River Vista Behavioral Health

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48424 Based on observation, interview, and record review, the hospital failed to protect and promote each patient’s rights. The hospital did not ensure patients were free from physical abuse and improper use of force during restraint or seclusion, did not implement policies designed to safeguard patient rights, and did not provide effective leadership oversight to prevent, identify, or address unauthorized patient restraint interventions. (Refer to A-0154) This failure resulted in the facility being unable to ensure compliance with the Conditions of Participation for Patients’ Rights at 42 CFR §482.13”

“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: 48424 Based on observation, interview, and record review, the facility failed to ensure all patients were free from physical abuse and excessive force during restraint or seclusion for 1 of 14 sampled patients (Patient 2) when Registered Nurse (RN) 2 pushed Patient 2 forcefully in the chest during a seclusion episode. This failure resulted in Patient 2 falling backward and hitting the back of his head on the wall. Findings: During a review of Patient 2’s “Patient Demographic Profile,” dated 6/2/26, the profile indicated Patient 2 was admitted to the facility on 5/18/26 with a diagnosis of unspecified psychosis (a mental condition which may cause hallucinations, delusions, or confused thoughts). During a concurrent interview and video review on 6/2/26 at 2:10 p.m. with the Director of Risk Management (DRM), Chief Executive Officer (CEO), and Assistant Chief Nursing Officer (ACNO), Patient 2 was observed being walked to the seclusion room by RN 2 and RN 3 on 5/28/26 at 10:13 p.m. RN 2 and RN 3 attempted to leave Patient 2 in the seclusion room, but Patient 2 made multiple attempts to follow staff out of the doorway. At 10:14 p.m., RN 2 was observed pushing Patient 2 forcefully in the chest to keep the patient inside of the seclusion room. Patient 2 fell backward and hit the back of his head on the wall. The DRM stated he had reviewed the video before the survey team reviewed it, but he did not see the push or the fall until the survey team reviewed the video with him. During an interview on 6/2/26 at 3:24 p.m. with the Milieu Manager (MM), the MM stated he was unaware of the incident and had not reviewed the video of Patient 2 being pushed by RN 2. The MM stated he did not have direct access to the facility’s stored video footage. The MM later reviewed the video on 6/2/26 at 3:51 p.m. and stated the video showed a struggle between staff and Patient 2 when staff entered the seclusion room. The MM stated Patient 2 ran toward the door and tried to exit the room. The MM stated RN 2 and RN 3 blocked the door and tried to close it. The MM stated staff needed to be careful with restraints and physical holds of patients, especially near doors, because patients could get hurt. The MM stated when staff saw Patient 2 kept running toward the door, staff should have instead stayed in the room with Patient 2 so he did not hurt himself. The MM stated the video showed RN 2 push Patient 2 away from the door. The MM stated Patient 2 then fell backward and hit the back of his head on the wall. The MM stated proper restraint procedures did not allow staff to push or shove a patient. The MM stated, “You should never extend your arms and push.” The MM stated staff should have remained in the room with the patient instead of attempting to close the door while pushing him away and risking injury. During a phone interview on 6/3/26 at 8:24 p.m. with RN 3, RN 3 stated he was one of the nurses who responded to the incident involving Patient 2 but did not remember much of the incident. RN 3 stated he was taught never to push or shove patients during Crisis Prevention Institute (CPI - training which focused on safe restraint and hold techniques) classes because patients could get hurt. RN 3 stated pushing and extending arms was not allowed under any circumstances. During a phone interview on 6/3/26 at 8:40 p.m. with Milieu Specialist (MS) 1, MS 1 stated he was on the scene during the incident with Patient 2. MS 1 stated Patient 2 was escorted to the seclusion room by RN 2 and RN 3. MS 1 stated he saw Patient 2 fall backward and hit the wall while Patient 2 was in the seclusion room and RN 2 and RN 3 guarded the door. MS 1 stated after the situation calmed down, neither RN 2 nor RN 3 reported Patient 2 was pushed, fell, or hit the wall. MS 1 stated staff were not supposed to push or shove patients under any circumstances. MS 1 