if they needed to consult the IM providers again, we would. The Director of Quality verified the attending physician was the psychiatrist. The Director of Quality was asked to show the physician’s order to consult for the IM physician to perform the H&P examination on admission. The Director of Quality stated there was no order for the IM physician to conduct the H&P examination, it had been a practice of the hospital to have the patient’s H&P examination to be done for medical clearance on admission. On 1/16/25 at 1400 hours, an interview and concurrent review of Patient 1’s closed medical record was conducted with the Nurse Manager. The Nurse Manager was asked if an order from the attending psychiatrist was needed to consult the IM physician for medical clearance and H&P examination. The Nurse Manager stated the IM physician knew when there were admissions. The IM physician would conduct the required medical clearance and H&P examination. The succeeding contact with the IM physician would be a consultation. On 1/16/25 at 1510 hours, a telephone interview was conducted with NP 1. NP 1 was asked how the IM provider was involved with the care of the patients at the hospital. NP 1 stated they would conduct the patient medical clearance and H&P examination on admission. The IM provider would see the newly admitted patients medically, they would do physical examination for medical clearance; and if the patient was on chronic medications, they would continue the medication for continuity of care. NP 1 was asked if the nurse sent the consultation request for a patient who developed diarrhea, nausea and vomiting. NP 1 stated that was a medical consult when the nurse requested certain medications, if needed medically, or patient needed medical attention, and the IM provider was called. On 1/22/25 at 1001 hours, a telephone interview was conducted with the Service Director for IM. The Service Director for IM was asked about the care provided for the patients in the hospital. The Service Director for IM stated when patients were admitted to the hospital, the IM provider was consulted. They got a list of the new patients admitted overnight who would need consultation for H&P examination, and they continued the consult if the nurse would call them for medical problems such as headache, HTN, or diarrhea. The IM provider would give orders if needed. However, there was no order for the IM physician for consultation. The findings were shared with the Service Director of IM. 2. On 1/15/25 at 1350 hours and 1/21/25 at 1512 hours, Patient 6’s closed medical record was reviewed with the CNO. Patient 6’s closed medical record showed Patient 6 was admitted to the hospital on 12/3/24 and discharged on 12/19/24. Review of the RN’s Progress Note dated 12/9/24 at 0800 hours, showed Patient 6 was experiencing diarrhea; and per the NP, Patient 6 was placed on contact precaution. The staff encouraged the patient to follow precautions and to stay in the room. On 1/21/25 at 1512 hours, during the interview and concurrent review of Patient 6’s closed medical record with the CNO, the CNO was asked about Patient 6’s contact precaution. The CNO stated Patient 6 was placed on contact precaution for diarrhea as per the telephone order. The staff would put a sign on the door for specific type of isolation. Patient 6’s contact isolation was the use of gown, gloves, and hand hygiene. However, there was no written order for the contact precaution. The CNO was asked when the contact isolation was discontinued. The CNO stated per RN’s Progress Note on 12/13/24 at 1200 hours, the RN spoke to the medical provider (NP 1) and discontinued the contact isolation as a telephone order. However, the order was not transcribed in Patient 6’s medical record. The CNO verified the findings. 3. On 1/15/25 at 1006 hours, Patient 3’s closed medical record was reviewed with the CNO. Patient 3’s closed medical record showed Patient 3 was admitted to the hospital on 12/2/24, and discharged on 12/17/24. Review of the RN’s Consultation Request for the IM provider (NP 1) for Patient 3 dated 12/6/24 at 0038 hours, showed Patient 3 complained of nausea and vomiting since earlier in the day. NP 1’s Consultation Reply dated 12/6/24 at 0812 hours, showed the treatment recommendations were to give Zofran every 6 hours along with Imodium every 6 hours PRN; and recommended clear liquid diet. The diagnosis for Patient 3 was acute nausea and vomiting, and acute diarrhea. The CNO was asked for the clear liquid diet recommendation. The CNO stated the medical provider did not write an order for the clear liquid diet. On 1/15/25 at 1254 hours, an interview was conducted with RN 6 and the CNO. RN 6 was asked how she would address the patient’s complaints of nausea, vomiting, and diarrhea. RN 6 stated she would communicate to the patient’s physician (medical provider) through the consultation request, hydrate and assess the patient, check the vital signs, and wait for the physician’s order. RN 6 stated she would notify the supervisor. RN 6 also said she would verbally endorse to the following nurse, update the change of shift report and the internal communication of the nurses anything related to the patient’s change in the medical condition. The nurse would also write in the progress note what happened during the shift. RN 6 was asked about the medical provider’s consultation reply. RN 6 stated the incoming nurse should check the Consultation Reply as the incoming nurse had been verbally informed and patient’s information had been updated. RN 6 was asked about the medical provider ’ s Consultation Reply with a diet recommendation. RN 6 stated the incoming nurse should check the consultation reply and communicate the diet recommendation to the dietician. On 1/15/25 at 1335 hours, during an interview with the CNO, the CNO stated the patient’s Kardex would be updated if there would be new orders; however, the consultation would not appear on the Kardex. The nurses updated the internal communication that used for reporting, but not all nurses updated it. The nurses would not see the consultation reply unless it was checked by nurse. On 1/16/25 at 1510 hours, a telephone interview was conducted with NP 1. NP 1 was asked about his consultation reply for the diet recommendations for the patients. NP 1 stated he would speak and address the diet recommendation with the patient’s nurse. The nurse should follow through, it was not transcribed as an order, the nurse should call him and if he gave the order, it would be a telephone order. 4. On 1/15/25 at 1107 hours, Patient 5’s closed medical record was reviewed with the CNO. Patient 5’s closed medical record showed Patient 5 was admitted to the hospital on 11/23/24, and discharged on 12/12/24. Review of Patient 5’s Consultation Request to NP 1 dated 12/6/24 at 0043 hours, showed Patient 5 was complaining of nausea and vomiting since earlier in the day. The Consultation Reply from NP 1 dated 12/6/24 at 0748 hours, showed the treatment recommendations were to give Zofran as needed for nausea and vomiting; and recommend clear liquid diet for now. The CNO was asked for the order of clear liquid diet. The CNO stated there was no diet order for clear liquid. Review of Patient 5’s MAR showed Patient 5 was given Zofran 4 mg po as needed for nausea and vomiting on 12/6/24 at 1152 hours, 12/7/24 at 0150, 0938, and 1638 hours. Patient 5 was also medicated with loperamide 2 mg 1 capsule every 6 hours as needed for diarrhea on 12/6/24 at 1507 and 2130 hours and 12/7/24 at 0750, 0937, and 1631 hours. On 1/21/25 at 1343 hours, a follow-up interview and concurrent review of Patient 5’s closed medical record was conducted with the CNO. The CNO was asked about the treatment recommendation of clear liquid diet for Patient 5. The CNO stated the nurses would not get notification if there was a consultation reply. The nurse would not see the consultation reply unless the nurse looked at the consultation ’ s requests. If the physician wanted to order the liquid diet, he should place it as an order. 5. On 1/22/25 at 1345 hours, Patient 13’s closed medical record was reviewed with Nurse Educator. Patient 13’s closed medical record showed Patient 13 was admitted to the hospital on 12/1/24, and discharged on 12/9/24. Review of Patient 13’s Consultation Request to NP 1 dated 12/5/24 at 1819 hours, showed Patient 13 reported mild diarrhea since earlier in the day. The Consultation Reply from NP 1 dated 12/6/24 at 0725 hours, showed the treatment recommendations were to give Imodium every 6 hours PRN and recommend clear liquid diet. The Nurse Educator was asked for the order of clear liquid diet. The Nurse Educator stated there was no diet order for clear liquid diet. The Nurse Educator was asked about NP 1’s recommendation of clear liquid diet written on the Consultation Reply. The Nurse Educator stated the nurse could call and ask the dietician for the diet recommendation. However, there was no documented evidence the nurse followed up on the diet recommendation. The findings were shared with the CNO. 40483 6. On 1/22/25 at 0837 hours, on interview and concurrent review of Patient 9’s medical record was conducted with the Director of Quality. Patient 9’s medical record showed Patient 9 was admitted to the hospital on 12/3/24. Review of the Medical History & Physical Examination dated 12/4/24 at 0000 hours, showed Patient 9 had a history of asthma. Review of Patient 9’s Master Treatment Plan showed the medical problems of asthma and food sensitivities. Review of Patient 9’s NP progress note dated 12/8/24, showed the problem was gastroparesis, poor po intake, and asthma. The note showed to add ensure, increase Zofran dose per request and add tiotropium inhaler. The Director of Quality verified the hospital’s P&P transcribing the provider’s orders did pertain to this patient. The Director of Quality was asked to show the transcribed order for the NP order in the progress note on 12/8/24. The Director of Quality reviewed the MAR, nursing progress notes, and provider’s orders and verified the order had not been transcribed and no follow-up phone call or clarification had been documented by the nursing staff in Patient 9’s chart. On 1/22/25 at 0900 hours, an interview and concurrent record review was conducted with the Nurse Educator. The Nurse Educator stated the nursing staff was expected to read the provider’s progress notes and act accordingly. The Nurse Educator stated if an order was unclear, the nurse was expected to call the provider who wrote the order and get clarification. The Nurse Educator stated the expectation was to follow the hospital’s P&P. The Nurse Educator stated the rationale for calling the provider was to ensure the patient received the intended treatment. On 1/22/25 at 0922 hours, an interview was conducted with the Director of Pharmacy. The Director of Pharmacy was asked to provide information about the medication, tiotropium. The Director of Pharmacy stated the medication was a bronchodilator and was used to treat both asthma and COPD. On 1/22/25 at 1002 hours, an interview was conducted with the Service Director of IM. The Service Director of IM was asked what was expected to be done if an NP placed an order in the progress notes, but it was not transcribed into the patient’s medical record as an order. The Service Director of IM stated all progress notes were to be reviewed by the nursing staff. The Service Director of IM stated if the NP did not place the order, but did place it in their progress notes, the nurse was expected to phone the provider and ask them if they wanted it. The Service Director of IM stated the nurses were expected to read the provider notes, follow-up, and call the provider. 7. On 1/22/25, Patient 10’s medical record was reviewed and showed Patient 10 was admitted to the hospital on 12/1/24. Review of Patient 10’s Master Treatment Plan showed the medical problems including ulcerative colitis, anemia, and possible fistula on the perianal area. Review of Patient 10’s Consultation Request dated 12/06/24, showed a medical consultation. Patient 10 had reported a history of ulcerative colitis and a current flare up. The patient had loose stool and small amount of dried blood observed with redness to perinea area. An opening on the right perianal area stool of leaking loose stool was observed. The patient states she usually received injections of Stelara (a medication used to treat ulcerative colitis) for treatment. Review of the NP’s Consultation Reply dated 12/6/24, showed to recommend the patient to be seen in the ED for further evaluation to rule out fistula by means of CT abdomen/pelvis. The patient could “be sent BLS scheduled pick up.” On 1/22/25 at 1002 hours, an interview was conducted with the Service Director of IM. The Service Director of IM was asked if a recommendation was an order or simply a recommendation for care. The Service Director of IM stated the consultation reply was for orders, the providers did not recommend but gave orders for the nursing staff to follow. The Service Director of IM was asked what was expected to be done if a NP placed an order in the consultation reply note, but it was not transcribed into the patient’s medical record as an order. The Service Director of IM stated all reply notes were to be reviewed by the nursing staff. The Service Director of IM stated if the NP did not place the order, but did place it in their reply note, the nurse was expected to phone the provider and ask them if they wanted it. The Service Director of IM stated the nurses were expected to read the reply notes to the nursing requests, follow-up, and call the provider if they had a concern about an order. On 1/22/25 at 1104 hours, an interview and concurrent review of Patient 10’s medical record was conducted with the Director of Quality. The Director of Quality verified the hospital’s P&P related to transcribing the provider’s orders did pertain to this patient. The Director of Quality was asked to show the transcribed order for the NP order in the consult reply note on 12/6/24, sending Patient 10 to the E) for further evaluation. The Director of Quality reviewed the nursing progress notes and provider’s orders and verified the order had not been transcribed, no follow-up phone call or clarification had been documented by the nursing staff in Patient 10’s medical record. On 1/22/25 at 1130 hours, an interview and concurrent record review was conducted with the Nurse Educator. The Nurse Educator stated the nursing staff was expected to read the provider’s consultation reply notes to the original concern and act accordingly. The Nurse Educator stated if an order was unclear, the nurse was expected to call the provider who wrote the order and get clarification, document the clarification, and act accordingly. The Nurse Educator stated the verbiage recommendation for the ED was confusing and required further follow up with the provider. The Nurse Educator stated the expectation was to follow the hospital’s P&P. The Nurse Educator stated the rationale for calling the provider was to ensure the patient received the intended treatment, such as being sent to the ED. 8. On 1/22/25, Patient 14’s medical record was reviewed and showed Patient 14 was admitted to the hospital on 12/2/24. Review of Patient 14’s Consultation Request dated 12/5/24, showed a medical consultation. Patient 14 complained of diarrhea. The patient came back from dinner early due to feeling dizzy and unwell. Review of the NP’s Consultation Reply dated 12/6/24, showed to recommend Imodium q 6 hours prn and BRAT diet for now. On 1/22/25 at 1002 hours. an interview was conducted with the Service Director of IM. The Service Director of IM was asked what was expected to be done if an NP placed an order in the consultation reply note, but it was not transcribed into the patient’s medical record as an order. The Service Director of IM was asked if a recommendation was an order or simply a recommendation for care. The Service Director of IM stated the consultation reply was for orders and providers did not recommend but gave orders for the nursing staff to follow. The Service Director of IM stated all reply notes were to be reviewed by the nursing staff. The Service Director of IM stated if the NP did not place the order, but did place it in their reply note, the nurse was expected to phone the provider and ask them if they wanted it. The Service Director of IM stated the nurses were expected to read the reply notes to the nursing requests, follow-up. and call the provider if they had a concern about an order. On 1/22/25 at 1406 hours, an interview and concurrent review of Patient 14’s medical record was conducted with the Director of Quality. The Director of Quality verified the hospital’s P&P related to transcribing physician’s orders did pertain to this patient. The Director of Quality was asked to show the transcribed order for the NP order in the consultation reply note on 12/6/24, ordering Patient 14 to be ordered Imodium every 6 hours as needed and to be placed on a BRAT diet. The Director of Quality reviewed the MAR, nutrition notes, nursing progress notes, and provider’s orders and verified the order had only been transcribed with the Imodium being ordered, but not the BRAT diet. The Director of Quality verified no follow-up phone call or clarification had been documented by the nursing staff in Patient 14’s medical record. On 1/22/25 at 1408 hours, an interview and concurrent record review was conducted with the Nurse Educator. The Nurse Educator stated the nursing staff was expected to read the provider’s consultation reply notes. The Nurse Educator stated if an order was unclear, the nurse was expected to call the provider who wrote the order and get clarification, document the clarification, and act accordingly. The Nurse Educator stated the verbiage recommendation for both the medication, Imodium and the BRAT diet was confusing and required further follow up with the provider. The Nurse Educator stated the expectation was to follow the hospital’s P&P. The Nurse Educator stated the rationale for calling the provider was to ensure the patient received the intended treatment.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the P&P for Infection Prevention and Control was implemented when the list of patients monitored for the reported signs and symptoms of nausea, vomiting, and diarrhea was not completed. This failure posed an increased risk for the spread of and exposure to communicable organisms to vulnerable patients and staff. Findings: Review of hospital’s P&P titled Surveillance Methods dated October 2024 showed the following: * There is a written plan describing the type of surveillance carried out to monitor the rates of hospital-acquired infections, the system used to collect and analyze data, and activities to prevent and control infection. * Various methods used to identify infections of the patients include: - Screening patients on admission. - Chart review, including microbiology, serology, and radiology result, as well as the other diagnostic studies - Review of laboratory results. - Review of pharmacy reports. - Review and input from physicians and other health care personnel. - Information from admitting and census sheets. * Approved criteria are used to determine whether infections identified are community acquired or hospital acquired. * The Infection Preventionist gathers pertinent data when a hospital acquired infection is suspected from the diagnosis by the physician, physician order of antibiotics or antiviral, positive culture result, and or observation of signs and or symptoms by nursing staff. - All pertinent data is recorded, including but not limited to date of admission, procedure performed, lab results, and date of onset of infection following the National Healthcare Safety Network (NHSN) and McGeer criteria in the absence of clear guidelines from NHSN. - Summaries are reviewed at the ICC meetings. - Any unusual pattern or trend specific infection that requires input from the ICC meeting will be brought to the meeting for review. * Surveillance Method: Cluster or outbreak investigations will become the immediate top priority at any time an unexpected occurrence or frequency of infections become evident. Indicators for such increased incidence may include reports of a particular organism, service, site, or ward. Examples may be clustering of any infection from specific unit or even from all units. Review of the hospital P&P titled Communication of Infection Control Information dated October 2024 showed in part: - The Infection Control Preventionist is responsible for managing the infection control program. He or she is responsible for surveillance, monitoring and reporting of infection control issues, concerns, and information to appropriate individuals, departments, and or agencies. - Disseminate information to staff results of surveillance, recommended changes, and enforcement of standards, through in-services, orientation, and education, posters, newsletters, email updates or personal counseling. - The Department heads share infection control information, issues, concerns through their scheduled staff meeting, or personal counseling. - Staff and personnel are responsible for bringing to infection control coordinator and their department heads, infection control issues of non-compliance to standard of care. They are responsible for reporting exposure incidents, possible outbreaks situation, personal illnesses or diseases that may constitute an infection or communicable condition. They are to inform Infection Control Department if a patient is placed in isolation precautions. On 1/14/25 at 1345 hours, an interview was conducted with the CNO. The CNO was asked who the Infection Control Preventionist was. The CNO stated the hospital had contracted services for infection control and prevention and she was the Infection Control contact person for the hospital. The CNO was asked if there was reported outbreak of C-diff or food poisoning. The CNO stated there was no reported food poisoning; however, the staff had reported nausea, vomiting, and diarrhea. She did not remember specific date, but she remembered a specific person who was Patient 1. a. On 1/14/25 at 1425 hours, Patient 1’s closed medical record was reviewed with the CNO. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 12/2/24 and discharged on 12/16/24. Review of the Nursing Progress Notes dated 12/4/24 at 1859 hours, showed Patient 1 had several episodes of watery light brown foul-smelling diarrhea during the late afternoon. Imodium was given with little effect. Patient 1 also complained of generalized abdominal pain, bloating, and some mild nausea. Patient 1’s abdomen was distended but soft. NP 1 was notified, and Patient 1 would be sent out for medical evaluation. The BLS transportation would be arranged for the patient to go to the nearest ER. Review of the Acute Nursing Progress Note dated 12/4/24 at 2000 hours, showed Patient 1 would be sent out to a hospital for assessment of uncontrolled diarrhea. b. Review of the medical records for Patients 2, 3, 4, 5, 6, and 7 showed the following: * Patient 2 received Zofran 4 mg po once on 12/5/24 at 2027 hours. The RN Progress Note showed on 12/6/24 at 0037 hours, the patient complained of nausea and vomiting started earlier in the day. The Consultation Request to NP 1 showed on 12/6/24 at 0033 hours, the patient reported nausea and vomiting since earlier in the day. NP 1’s consultation reply showed on 12/6/24, the NP recommended Zofran for nausea and vomiting and clear liquid diet; and the diagnosis was acute nausea and vomiting and acute diarrhea. - Patient 3 received Zofran 4 mg po on 12/5/24 at 2344 hours and 12/6/24 at 1251 hours. On 12/6/24 at 0038 hours, the RN consulted NP 1 for the patient’s complaint of nausea and vomiting since earlier in the day. NP 1 consultation reply showed on 12/6/24 at 0812 hours, to give the patient Zofran with Imodium every 6 hours as needed and recommended clear liquid diet and the diagnosis was acute nausea, vomiting, and acute diarrhea. - Patient 4 received Zofran 4 mg po on 12/6/24 at 0013 hours. On 12/7/24 at 0017 hours, the RN consulted NP 1, the patient endorsed feeling bloated and experienced nausea and vomiting for the past 24 hours; however, there was no reply from NP 1. - Patient 5 was given Zofran 4 mg po on 12/6/24 at 1152 hours, 12/7/24 at 0150, 0938, and 1628 hours; and loperamide 2 mg po on 12/6/24 at 1507 and 2130 hours and on 12/7/24 at 0750, 0937, and 1631 hours. The RN placed a consolation request to NP 1 on 12/6/24 at 0043 hours, for patient’s complaint of nausea and vomiting since earlier in the day. NP 1’s Consultation Reply dated 12/6/24 at 0748 hours, showed to give Zofran as needed for nausea and vomiting and recommend clear liquid diet and the diagnosis was acute nausea and vomiting. - Patient 6’s medical record showed on 12/4/24 at 0648 hours, the LVN placed a consultation request to a medical physician for patient’s complaint of diarrhea. NP 1 consultation reply dated 12/4/24 at 0940 hours, showed to give Imodium 2 mg every 8 hours as needed for 3 days, and the diagnosis was acute diarrhea. On 12/9/24 at 0800 hours, RN’s Progress Note showed Patient 6 was experiencing diarrhea and as per the NP, to place Patient 6 on contact Precaution. The staff encouraged the patient to follow precautions and to stay in the room. The CNO was asked about Patient 6’s contact precaution. The CNO stated Patient 6 was placed on contact precaution for diarrhea as per the telephone order. The staff would put a sign on the door for specific type of isolation. For Patient 6’s contact isolation was the use of gown, gloves, and hand hygiene. The CNO was asked when the contact isolation was discontinued. The CNO stated as per the RN’s Progress Note on 12/13/24 at 1200 hours, the RN spoke to NP 1 and discontinued the contact isolation as a telephone order. - Patient 7’s medical record showed on 12/4/24 at 1242 hours, the patient was given Bentyl 20 mg for abdominal cramps. On 12/8/24 at 2043 hours, the RN sent the Consultation Request to a medical physician for the patient requested to be seen, experienced diarrhea as of today. However, there was no reply from the medical physician. c. On 1/22/25 at 0845 hours, review of the medical records for Patients 11, 12, and 13 was conducted with the Nurse Educator. - Patient 11’s medical record showed on 12/5/24, the patient received Zofran 4 mg po at 0352 hours for nausea and refused at 1042 hours. The RN Progress note dated 12/5/24. showed the patient complained of nausea and vomiting; however, the patient refused Zofran as the medication made her vomit after she took the medication. - Patient 12’s medical record showed on 12/7/24 at 1422 hours, the patient was given Zofran 4 mg po for nausea and vomiting; and was reassessed as not effective. On 12/8/24 at 0914 hours, the RN Progress Note showed Patient 12 refused the 0900 hours medications, including Lexapro and gabapentin due to nausea and diarrhea. - Patient 13’s medical record showed on 12/5/24 at 1819 hours, the RN sent a consultation request to NP 1 for patient’s complaint of mild diarrhea. On 12/6/24 at 1105 hours, the patient was given Imodium 2 mg po for diarrhea as needed. NP 1’s Consultation Reply dated 12/6/24 at 0752 hours, showed to give the patient Imodium every 6 hours as needed and recommend clear liquid diet. On 1/16/25 at 1308 hours, a telephone interview was conducted with the Infection Control Preventionist and Associate Infection Control Preventionist. The Associate Infection Control Preventionist was asked if the hospital had reported incidence of patients who had nausea, vomiting, and diarrhea during 12/4 to 12/9/24. The Associate Infection Control Preventionist stated there were patients reported during the 12/4 to 12/9/24 but could not recall the specific date. The Associate Infection Control Preventionist stated there was no outbreak but had clusters of patients who had the reported symptoms of nausea, vomiting, and diarrhea; there was no trends, no cohorting, no verifiable cause of symptoms. There was no test that turned out to verify it was an infectious outbreak. From the time they were informed, they started monitoring the symptoms and collaborating with the nursing team’s report of symptoms. The Associate Infection Control Preventionist was asked what intervention was done during the monitoring. The Associate Infection Control Preventionist stated they had the EVS to monitor cleanliness of the environment, they used glogerm and immediately once they got the report, the EVS cleaned with bleach to prevent potential spread. Review of the List of Patients monitored for the reported sign and symptom of nausea, vomiting. and diarrhea showed five patients exhibited the symptoms on 12/4/24 and one patient exhibited the symptom on 12/5/24. The surveillance report was undated and there was no documented evidence of the intervention or education provided to staff or the EVS. On 1/16/25 1505 hours, interview was conducted with the Director of Quality. The Director of Quality was asked about the Infection Control Monitoring for the symptoms reported to the Infection Control. The Director of Quality stated there were only few patients listed on the monitoring sheet. The Director of Quality stated this happened when the staff did not report to the administration what was going on in their units. On 1/21/25 at 0917 hours, a follow-up telephone interview was conducted with the Infection Control Preventionist and the Associate Infection Control Preventionist. The Associate Infection Control Preventionist was asked for the documentation of what was done during the visit at the hospital for monitoring and intervention for the six patients reported with nausea, vomiting, and diarrhea. The Associate Infection Control Preventionist stated the hand hygiene and PPE rounds was documented; if there was concern, it was corrected on the spot; if not corrected, they spoke to the staff. There was no clear cut with the patients ’ reported symptoms. The EVS was educated about disinfection and contact time for the bleach. The Associate Infection Control Preventionist stated they checked with the nursing staff to follow up if there were other patients with reported symptoms and there were no additional cases reported. However, there was no documented evidence of the education and intervention performed during the visit. The Associate Infection Control Preventionist was informed there were patients with nausea, vomiting, and diarrhea with the same symptoms of nausea, vomiting and diarrhea; however, these patients were not included on their surveillance list. The Associate Infection Control Preventionist was asked if all the staff were informed of the purpose of their presence at the hospital and if they communicated with the physicians. The Associate Infection Control Preventionist stated they informed the supervisors and the staff; however, they did not meet with the night shift staff. On 1/22/25 at 1430 hours, an interview was conducted with the Director of Quality and Nurse Educator. The Nurse Educator was asked if he was aware of the Infection Control’s presence in the hospital for the patients reporting of nausea, vomiting, and diarrhea. The Nurse Educator stated he heard from the Nurse Manager that there was GI issue going around. The Nurse Educator stated he did not know the Infection Control was at the hospital to address the issue. The Director of Quality was asked how the staff would know the Infection Control’s presence at the hospital. The Director of Quality stated the Infection Control reported to the CNO, the Nurse Educator would not know the Infection Control’s presence at the facility. The Director of Quality was asked how the monitoring was done for one day on the list. The Director of Quality stated they did not have other reported patients; they had only what was on the list. The findings were share with the CNO and Director of Quality.