stated CPI classes did not teach staff to push a patient as a way to hold or restrain the patient. During an interview on 6/3/26 at 4:08 p.m. with the ACNO, the ACNO stated she did not review Patient 2’s video prior to viewing it with the survey team. The ACNO stated the video did not show proper use of CPI when Patient 2 was pushed and fell. The ACNO stated staff were not taught to push or shove patients. During an interview on 6/4/26 at 2:30 p.m. with the DRM, CEO, and ACNO, all stated only the DRM had reviewed the footage before the survey team reviewed it. The DRM stated he did not see the push or fall because he did not view all camera angles. The DRM stated the whole leadership team and the MM should have viewed the video from all camera angles, so they did not miss a significant event like the push and fall involving Patient 2. During a review of the facility’s behavior management agreement, undated, the agreement indicated, “... to use physical restraint and/or seclusion, there must be imminent risk of self-harm or harm to others. The least restrictive intervention must be used and excessive force is prohibited ... physical restraints/holds are never used to coerce, punish, or for staff convenience ...” During a review of the “[Nonviolent Crisis Intervention] with Advanced Physical Skills Training” workbook, dated 2023, the workbook indicated, “... Safety interventions range from verbal and environmental non-restrictive intervention to non-restrictive disengagement and restrictive intervention. The goal is to choose the Safety Intervention that is a last resort, reasonable, and proportionate ...” During a review of the facility’s policy and procedure (P&P) titled “Patient Rights and Responsibilities,” dated 10/2025, the P&P indicated, “... 2. Each patient shall be treated with respect and dignity in the provision of all care and treatment at [the facility]. 3. Be assured of reasonable safety within the care setting, including the right to be free from mental, physical, sexual, and verbal abuse, neglect, mistreatment, exploitation, humiliation, and retaliation ...” During a review of the facility’s P&P titled “Proper Use and Monitoring of Physical/Chemical Restraints,” dated 10/2025, the P&P indicated, “... physical restraints (holds) may only be done using techniques trained through the aggression management program ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39474 The facility failed to ensure compliance with the Condition of Participation for Patient Rights, 42 CFR §482.13, when: 1. Patient 1 and Patient 11 were subjected to physical restraint that was not implemented in accordance with facility policy and safe restraint practice, placing the patients at risk for physical and psychological harm. (Refer to A-0154) 2. Patient 32 was subjected to prolonged physical restraint and the facility failed to ensure a post-restraint assessment for injury was completed and documented. (Refer to A-0154) 3. A fire egress door was not readily operable in the event of an emergency. (Refer to A-0144) 4. Patient care bathroom environments were not maintained in a manner that minimized ligature and self-harm risk. (Refer to A-0144) 5. Expired emergency medication was available in a treatment cart. (Refer to A-0144) The cumulative effect of these failures resulted in the facility’s inability to ensure and promote patient rights, including the right to receive care in a safe setting and to be free from unsafe restraint practices, in accordance with 42 CFR §482.13.”

“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: 33922 The facility failed to ensure the Condition of Participation for Quality Assessment and Performance Improvement Program §482.21 was met when: 1. The Quality Assessment Performance Improvemnt Program (QAPI) failed to collect, analyze, and use restraint-related data to identify unsafe restraint (when staff hold a patient down against their will or restrict their movement) practices, adherence to de-escalation expectations, staff training needs, and patterns by unit, shift, or staff. (Refer to A-0273 and A-0154) 2. The QAPI program failed to collect, analyze, and use antimicrobial stewardship (process to review how antibiotics are prescribed and used, aiming to improve patient outcomes) data to evaluate duration of therapy, effectiveness of treatment, and related complications. (Refer to A-0273 and A-0750) The cumulative effect of these failures resulted in the facility’s inability to maintain an effective, ongoing, data-driven QAPI program capable of identifying and reducing patient care and patient safety risks.”

“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: 51620 Based on observation, interview, and record review, the facility failed to ensure patients received care in a safe setting when: 1. A fire egress door was not readily operable in the event of an emergency. This failure had the potential to prevent or delay safe evacuation of patients and staff. 2. Patient-accessible bathroom environments contained ligature and other self-harm risks, including non-ligature-resistant toilet seats and other environmental features that were not identified and mitigated through the facility’s risk assessment process. These failures had the potential to place patients at risk for self-harm or injury. 3. Expired emergency medication was available for patient use in a treatment cart. This failure had the potential to result in administration of medication with reduced effectiveness during an emergency. Findings: 1. During a concurrent observation and interview on 3/23/26 at 2:14 p.m. on the Adolescent Unit with Assistant Chief Nursing Officer (ACNO), a secondary fire egress exit door was observed to have a permanent sign on the wall to the right of the door noting it was an exit door. On the door were 5 signs instructing staff and patients to, “Stop - Do Not Enter” through the door. ACNO stated that the staff were using this door to get from the adolescent unit to the adult unit instead of going around through the sally port doors where there is an additional safety measure. ACNO stated because the staff continued to use the door as a pass through it was made inoperable. ACNO stated there was a button at the nurse’s station that, when pressed, would open all locked doors on every unit; at this time, this is the only way to unlock the door. ACNO stated this would not be beneficial if the fire was located near the nurse’s station. During an interview on 3/23/26 at 2:35 p.m. with Director of Performance Improvement & Risk Management (DPIRM), DPIRM stated the door was disengaged for the badge system because staff were not compliant and continued to use this door. He stated there was no risk assessment done on this change and evacuation signs were not changed. During an interview on 3/26/26 at 2:50 p.m. with Director of Environment and Plant Ops (DEPO), DEPO stated the facility disengaged the door so staff could not use it as a passthrough. DEPO stated that the button at the nurse’s station would need to be pressed in the event of a fire. DEPO stated he did not consider this an issue. DEPO stated the evacuation map was not updated and no risk assessment was completed, and this was not identified on their environmental rounds. During a review of the facility’s policy and procedure titled, “Environmental Rounds” effective date 06/2025, indicated, “ ... as part of an ongoing environment of care program, the Safety Officer shall coordinate the environmental tours of the facility to identify and evaluate information concerning safety, security, fire safety, hazardous conditions, exposure to hazardous materials and wastes, medical equipment, utilities, and staff knowledge ...” During a review of professional reference from the Life Safety Code (NFPA 101) Published by the National Fire Protection Association (NFPA) in which it requires, “ ...doors must be readily operable from the egress side when a building is occupied ...” and “ ...that all occupancies, including health care facilities, have unobstructed and readily accessible means of egress to allow for safe evacuation during emergencies..” (NFPA 101: Life safety Code, Means of Egress Requirements (NFPA, latest edition). During a review of NFPA 101: Life Safety Code Chapters 18/19 dated 2024, indicated, “ ...door locking in specialized units (e.g., psych, dementia, forensic) is permitted if the locks release automatically upon fire alarm activation. This includes smoke detection, water flow from the sprinklers and manual fire alarm system activation. National Fire Protection Association. (2024). NFPA 101: Life Safety Code (2024 ed., Chapters 18 & 19). NFPA. 2. During a concurrent observation and interview on 3/23/26 at 3:07 p.m. on the Adolescent Unit with the ACNO, the seclusion bathroom was observed to have a toilet that did not have a molded-in toilet seat. Observation showed there was a space between the toilet seat that could be used to tie a ligature. ACNO stated patients were never left unattended but did acknowledge that it might take a short time to break the toilet seat rendering it a weapon to be used against themselves, staff, or other patients. During a concurrent observation and interview on 3/26/26 at 3:15 p.m. on the Adolescent Unit seclusion bathroom with DPIRM, DPIRM stated there was a potential for a patient to break the toilet seat and possibly use it to harm themselves or others. During a concurrent observation and interview on 3/26/26 at 3:29 p.m. in the bathrooms located near the Gym with DPIRM. The Gym bathrooms were observed to have toilets that did not have a molded-in toilet seat. Observation showed there was a space between the toilet seat that could be used to tie a ligature and there was a potential for a patient to break the toilet seat and possibly use it to harm themselves or others. DPIRM stated that because there was a locked door on the bathrooms, patients were not visible to the staff. DPIRM stated that having the patient behind the locked bathroom door was not ideal. DPIRM stated that because the door opened inward, the door could be blocked by the patient. DPIRM stated the power outlets were not tamper-resistant and had regular screws which was a safety issue. DPIRM stated the swinging