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the patient grievance was promptly processed as evidenced by: 1. The grievance was not initiated by the Patient Advocate for one of 12 patients (Patient 1) as per the hospital’s P&P. 2. The Patient Advocate’s phone number posted in the lobby was not available for the patients or visitors to leave message to file a grievance. These failures created the risk of unresolved safety and quality concerns, and substandard patient care to the patients. Findings: Review of the hospital’s P&P titled Grievances and Complaints dated October 2023 showed the following: * The definition of the complaint is the written or verbal expression of concern that can be resolved promptly by staff who are present at the time of the complaint. Complaints typically involve minor issues, such as room, housekeeping, or food preferences, which may not require investigation or peer-review processes. * The definition of the grievance is the written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights, hospital compliance with regulatory agencies, or if the patient requests a formal written response to their concern. * All complaints and grievances are to be submitted verbally or in writing to the Patient Rights Representative, either by the patient, the patient’s representative, or a staff member if a patient is unable to execute a written complaint. Review of the Patient Advocate’s Job Description showed the following key responsibilities as the Patient Advocate: * Act as in house Patients’ Rights Representative. * Meet with the patients within two working days of receiving a grievance. * Document the patient meeting in the patient grievance form. * Complete the patient complaint log when finished addressing the patient’s needs in a timely manner. * Report back to the administrator all crisis investigations within 48 hours. * Handle post-patients’ complaint letters and responses. 1. On 10/14/24, an interview and concurrent closed medical record review was conducted with the CNO. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 9/9/24, and discharged on 9/12/24. Review of the Progress Note dated 9/12/24 at 1007 hours, showed Therapist 1 and the Patient Advocate had three-way phone call with Patient 1’s family member regarding Patient 1’s discharge planning. Review of the Call Log dated 9/12/24 at 1041 hours, showed Patient 1’s family member called the Patient Advocate. On 10/14/24 at 1007 hours, an interview was conducted with Therapist 1. When asked, Therapist 1 stated she recalled Patient 1’s family member voiced concerns about Patient 1’s care during the three-way call with the Patient Advocate. On 10/14/24 at 1123 hours, the CNO and Director of PI and Risk Management were interviewed. When asked, the CNO and Director of PI and Risk Management stated if the patient or patient representative’s concerns were resolved at the moment, it was considered as complaint and not grievance. When asked, the CNO and Director of PI and Risk Management stated there was no grievance filed related to Patient 1. The CNO and Director of PI and Risk Management stated the concerns Patient 1’s family member voiced might be considered as a complaint not grievance. When asked, the CNO and Director of PI and Risk Management stated the Patient Advocate had no longer worked in the hospital, so they were not able to identify the concerns were resolved at the moment. On 10/15/24 at 1223 hours, the CNO verified the above findings. 45560 2. On 10/14/24 at 1110 hours, during an observation in the main hospital lobby, a posting showed the name and phone number of the Patient Advocate. On 10/14/24 at 1113 hours, a phone call was made to the posted number of the Patient Advocate. The call was gone directly to the recorded voice mail saying the mailbox was full and could no longer accept messages. On 10/15/24 at 1150 hours, an interview was conducted with Receptionist 1. Receptionist 1 stated the only number for the Patient Advocate was the one listed on the posting in the main hospital lobby. On 10/15/24 at 1348 hours, the CNO was notified and acknowledged the above findings.”

“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: 35310 Based on observation, interview, and record review, the hospital failed to ensure the patients received care in a safe setting when the reusable blood pressure cuff was not cleaned between the patient use. This failure had the potential to result in unsafe care and poor clinical outcomes to the patients. Findings: Review of the Reusable Blood Pressure Cuffs’ Instructions For Use dated February 2021 showed the following types of wipes are compatible for use on the reusable cuffs. The user must inspect after cleaning to verify that removal of soil and contaminants is complete. Use one or more of the following methods and allow to air dry: * Wipe with enzymatic cleaner per manufacturer’s instruction. Rinse with a damp cloth. * Wipe with 0.5 % bleach and water solution. Rinse with a damp cloth. * Wipe with 70% isopropyl alcohol. Rinse with a damp cloth. On 10/14/24 at 0851 hours, a tour of the Specialty Unit was conducted. The following was observed: * MHW 1 was observed checking a patient’s BP by using a reusable BP cuff. The reusable BP cuff was directly placed to the patient’s bare arm. * The patients were observed in line waiting for their turns to have their BPs be taken. * MHW 1 was observed not cleaning the reusable BP cuff between the patient use. Upon completion of the BP measurement, MHW 1 was asked to provide a copy of the Vital Signs sheet. Review of the Vital Signs sheet for Specialty Unit dated 10/14/24, showed 19 patients had their BPs be measured. On 10/15/24 at 1223 hours, the CNO was interviewed. When asked, the CNO stated the reusable BP cuff was to be cleaned between the patient’s use. The CNO verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 39199 Based on observation, interview, and record review, the hospital failed to ensure the staff monitored the vital signs, nutrition, hydration, hygiene, and elimination needs in accordance with the hospital’s P&P for two of 12 sampled patients (Patients 8 and 9) when they were restrained or secluded. This failure posed the potential to result in unsafe care to the patients. Findings: Review of the hospital’s P&P titled Seclusion and Restraints dated March 2024 showed seclusion is the involuntary confinement and isolation of a person, alone in a room or an area, where the patient is physically prevented from leaving. The clinical staff completes documentation on the seclusion and restraints flowsheet. The following patient needs are assessed on a continuous 1:1 basis and documented in the medical record every 15 minutes: vital signs, nutrition and hydration needs, and hygiene and elimination needs. 1. On 10/14/24 at 0831 hours, a tour of the 2W Unit was conducted with the House Supervisor. Patient 8 was observed in the seclusion room in the 2W Unit. MHW 3 was observed conducting 1:1 direct observation of Patient 8 from the outside of the seclusion room door. The House Supervisor stated Patient 8 was a danger to self and others and placed in the seclusion room due to displaying poor boundaries with peers, lunging at staff, and unsuccessful attempts at de-escalation. On 10/15/24 at 1000 hours, an interview and concurrent medical record review was conducted with the CNO. Patient 8’s medical record showed Patient 8 was admitted to the hospital on 10/12/24. Review of Patient 8’s Seclusion/Restraint Record showed Patient 8 was placed in seclusion on 10/14/24 at 0753 hours, and remained there until 10/14/24 at 0930 hours. There was no documentation in the Seclusion/Restraint Record to show the following patient needs were assessed and documented every 15 minutes as per the hospital’s P&P: vital signs, nutrition, hydration, hygiene, and elimination needs. On 10/15/24 at 1000 hours, the CNO verified the findings and stated there was no section on the Seclusion/Restraint Record for staff to document the assessment of patient’s needs (nutrition, hydration, hygiene, and elimination) every 15 minutes. 2. On 10/14/24 at approximately 0855 hours, a Code Grey in the 1W Unit was announced overhead during the hospital tour with the House Supervisor. On 10/14/24 at 0900 hours, Patient 9 was observed in the seclusion room in the 1W Unit. On 10/15/24 at 1030 hours, an interview and concurrent medical record review was conducted with the CNO. Patient 9’s medical records showed Patient 9 was admitted to the hospital on 10/8/24. Review of Patient 9’s Seclusion/Restraint Record showed Patient 9 was placed in seclusion on 10/14/24 at 0900 hours, and remained there until 1100 hours on the same day. The record showed Patient 9 refused vital sign measurements from 0915 to 1015 hours; however, there were no documented attempts to obtain their vital signs every 15 minutes from 1015 to 1100 hours. Additionally, the record lacked documentation showing the patient’s needs were assessed and recorded every 15 minutes in accordance with the hospital’s P&P, specifically for nutrition and hydration needs, as well as hygiene and elimination needs. On 10/15/24, the CNO verified the findings and stated there was no section on the Seclusion/Restraint Record for staff to document the assessment of patient needs (nutrition, hydration, hygiene, and elimination) every 15 minutes.”

“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: 39199 Based on observation, interview, and record review, the hospital failed to ensure the face-to-face evaluation for one of 12 sampled patients (Patient 9) was completed within one hour of the initiation of restraint or seclusion. This failure to conduct the face-to-face evaluation in a timely manner had the potential to prolong seclusion and could lead to unsafe care. Findings: Review of the hospital’s P&P titled Seclusion and Restraints dated March 2024 showed the physician, licensed independent practitioner (LIP), or trained RN will conduct a face-to-face assessment of the patient and document the physical behavioral assessment in the patient’s medical record within one hour of the initiation of seclusion or restraint. Telehealth methodology cannot be used to conduct the face-to-face evaluation. Evaluation includes the patient’s immediate situation, the patient’s reaction to the intervention, the patient’s medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. On 10/14/24 at approximately 0855 hours, a Code Grey in the 1W Unit was announced overhead during the hospital tour with the House Supervisor. On 10/14/24 at 0900 hours, Patient 9 was observed in the seclusion room in the 1W Unit. On 10/15/24 at 1030 hours, an interview and concurrent review of Patient 9’s medical record was conducted with the CNO. Patient 9’s medical record showed Patient 9 was admitted to the hospital on 10/8/24. Review of Patient 9’s Attending Clinician Order for Seclusion/Restraint dated 10/14/24 at 0857 hours, showed the seclusion/restraint was indicated because of the patient’s homicidal behavior or threats with the plan and imminent danger to self or others due to their thought disorder. Review of Patient 9’s Seclusion/Restraint Record showed Patient 9 was placed in seclusion on 10/14/24 at 0900 hours, and remained there until 1100 hours on the same day. Review of the Seclusion/Restraint Post Conference for Staff showed the face-to-face assessment was conducted on 10/14/24 at 1200 hours, which was not within one hour of the initiation of seclusion. On 10/15/24 at 1030 hours, the CNO verified the face-to-face assessment was not conducted within one hour of when Patient 9 was placed in seclusion.”

“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: 39199 Based on interview and record review, the hospital failed to ensure the staff monitored one of 12 sampled patients (Patient 9) at the frequency as ordered by the physician. This failure could compromise the patient’s safety. Findings: On 10/15/24 at 1030 hours, an interview and concurrent review of Patient 9’s medical record was conducted with the CNO. Patient 9’s medical record showed the patient was admitted to the hospital on 10/8/24. Review of the physician’s order dated 10/8/24, showed Patient 9’s required level of observation was every five minutes, around the clock. Review of Patient 9’s Psychiatric Evaluation dated 10/9/24 at 0700 hours, showed Patient 9 was admitted on a 5250 legal hold for Gravely Disable (GD), bizarre behaviors and a disorganized thought process, presenting with non-redirectable manic behaviors. The Plan of Care section showed Patient 9 had auditory and visual hallucinations and aggressive and violent behaviors; posed a danger to self; and level of observation was to be conducted every 15 minutes. Review of the Patient Observation Record dated 10/14/24, showed documentation of Patient 9’s specific location and activity/behavior (such as walking/pacing, withdrawn, etc.) at specified intervals. However, the documentation showed Patient 9 was not monitored every five minutes as ordered; instead, the staff monitored Patient 9’s location and activity every 15 minutes. On 10/15/24 at 1030 hours, and interview was conducted with the CNO. The CNO stated the physician’s order dated 10/8/24, for required level of observation every five minutes was still active and in effect despite the psychiatric evaluation showing the level of monitoring was every 15 minutes. The CNO stated the frequency of monitoring should be based on the physician’s orders. The CNO verified Patient 9 was monitored every 15 minutes instead of every five minutes.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff completed the AMA form for one of 12 sampled patients (Patient 1) as per the hospital’s P&P. This failure had the potential to result in unsafe care and poor clinical outcomes to the patient. Findings: Review of the hospital’s P&P titled AMA (Against Medical Advice) Discharge dated June 2024 showed if the patient is to be discharged AMA, the patient or guardian should be asked to sign the AMA documentation form in the presence of at least one witness. If the patient or guardian refuses to sign, the unit nurse is to write “patient refuses to sign” on the signature line and then sign their own name and title with date and time. On 10/14/24, Patient 1’s closed medical record was reviewed with the CNO. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 9/9/24, and discharged on 9/12/24. Review of the Request for Discharge by Voluntary Patient or Representative (AMA) dated 9/12/24, showed Patient 1 did not sign the AMA form. Further review of the Request for Discharge by Voluntary Patient or Representative (AMA) form showed the sections for “if patient did not sign, please indicate the reason” and “witness” signature and date/time were blank. On 12/15/24 at 1223 hours, the CNO verified the above findings.”

“Treatment Plan - Goals CFR(s): [The written plan must include] Short-term and long range goals; This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the short and long-term goals were included in the Master Treatment Plan for 11 of 12 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) as per the hospital’s P&P. This failure created the increased risk of poor health outcomes to the patients in the hospital. Findings: Review of the hospital’s P&P titled Master Treatment Plan dated October 2023 showed the Master Treatment Plan shall contain specific Short-and Long-Term Goals which are individualized specific to the patients’ ages, diagnoses, circumstances, and needs. 1. On 10/14/24, Patient 1’s closed medical record was reviewed with the CNO. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 9/9/24, and discharged on 9/12/24. Review of the Psychiatric Problem Sheet initiated by the RN on 9/9/24 at 2355 hours, showed the short and long-term goals and interventions for the problem related to suicidal ideation and danger to self. Review of the Master Treatment Plan dated 9/10/24, showed the treatment plan was formulated by the multi-disciplinary team including nursing, physician, and social services. However, the Master Treatment Plan failed to show the short and long-term goals as per the hospital’s P&P. 2. On 10/14/24, Patient 2’s medical record was reviewed with the CNO. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 10/7/24. Review of the Master Treatment Plan for Patient 2 failed to include the short and long-term goals as per the hospital’s P&P. 3. On 10/14/24, Patient 3’s medical record was reviewed with the CNO. Patient 3’s medical record Patient 3 was admitted to the hospital on 9/20/24. Review of the Master Treatment Plan for Patient 3 failed to include the short and long-term goals as per the hospital’s P&P. 4. On 10/14/24, Patient 4’s closed medical record was reviewed with the CNO. Patient 4’s clsoed medical record showed Patient 4 was admitted to the hospital on 9/2/24, and discharged on 9/12/24. Review of the Master Treatment Plan for Patient 4 failed to include the short and long-term goals as per the hospital’s P&P. 5. On 10/14/24, Patient 5’s closed medical record was reviewed with the CNO. Patient 5’s closed medical record showed Patient 5 was admitted to the hospital on 9/7/24. Review of the Master Treatment Plan for Patient 5 failed to include the short and long-term goals as per the hospital’s P&P. On 10/15/24 at 1314 hours, the CNO and Director of the Clinical Services verified the above findings. 39199 6. On 10/15/24, Patient 7’s closed medical record was reviewed with the CNO. Patient 7’s closed medical record showed Patient 7 was admitted to the hospital on 9/13/24, and discharged on 9/19/24. Review of Patient 7’s Master Treatment Plan, signed by the patient on 9/15/24, did not include the patient’s individualized short and long-term goals as per the hospital’s P&P. 7. On 10/15/24, Patient 8’s medical record was reviewed with the CNO. Patient 8’s medical record showed Patient 8 was admitted to the hospital on 10/12/24. Review of Patient 8’s Master Treatment Plan, signed by the patient on 10/13/24, did not include the patient’s individualized short and long-term goals as per the hospital’s P&P. 8. On 10/15/24, Patient 9’s medical record was reviewed with the CNO. Patient 9’s medical record showed Patient 9 was admitted to the hospital on 10/8/24. Review of Patient 9’s Master Treatment Plan signed by the patient on 10/10/24, did not include the patient’s individualized short and long-term goals as per the hospital’s P&P. On 10/15/24 at 1050 hours, the CNO verified the findings and stated the patients’ short and long-term goals were documented on their problem sheets but was not included on their Master Treatment Plans. 45560 9. On 10/15/24, Patient 6’s medical record was reviewed. Patient 6’s medical record showed Patient 6 was admitted to the hospital on 10/3/24. Review of the Master Treatment Plan for Patient 6 failed to include the short and long-term goals as per the hospital’s P&P. 10. On 10/15/24, Patient 10’s medical record was reviewed. Patient 10’s medical record showed Patient 10 was admitted to the hospital on 10/10/24. Review of the Master Treatment Plan for Patient 10 failed to include the short and long-term goals as per the hospital’s P&P. 11. On 10/15/24, Patient 11’s medical record was reviewed. Patient 11’s medical record showed Patient 11 was admitted to the hospital on 10/11/24. Review of the Master Treatment Plan for Patient 11 failed to include the short and long-term goals as per the hospital’s P&P. On 10/15/24 at 1314 hours, the CNO verified the above findings.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the master treatment plan was developed for one of 12 sampled patients (Patient 1) as per the hospital’s P&P. This failure created the increased risk of poor health outcomes to the patients in the hospital. Findings: Review of the hospital’s P&P titled Master Treatment Plan dated October 2023 showed the following: * Each patient admitted to the hospital shall have a written, individualized master treatment plan (MTP) that formulates a plan of care that meets the patient’s objectives and needs. Treatment shall be planned, reviewed, and evaluated at regular intervals by a multidisciplinary treatment team. This team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. Ultimate responsibility for the development and implementation of the master treatment plan shall rest with the physician. * Within eight hours of admission, the RN will initiate the mater treatment plan. This initial plan shall include high risk and critical medical problems and appropriate physician and nursing interventions as determined by the initial assessments, the physician’s treatment plan, and the physician’s order. * Within 72 hours of admission, member of the treatment team shall further develop the master treatment plan that is based on a comprehensive assessment of the patient’s presenting problems, physical health, emotional and behavioral status. The team will consist of the physician, nursing staff, social services staff, adjunctive therapy staff, and other clinical disciplines, as appropriate. * The treatment plan is developed and reviewed on the same day as the treatment team meeting. On 10/14/24, Patient 1’s closed medical record was reviewed with the CNO. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 9/9/24 at 2010 hours, and discharged on 9/12/24. a. Review of the Nursing Admission Assessment dated 9/9/24 at 2257 hours, showed RN 8 developed the initial treatment plan for Patient 1. Review of Patient 1’s Psychiatric Evaluation dated 9/10/24 at 0700 hours, showed the Psychiatric Evaluation for Patient 1 was conducted. On 10/15/24 at 1324 hours, the CNO was interviewed. When asked, the CNO stated the nursing admission assessment included the initial treatment plan. The CNO verified RN 8 developed the initial treatment plan prior to physician’s treatment plan. b. Review of the Master Treatment Plan showed the following treatment team’s signatures: * The physician signed on 9/10/24 at 0738 hours, * The Social Services staff signed on 9/10/24 at 1519 hours. * The nursing staff signed on 9/10/24 at 1522 hours. * Patient 1 signed on 9/10/24 at 1519 hours. On 10/15/24 at 1324 hours, the CNO was interviewed. When asked when the members of the team including physician, social services staff, and nursing staff had met for the master treatment plan, the CNO was not able to answer. The CNO verified the above findings.”