hardware on the doors were not anti-ligature hardware and could be used to secure a ligature. During review of the facility’s document “Environmental/Ligature Risk Assessment Prevention/ Mitigation Plan” dated 8/20/25, the assessment did not identify the electric outlet switch plates, tamperproof screws, the door close hinges, and toilet seats as a high potential to cause harm. During a review of National Fire Protection Association, NFPA 99: Health care facilities code dated 2024, indicated, “ ...NFPA 99 requires that electrical outlets in psychiatric patient care areas are tamper-resistant (TR) to protect patients (National Fire Protection Association [NFPA], 2024). Furthermore, in psychiatric hospitals and wards, outlets must be both tamper-resistant and equipped with ground fault circuit interrupters (GFCI) in all patient-accessible areas. This combination of protection, along with potential arc-fault protection, ensures safety against intentional misuse and accidental contact ...” National Fire Protection Association. (2024). NFPA 99: Health care facilities code (2024 ed.). 3. During a concurrent observation and interview on 3/23/26 at 3:10 p.m. on the adolescent unit triage area with Assistant Chief Nursing Officer, (ACNO), a treatment cart was observed with expired Narcan Nasal Spray (naloxone - is an emergency medicine that can quickly reverse an opioid overdose. It works by blocking the effects of opioids-drugs like fentanyl, heroin, or prescription painkillers-so the person can start breathing normally again), dated July 2025. ACNO stated expired Narcan should not be available for use. ACNO stated having expired medication placed patients at risk for receiving less than 100% potent medication. During an interview on 3/24/26 at 10:50 a.m. with DPIRM, DPIRM stated expired medication should not be housed anywhere where staff could administer outdated medication to the patients. During a review of the facility’s policy and procedure titled, “Emergency Medications”, effective date 10/2025, indicated, “ ...the Pharmacy in collaboration with hospital leadership and the medical and nursing staff ensures the availability, control, security and overall safe management of emergency medications ...” During a review of the professional article, “Best Practices for Managing Expired Medications in Hospitals: A Guide for Patient Safety and Regulatory Compliance” dated 2024, indicated that, “ ...expired medications reduce potency, and may contribute to patient harm ...” The article further stated, “ ...U.S. hospitals must comply with strict FDA and DEA regulations preventing expired medications from reaching patients ...” Carter, E. (2024). Best Practices for Managing Expired Medications in Hospitals: A Guide for Patient Safety and Regulatory Compliance. During a review of the professional article regarding expired medication from the Food and Drug Administration (FDA) (undated), the FDA indicated, “ ...expired medications may lose potency, fail to deliver therapeutic benefit, and may produce toxic degradation compounds, placing patients at risk ...” U.S. Food and Drug Administration. (n.d.). Expiration dates: Questions and answers. U.S. Department of Health & Human Services. https://www.fda.gov”

“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: 39474 A-0154 - Use of Restraint or Seclusion Based on observation, interview, and record review, the facility failed to ensure physical restraint was implemented, monitored, and discontinued in accordance with facility policy and safe clinical practice for 3 patients (Patient 1, Patient 11, and Patient 32). Deficient practices included: 1. Failure to attempt and/or document less restrictive interventions prior to initiation of physical restraint, including initiation of restraint without evidence of an immediate physical safety risk. 2. Use of physical restraint in a manner inconsistent with facility policy, including placement of patients in the prone position. 3. Failure to conduct and/or document required post-restraint assessment and reassessment, including assessment for injury. These deficient practices had the potential to place patients at risk for physical injury, psychological harm, and violation of patient rights. Findings: 1. a. During an observation of non-audio surveillance video on 3/24/26 at 9:45 a.m. of surveillance video dated 3/18/26 at 8:42:43 a.m., Patient 1, a 63-year-old male with a history of anxiety disorder and suicidal ideation, was physically restrained by Mental Health Technician (MHT) 1 and forced from a standing position to a flat prone position on the ground. MHT 1 was assisted by MHT 2, MHT 3, and Registered Nurse (RN) 2, who restrained Patient 1 by his limbs and held him in a prone position for approximately 2 minutes and 13 seconds before placing him into a seated position. During an interview on 3/24/26 at 9:55 a.m., the Director of Performance Improvement and Risk Management (DPIRM) acknowledged MHT 1, MHT 2, MHT 3, and RN 2 did not follow facility policy and procedures during the restraint of Patient 1. The DPIRM acknowledged MHT 1 should have attempted less restrictive measures prior to initiation of physical restraint for Patient 1. During an interview on 3/24/26 at 10:45 a.m., the Training Coordinator (TC) acknowledged MHT 1 should have attempted less restrictive measures prior to initiation of physical restraint for Patient 1. The TC acknowledged staff did not follow facility policy and procedures for the application of physical restraint with Patient 1. During an interview on 3/24/26 at 3:04 p.m., the Assistant Chief Nursing Officer (ACNO) acknowledged MHT 1 should have attempted less restrictive measures prior to initiation of physical restraint for Patient 1 and acknowledged staff did not follow facility policy and procedures during the restraint event. 