“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: 39796 Based on interview and record review, the hospital failed to ensure the nursing care and services were provided for three of six sampled patients (Patients 1, 2 and 3) when the nursing staff did not ensure the pain management for Patients 1, 2, and 3 as per the hospital’s P&P. This failure created the increased risk of poor health outcomes to the patients in the hospital. Findings: Review of the hospital’s P&P titled Pain Assessment/Management and Safe Opiate Prescribing dated June 2024 showed the following: * Pain management and safe opiate prescribing is a priority. * The patients have the right to appropriate assessment and management of pain. The procedure includes the initial assessment of any pain that a patient may be experiencing is documented as part of nursing assessments. A 1-10 numeric Pain Intensity Scale is used. The assessment includes the location and description of the pain the patient is experiencing. * Reassessment of a patient’s pain is done by the nursing staff every shift or as appropriate after medication administration and documented on the nursing progress note. Any significant change will be reported to the Internist. 1. Review of Patient 1’s closed medical record was initiated on 9/13/24 at 0730 hours. Patient 1’s closed medical record showed the patient was admitted to the hospital on 8/24/24, and discharged on 8/29/24. Review of the RN Progress Note dated 8/24/24 at 1807 hours, showed the RN documented a problem of physical assault. The RN Progress Note showed at approximately 1630 hours, Patient 1 was involved in a physical altercation with other patients. Patient 1 suffered minor scratches and reported pain to her head. However, review of Patient 1’s closed medical record failed to show documented evidence the RN had performed a complete pain assessment as per the hospital’s P&P. On 9/17/23 at 1008 hours, an interview and concurrent review of Patient 1’s closed medical record was conducted with the CNO and Director of Quality. When asked if the staff needed to assess Patient 1’s reported head pain, the CNO stated if someone reported pain, it would be assessed, but the CNO could not speak for the nurses. When asked if the pain assessment was documented, the Director of Quality stated no. The CNO acknowledged the findings. On 9/17/24 at 1038 hours, an interview and concurrent review of Patient 1’s closed medical record was conducted with RN 1, the CNO, and Director of Quality. RN 1 stated there was a minor scratch on Patient 1’s face and the patient reported pain on the head. RN 1 stated the patient complained of pain all over her body to the paramedic staff. RN 1 was asked if the pain assessment was documented. RN 1 stated it was reported to the doctor but not documented. RN 1 also confirmed there was an order for Tylenol (pain medication), but the CNO found it was not given. RN 1 stated probably, it was offered, but the patient declined. On 9/17/24 at 1635 hours, the CNO, Director of Quality, and CEO were informed and acknowledged the findings. 40483 2. Review of Patient 2’s medical record showed Patient 2 was admitted to hospital on 7/31/24. Review of the MAR dated 8/11/24, showed Patient 2 had a physician’s order for acetaminophen (or Tylenol) oral tablet 325 mg, one tablet every four hours as needed. Review of the flowsheet dated 8/11/24 at 0611 hours, showed Patient 2 was assessed for a pain scale of 8 (on a pain scale of 0 to 10 with 0 = no pain and 10 = most pain). Review of MAR dated 8/11/24 at 0611 hours, showed one acetaminophen 325 mg tablet was administered to Patient 2. No documented pain reassessment for effectiveness after Patient 2 received a 325 mg acetaminophen tablet was found in Patient 2’s medical record. Review of the MAR dated 8/11/24 at 1416 hours, showed one acetaminophen 325 mg tablet was administered to Patient 2. Review of the flowsheet dated 8/11/24 at 1416 hours, no documented assessment or reassessment for pain even though a pain medication was given to Patient 2. Review of the flowsheet dated 8/11/24 at 2031 hours, showed Patient 2 was assessed for a pain level of 8. Review of the Acute Nursing Progress Note dated 8/11/24 at 2031 hours, showed Patient 2 was assessed for a pain level of 8. Review of the MAR dated 8/11/24 at 2031 hours, showed one acetaminophen 325 mg tablet was administered to Patient 2. No documented pain reassessment for effectiveness after Patient 2 received a 325 mg acetaminophen tablet was found in Patient 2’s medical chart. Review of the Acute Nursing Progress Note dated 8/14/24 at 2030 hours, showed Patient 2 was assessed for a pain level of 0. Review of MAR dated 8/14/24 at 2030 hours, showed one acetaminophen 325 mg tablet was administered to Patient 2 for the pain level of 0. No documented pain reassessment for effectiveness after Patient 2 received a 325 mg acetaminophen tablet was found in Patient 2’s medical chart. On 9/17/24 at 1320 hours, a concurrent interview and review of Patient 2’s medical record was conducted with the CNO. The CNO reviewed the P&P and verified it applied to Patient 2. The CNO stated the expectation was for the nursing staff to assess the patient for pain using the 1 to 10 pain scale as shown in the policy. The purpose was to determine if the patient had pain, to treat the pain, and then reassess to see how effective the treatment was. The pain assessment was to be documented in the patient’s medical records in the flowsheet, nursing progress note, or the memo field. The CNO stated the next step in the process was to provide the patient with pain relief in the form of the prescribed medication. The CNO also stated the nurse was expected to return and reassess the patient’s pain after taking the treatment (medication) to assess the effectiveness of medication and document the reassessment in the patient’s medical record. The CNO reviewed Patient 2’s medical record and verified the above documented notes, memos, and flowsheets. The CNO reviewed Patient 2’s medical record including the MAR with the times pain medications was given, nursing progress notes, and flow sheets on 8/11 and 8/14/24. The CNO verified on 8/11/24, Patient 2 had an order for acetaminophen. The CNO reviewed and verified Patient 2 was given the pain medication on 8/11/24 at 0611 hours for a documented a pain level of 8, but there was no documented reassessment for effectiveness of treatment. The CNO reviewed and verified Patient 2 was given the pain medication on 8/11/24 at 1416 hours, but no documented pain assessment and reassessment for the effectiveness of the administered pain medication were found in the patient’s medical record. The CNO reviewed and verified Patient 2 was given the pain medication on 8/11/24 at 2031 hours, for a documented pain level of 8, but there was no documented reassessment for effectiveness of treatment. 3. Review of the patient’s medical record showed Patient 3 was admitted to hospital on 9/4/24. a. Review of the MAR showed Patient 3 had a physician’s order for acetaminophen 325 mg tablet, two oral tablets every four hours as needed. Review of the MAR dated 9/6/24 at 0648 hours, showed two acetaminophen 325 mg tablets were administered to Patient 3. On 9/6/24 at 0648 hours, no pain assessment or reassessment was documented in Patient 3’s medical chart. Review of the MAR dated 9/6/24 at 1251 hours, showed two acetaminophen 325 mg tablets were administered to Patient 3. On 9/6/24 at 1251 hours, no pain assessment or reassessment was documented in Patient 3’s medical chart. Review of the MAR dated 9/7/24 at 1036 hours, showed two acetaminophen 325 mg tablets were administered to Patient 3. Review of the flowsheet dated 9/7/24 at 1041 hours, showed Patient 3 was assessed for a pain level of 4. No documented pain reassessment for effectiveness after Patient 3 received two acetaminophen 325 mg tablets was found in Patient 3’s medical record. Review of the MAR dated 9/10/24 at 1059 hours, showed two acetaminophen 325 mg tablets were administered to Patient 3. Review of the flowsheet dated 9/10/24 at 1100 hours, showed Patient 3 was assessed for a pain level of 4. No documented pain reassessment for effectiveness after Patient 3 received two acetaminophen 325 mg tablets was found in Patient 3’s medical record. b. Review of the MAR dated 9/10/24, showed Patient 3 had an order for ibuprofen (pain medication) oral tablet 400 mg, one tablet every six hours as needed. . Review of the MAR dated 9/10/24 at 0139 hours, showed one ibuprofen oral 400 mg tablet was administered to Patient 3. Review of the flowsheet dated 9/10/24 at 0140 hours, showed Patient 3 was assessed for a pain level of 8. No documented pain reassessment for effectiveness after Patient 3 received one ibuprofen oral 400 mg tablet was found in Patient 3’s medical record. Review of the MAR dated 9/10/24 at 0822 hours, showed one ibuprofen oral 400 mg tablet was administered to Patient 3. Review of the Acute Progress Note dated 9/10/24 at 0822 hours, showed Patient 3 was assessed for a pain level of 0 and the reassessment scale score was left blank. On 9/17/24 at 1320 hours, a concurrent interview and review of Patient’s 3 medical record was conducted with the CNO. The CNO reviewed the P&P and verified it applied to Patient 3. The CNO stated the expectation was for the patient to be assessed by the nursing staff for pain using the 1 to 10 pain scale as shown in the policy prior to receiving pain medication. The assessment was to be documented in the patient’s medical record. The CNO stated the next step in the process was to provide the patient with pain relief in the form of the prescribed medication. The CNO also stated the nurse was expected to return and reassess the patient’s pain after taking the pain medication to assess the effectiveness of medication and document the reassessment in the patient’s medical record. The CNO reviewed Patient 3’s medical record and verified the above documented notes and flowsheets. The CNO verified on 9/6/24, Patient 3 had an order for acetaminophen, and ibuprofen, both pain relievers. The CNO reviewed Patient 3’s medical record, including the MAR, the times pain medications were given, the nursing progress notes, memos, and flow sheets on 9/6, 9/7, and 9/10/24. On 9/17/24 at 1635 hours, the CNO, Director of Quality, and CEO were informed and acknowledged the findings.”