1. b. During an observation of non-audio surveillance video on 3/25/26 at 8:50 a.m. of surveillance video dated 3/6/26 at 5:17 p.m., the physical restraint episode involving Patient 11 and MHT 1 was reviewed. The video showed Patient 11, a 24-year-old male with a history of depression, had turned his body and began to walk away from MHT 1 when MHT 1 approached from behind and initiated physical restraint of Patient 11’s arm. During an interview on 3/25/26 at 9:40 a.m., MHT 1 stated that he had physically restrained Patient 11 due to previous aggressive behavior in the morning, and that he anticipated that Patient 11 would become aggressive, so he pre-emptively used physical restraints on Patient 11 despite the fact Patient 11 had turned and started to walk away. During a concurrent observation and interview on 3/25/26 at 1:35 p.m., the Training Coordinator (TC) and Milieu Manager (MM), after review of the video, stated the initiation of the physical restraint was not warranted, as Patient 11 had already turned and started to walk away. During a review of facility policy titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 10/2025, the policy indicated, “...to support each patient’s right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm...Less Restrictive Interventions: Measures which modify the environment, enhance interpersonal interaction, or provide treatment so as to minimize or eliminate the problems/behaviors which place the patient at risk. Examples of less restrictive measures include but are not limited to: verbal interventions such as talking quietly with the patient and environmental intervention through reduction of stimuli causing irritation...4.1 If physical restraint is indicated, physical restraints (holds) may only be done using techniques trained through the aggression management program. In no case may a patient be held in a prone position....” 50852 2. a. During an observation of non-audio surveillance video on 3/24/26 at 9:45 a.m. of surveillance video dated 3/18/26 at 8:42:43 a.m., Patient 1, a 63-year-old male with a history of anxiety disorder and suicidal ideation, was physically restrained by Mental Health Technician (MHT) 1 and, from a standing position, was physically forced to a flat prone position on the ground. MHT 1 was assisted by MHT 2, MHT 3, and Registered Nurse (RN) 2, who restrained Patient 1 by his limbs, forcing Patient 1 to remain in a prone position for approximately 2 minutes and 13 seconds before placing Patient 1 into a seated position. During an interview on 3/24/26 at 9:55 a.m. with the Director of Performance Improvement and Risk Management (DPIRM), the DPIRM acknowledged Patient 1 should not have been placed in the prone position during the physical restraint on 3/18/26. The DPIRM acknowledged MHT 1, MHT 2, MHT 3, and RN 2 did not follow the facility policy and procedures when MHT 1 forced Patient 1 into a prone position on the ground during physical restraint proceedings. The DPIRM acknowledged Patient 1 could have been physically injured and psychologically distressed when MHT 1 placed Patient 1 prone on the ground and MHT 2, MHT 3, and RN 2 held Patient 1 in the prone position for approximately 2 minutes and 13 seconds. During an interview on 3/24/26 at 10:45 a.m. with the Training Coordinator (TC), the TC acknowledged MHT 1 restrained Patient 1 on the floor in a prone position on 3/18/26 and did not follow facility policy when placing Patient 1 in a prone position. The TC acknowledged MHT 1, MHT 2, MHT 3, and RN 2 did not follow facility policy and procedures for the application of patient restraint with Patient 1. During an interview on 3/24/26 at 3:04 p.m. with the Assistant Chief Nursing Officer (ACNO), the ACNO acknowledged that Patient 1 should not have been forced into the prone position during the physical restraint on 3/18/26. The ACNO acknowledged MHT 1, MHT 2, MHT 3, and RN 2 did not follow the facility policy and procedures when MHT 1 forced Patient 1 into a prone position on the ground during physical restraint proceedings. 2. b. A review of Patient 32’s record showed that on 2/20/2026 at approximately 12:30 a.m., Patient 32, a 32-year-old male, was restrained by staff. Review of the “Nursing Note,” dated 2/20/2026 at 12:10 p.m., indicated, “Writer was called to pts (patient) room. Pt states last night he received bruises from staff ...the staff came at him excessively ...Pt reports they did him dirty holding him down ...Pt noted to have bruises to the arm, shoulder, neck & thigh ...” During an interview on 3/25/26 at 2:02 p.m., the Milieu Manager (MM) stated the physical restraint of Patient 32 lasted a total of one and one-half hours and that Patient 32 was restrained in the prone position. The MM stated that four staff members restrained Patient 32’s arms and legs. The MM stated that Patient 32 received an injection 10 minutes after initiation of the restraint, but it was not immediately effective. During a phone interview on 3/26/26 at 1:55 a.m., Registered Nurse (RN) 1 stated Patient 32 was held in a prone position for one and one-half hours. RN 1 stated potential complications after a prolonged restraint could include breathing problems, bruising, and injury. During a review of facility policy titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 10/2025, the policy indicated, “...to support each patient’s right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others...4.1 If physical restraint is indicated, physical restraints (holds) may only be done using techniques trained through the aggression management program. In no case may a patient be held in a prone position...” 