“PATIENT RIGHTS: GRIEVANCE PROCEDURES CFR(s): 482.13(a)(2)(i) [At a minimum:] The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. This Standard is not met as evidenced by: 39796 Based on interview and record review, the hospital failed to ensure the grievance log was maintained for one of 10 sampled patients (Patient 5). This failure had the potential to result in the unresolved complaints or grievances for the patient. Findings: Review of the hospital’s document titled Adolescent Program Patient Handbook (undated) showed the patients with questions about their treatments or those who feel they are being treated unfairly are encouraged to discuss their concerns with their doctors and the treatment team directly. Each patient has the rights to file a written grievance, and the form to file a written grievance maybe obtained online, from the hospital staff or from the Patient Rights Advocate. Review of the Job Description for the Court Liaison and Patient Advocate showed the key responsibilities. The responsibilities for the Patient Advocate include to act as a in house Patients’ Rights Representative and document the patient meeting in the patient grievance form. On 7/9/24 at 1311 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated a call was made to the hosptial’s Patient Advocate on 6/24, 6/25 and 6/26/24. Family Member 1 stated Family Member 1 was not receiving a return call from the hosptial’s Patient Advocate. On 7/10/24 at 1338 hours, an interview and concurrent record review was conducted with the Court Liaison/Patient Advocate. The Court Liaison/Patient Advocate was asked if the Court Liaison/Patient Advocate received a phone call from Family Member 1 on 6/24, 6/25, and 6/26/24. The Court Liaison/Patient Advocate stated the Court Liaison/Patient Advocate did not receive any. When asked if they keep a copy of the call log, the Court Liaison/Patient Advocate stated there was no call log. When asked how to prove if the concern was addressed, the Court Liaison/Patient Advocate stated they would check the grievance log. When asked if he was able to speak with Family Member 1, the Court Liaison/Patient Advocate stated no, only with the patient. The Court Liaison/Patient Advocate further stated Family Member 1 had filed a complaint with the Behavioral Health Services because no one had called her and wanted to take Patient 5 against medical advice. However, the hospital failed to show documented evidenced of the call log for the complaints. On 7/10/24 at 1352 hours, review of the hospital’s grievance log for June abd July 2024 was conducted and showed no documented evidenced the grievance report was filed for Patient 5. On 7/11/24 at 1545 hours, the findings were shared with the CNO, Director of Performance Improvement and Risk Management, and Nurse Manager. The CNO acknowledged the findings.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 40483 Based on observation, interview, and record review, the hospital failed to ensure the five patient access phones were in the working order on each unit. This failure posed the potential for the patients not being allowed to exercise the patient’s rights. Findings: Review of the hospital’s P&P titled Patient’s Rights dated 4/2024 showed the following: * Patients will have reasonable access to telephones, both to make and receive confidential calls or to have such calls made for them. * Good cause for denial of patient’s rights: The exercise of a specific right would be injurious to the patient or peers or there is evidence that a specific right if exercised would seriously infringe on the rights of others or that the facility would suffer serious damage if the specific right was not denied and there is no less restrictive way to prevent against those occurrences. * Patients’ rights may be denied for good cause with a provider’s order. The denial of patients’ rights must be reviewed and renewed every 24 hours. On 7/10/24 at 1525 hours, a tour of Unit 2 West was conducted with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff had turned on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone to have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial the phone number but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair. On 7/10/24 at 1537 hours, a tour of Unit 2 East was conducted with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff turn on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone did not have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial the phone number but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair. On 7/10/24 at 1548 hours, a tour of Unit 1 West was conducted with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch to on for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff turn on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone did have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair. On 7/10/24 at 1559 hours, a tour of Unit 1 East was conducted with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch to on for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff turn on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone did have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial the phone number but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair. On 7/11/24 at 1048 hours, a tour of the Specialty (Adolescent) Unit was initiated with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch to on for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff turn on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone did have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial the phone number but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair. On 7/11/24 at 0953 hours, an interview was conducted with Patient 9. Patient 9 stated she was not able to have a confidential phone conversation as the staff always knew when she would be talking on the phone. Patient 9 stated the silver phone on the wall did not work and were known broken; and the hospital did not fix the phone. Patient 9 stated the hospital left them broken so they could control phone use. Patient 9 stated the only way to get to speak with the outside world, was to sign up for a phone time and then the nurses gave the patient a portable phone. Patient 9 stated she had to ask for the phone and didn’t have free access to it. The nursing staff had controlled it. Patient 9 stated she did not like having to ask for a phone as it was intimidating. Patient 9 also stated she did not always get access to the phone when she signed up for it. Patient 9 stated she thought some of the nurses show favoritism and gave the phone to those they liked. On 7/11/24 at 1009 hours, an interview was conducted with Patient 6. Patient 6 she was on the phone list for today and had signed up for portable phone use at two time slots. Patient 6 stated she signed up on the list for two times slots which would be at 0800 and 1800 hours as the sign stated patients had only had 10 minutes of phone time, which she felt was not sufficient for her needs. Patient 6 stated she was aware the silver phone on the wall was broken and the hospital had not fixed it. Patient 6 stated she did not like the system in place to use the phone as the patients didn’t have complete privacy or anonymity. The portable phones were regulated, and nursing staff knew both who and when patients were talking on the phone. On 7/11/24 at 1545 hours, the findings were shared with the CNO, Director of Performance Improvement and Risk Management and Nurse Manager. The CNO acknowledged the findings.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 26756 Based on observation, interview, and record review, the hospital failed to implement their P&Ps related to Restraint and Seclusion and Patient’s Rights for one of 10 sampled patients (Patient 3). Patient 3 was subjected to staff excessive force and unnecessary restraints during a physical struggle with a MHW 1 when there was no evidence of imminent danger for self, staff, or others. This incident violated Patient 3’s right to be free from the restraints imposed to as a mean of discipline, coercion, or convenience by staff. Findings: Review of the hospital’s P&P titled Seclusion and Restraints revised 3/2024 showed the following: * It is the hospital’s policy to maintain a restraint free environment. The confinement of patients through the use of restraints is only used to protect a patient or others from harm when alternative less restrictive measures are determined to be ineffective and are necessary to ensure the immediate safety of the patients and others. Restraints are never to be used as a coercive, disciplinary, or retaliatory action. * Behavioral restraint: A restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move the arms, legs, body, or head freely; or a drug or medication used to manage the patient’s behavior. Review of the hospital’s P&P titled Patient’s Rights revised 4/2024 showed each patient involuntary detained for evaluation or treatment shall have the following rights that cannot be denied: - Treatment services that are the least restrictive of personal liberty. - Dignity, privacy, and humane care. - Be free from harm including unnecessary or excessive physical restraint, isolation, medication, abuse, or neglect. During the hospital’s tour to the “Special Unit” conducted on 7/10/24 at 1000 hours, Patient 3 was observed exiting the group meeting and sitting on a table in the day hall along with two other patients. They were coloring books. On 7/10/24 at 1030 hours, an interview was conducted with Patient 3. Patient 3 stated she did not like the hospital due to lack of staff professionalism. Patient 3 stated the staff used inappropriate language and was aggressive with them. Patient 3 stated she was standing in front of her room on 7/7/24 approximately at 1700 hours, just looking to see what was going on with a peer in front of her room when MHW 1 grabbed her from behind and twisted her arm. Patient 3 stated she tried to break free from MHW 1 and fought MHW 1 back. Patient 3 stated she felt scared and physically hurt. Patient 3 stated she did not understand why she was treated that way when she was not doing anything wrong. “I was just standing there.” On 7/10/24 at 1445 hours, an interview with MHW 1 was conducted. MHW 1 stated on 7/7/24, all the patients in the unit were kicking the doors and walls. MHW 1 stated he asked Patient 3 to go into her room because they did not want the patients to see what was going on since they were children. MHW 1 stated Patient 3 would not go to her room and kept fighting about it. MHW 1 stated Patient 3 was watching the incident right across her room with another patient and “ instigating.” When asked what was done to redirect Patient 3 back to her room, MHW 1 stated we just kept saying to go back to her room, so he had to grab Patient 3 and put Patient 3 in her room because there was someone inside the seclusion room at that time. MHW 1 stated Patient 3 was threatening, yelling, and starting to fight with him. MHW 1 stated Patient 3 just would not go back to her room, MHW 1 did not have help from other staff, and he did not know what to do as there were too many things happening at once. MHW 1 stated he could have done something different, but he did not think,” it just happened all at once.” A concurrent video review and interview with MHW 1 was conducted on 7/10/24 at 1500 hours. MHW 1 confirmed he was the staff present on the video and reviewed the video recording with the survey team. The video recording was dated 7/7/14 starting at 1700 hours. The video recording had no audio and captured the following: - Patient 3 was observed standing in front of her room in the hallway. MHW 1 approached Patient 3 and briefly spoke to the patient, but Patient 3 was hesitating. MHW 1 was using excessive force, grabbed Patient 3 from behind and a struggle began as Patient 3 tried to break free. MHW 1 twisted Patient 3 arms during the struggle. For three intense minutes, MHW 1 and Patient 3 grappled, with Patient 3 resisting to the physical hold up and down the hallway. Eventually, MHW 1 managed to force Patient 3 to her room. There was no evidence of a valid reason or imminent danger to self or others for the physical hold. Review of Patient 3’s Kardex (patient information) dated 7/10/24, showed Patient 3 was admitted to the hospital on 7/1/24, with diagnoses of major depressive disorder (mental health condition characterized by persistent low mood or feelings of sadness). Review of the Psychiatric Progress Note assessment dated 7/8/24 at 0940 hours, showed Patient 3 was alert and oriented to time, place, and person with appropriated thought process. Patient 3’s chief of complaint was “I didn’t do anything.” The Psychiatric Progress Note showed per staff, last night the patient refused to go to room and was aggressive; the staff could not redirect the patient and the emergency medications were given. Review of the Mental Health Worker’s Job Description showed one of the MHW responsibilities is to follow professional crisis management procedures accurately when needed. The MHW’s skills and abilities include to demonstrate the appropriate professional boundaries, treat youth with respect; demonstrate the ability to set limits for the patients, use the de-escalation techniques appropriately, exhibit calm and controlled attitude, and do not overreact to allow his own actions to further deteriorate the situation. On 7/10/24 at 1400 hours, an interview was conducted with the Director of Performance Improvement & Risk Management. The Director of Performance Improvement & Risk Management stated she was not aware of the incident and also stated the management team did not review all incidents video footage; they reviewed the videos only if “the incident warrants an investigation.” On 7/10/24 at 1430, the Director of Performance Improvement & Risk Management, Nurse Manager, and CNO acknowledged the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 39796 Based on interview and record review, the hospital failed to ensure the physician’s order of seclusion for management of violent behaviors was renewed when the physician’s order was exceeding two hours as per the hospital’s P&P for one of 10 sampled patients (Patient 5). This failure could lead to the unnecessary restraint use for the patient. Findings: Review of the hospital’s P&P titled Seclusion and Restraints revised 3/2024 showed the maximum length of time of the restraint or seclusion is not exceed two hours for children and adolescent ages 9 to 17 years old. The trained RN will reassess the patient hourly and before the seclusion or restraint order expires, re-valuate the patient. If the need for seclusion or restraint continues, discuss need for other interventions and obtains a new order (Not to exceed two hours for children and adolescent ages 9 to 17 years old). Review of Patient 5’s medical record was initiated on 7/10/24. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 6/22/24 and discharged on 7/2/24. Review of the Seclusion and Restraint showed on 6/28/24 at 1731 hours, the physician ordered seclusion and restraint for Patient 5. The type of restraint was “Physical Restraint (Hold).” The restraint would not be exceed two hours. The indications for the use of restraint included “Imminent Danger to self or others due to Thought Disorder.” Review of the Seclusion/Restraint Record section of the Seclusion and Restraint showed on 6/28/24 at approximately 1725 hours, Patient 5 approached the nursing station and was demanding to use the phone. The patient was told about the phone time and refused to listen. The patient began swearing the staff, refused to leave the nursing station, and refused to stand behind the red tape. The patient was threatening towards the staff. The patient was guided to the seclusion room by the staff and began fighting with the staff. The staff then restrained the patient, and the patient was taken to the seclusion room. The door of the seclusion room was locked at 1736 hours. Review of the Seclusion/Restraint Record section of the Seclusion and Restraint showed Patient 5 was alert, agitated, and restless. The seclusion was started on 6/28/24 at 1836 hours and ended on 6/28/24 at 1950 hours. The restraint was started on 6/28/24 at 1831 hours and ended on 6/28/24 at 1835 hours. Review of the Patient Observation Record dated 6/28/24, showed the staff performed and documented an observation every 15 minutes. The Patient Observation Record included the time, staff initials, location code activity and behavior code. Further review of the Patient Observation Record showed Patient 5 was in the seclusion room from 1800 hours to 2230 hours. Patient 5 was placed on the seclusion room more than two hours which was inconsistent with the physician’s order. Patient 5 was in the seclusion room at 1800 hours which was inconsistent with the RN narrative notes. On 7/10/24 at 1448 hours an interview and concurrent review of Patient 5’s medical record was conducted with the CNO. The CNO was asked what time the seclusion should be ended for Patient 5. The CNO stated it should have been discontinued at 2000 hours and the documentation from 2000 to 2215 hours was incorrect. The CNO was informed and acknowledged the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 39796 Based on interview and record review, the hospital failed to ensure the nursing staff monitored the vital signs as per the hospital’s P&P for one of 10 sampled patients (Patient 5) when the patient was restrained or secluded. This failure could lead to the inappropriate use of restraints and seclusion and unsafe care for the patient. Findings: Review of the hospital’s P&P titled Seclusion and Restraints revised 3/2024 showed the clinical staff completes documentation on the S&R flow sheet. The following patient needs will be assessed on a continuous 1:1 basis and documented in the medical record every 15 minutes: - Staff will determine based on visual and verbal assessment if patient is continuing meet criteria based on if the patient is still exhibiting imminent danger to self or others. - Readiness for discontinuation of S&R. - Vital signs every 15 minutes. Review of Patient 5’s medical record was initiated on 7/10/24. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 6/22/24 and discharged on 7/2/24. Review of the Seclusion and Restraint showed on 6/28/24 at 1731 hours, the physician ordered seclusion and restraint for Patient 5. The indications for the use of restraint included “Imminent Danger to self or others due to Thought Disorder.” Review of the Seclusion/Restraint Record section of the Seclusion and Restraint showed Patient 5 was alert, agitated, and restless. The seclusion was started on 6/28/24 at 1836 hours and ended on 6/28/24 at 1950 hours. The restraint was started on 6/28/24 at 1831 hours and ended on 6/28/24 at 1835 hours. Review of the Seclusion/Restraint Record section of the Seclusion and Restraint showed on 6/28/24 at approximately 1725 hours, Patient 5 approached the nursing station and was demanding to use the phone. The patient was told about the phone time and refused to listen. The patient began swearing the staff, refused to leave the nursing station, and refused to stand behind the red tape. The patient was threatening towards the staff. The patient was guided to the seclusion room by the staff and began fighting with the staff. The staff then restrained the patient, and the patient was taken to the seclusion room. The door of the seclusion room was locked at 1736 hours. Review of the Patient Observation Record dated 6/28/24, showed the hospital staff performed and documented an observation every 15 minutes. Further review of the Patient Observation Record showed Patient 5 was in the seclusion room from 1800 hours to 2230 hours. Review of the Seclusion and Restraint dated 6/28/24, showed the following: * The Seclusion/Restraint Assessment section showed the vital signs was left blank. * The Seclusion/Restraint Treatment Team Debriefing section was left blank. On 7/11/24 at 1105 hours, an interview and concurrent medical record review was conducted with the CNO. The CNO was asked if they needed to take and documented the patient vital signs while the patient was placed on seclusion. The CNO stated if the patient refused the vital signs, it should have been documented. The CNO was also asked how the staff knew if the patient was ready for the removal from the seclusion room. The CNO stated staff did the assessment to make sure the patient was ready; staff asked the question; and the CNO showed the assessment section of the Seclusion and Restraint form. The CNO stated there should be some notation that the patient refused, but there was no documentation. The CNO was informed and acknowledged the findings.”