38479 3. During a review of Patient 32’s record related to an allegation of pain and bruising after being held down for a prolonged period of time, the Nursing Note dated 2/20/2026 at 12:10 p.m. indicated, “Writer was called to pts room. Pt states last night he received bruises from staff...the staff came at him excessively...Pt reports they did him dirty, holding him down...Pt noted to have bruises to the arm, shoulder, neck & thigh...” During a concurrent interview and record review on 3/25/26 at 2:02 p.m., the DPIRM reviewed Patient 32’s “Restraint and Seclusion” record and stated there was no documented evidence that a body check was conducted to assess for bodily injury after the physical restraint. The DPIRM confirmed there was no body check conducted after the restraint. During a phone interview on 3/26/26 at 1:55 a.m., RN 1 stated a body check should have been completed and documented to assess for injury. RN 1 stated potential complications after a prolonged restraint included breathing problems, bruising, and injury. During an interview on 3/26/26 at 10:05 a.m., House Supervisor (HS) 1 stated it is important to do a body check after physical restraint to assess and address any injuries and refer to a physician as needed. During a review of the facility policy and procedure titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 10/2025, the policy indicated, “...The patient’s right, dignity, privacy, safety, and well-being will be supported and maintained...Patients in restraint/seclusion will be closely monitored and evaluated...Any injuries sustained and treatment received for these injuries...The assessment includes...signs of any injury associated with the use of restraint/seclusion...Circulation and skin integrity...Mental status...Range of motion...” During a review of facility policy titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 10/2025, the policy indicated, “...to support each patient’s right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others...4.1 If physical restraint is indicated, physical restraints (holds) may only be done using techniques trained through the aggression management program. In no case may a patient be held in a prone position....””

“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: 33922 Based on observation, interview, and record review, the facility failed to ensure data was collected and analyzed to monitor the quality of care provided to patients when: 1. The Quality Assurance Performance Improvement (QAPI) Program failed to track incidents of physical restraint (when staff hold a patient down against their will or restrict their movement) for trends or training needs. In addition, the QAPI Program failed to determine if staff followed de-escalation procedures prior to applying physical restraint on patients and applied physical restraint safely and according to policy. This failure resulted in the potential for lack of verbal de-escalation by staff and improper physical restraint procedures to go unidentified throughout the facility placing patients at risk for injury or psychosocial harm. 2. The QAPI Program failed to track and trend antibiotic (A medication that kills bacteria or stops them from growing) use throughout the facility for duration, effectiveness, or complications. This failure had the potential to lead to prolonged ineffective antibiotic treatment, resistance, or adverse events. Findings: 1. During the survey, deficiencies were identified related to the use of physical restraint on patients (Refer to A-154). On 3/25/26 at 1:35 p.m. video footage of Patient 1 and Patient 11’s physical restraint episodes were reviewed with the facility’s restraint trainers, Milieu Manager (MM) and Training Coordinator (TC), in the presence of the Director of Risk Management (DPIRM). After review of the video footage, MM and TC confirmed staff did not use safe physical restraint technique and did not implement adequate verbal de-escalation technique prior to the application of physical restraint for Patient 1 and Patient 11. During an interview on 3/25/26 at 3:20 p.m. with DPIRM, DPIRM stated video footage of restraint episodes was reviewed during the Safety Council meetings if there was an injury, if a patient filed a grievance, or if an allegation was made related to physical restraint. DPIRM further stated that the restraint trainers only reviewed the video footage of the restraint episodes he selected for review. DPIRM confirmed that, unless a patient was injured or made an allegation, the restraint episode would not be reviewed for quality assurance or training purposes. During a review of the facility’s QAPI Committee Meeting Minutes from April 2025- January 2026, the minutes revealed the facility tracked the number of physical restraint episodes which occurred monthly. There was no documentation which indicated restraint episodes were reviewed to identify adherence to facility policy, safety concerns, or staff training needs. In addition, there was no documentation which indicated restraint episodes were tracked to identify trends. During an interview with the facility’s QAPI committee members on 3/27/26 at 9:30 a.m., DPIRM stated the QAPI committee did not track physical restraint episodes to identify patterns in units, shifts, or staff members initiating the restraint and confirmed the committee only used data to track the total number of restraint episodes. DPIRM stated the QAPI Committee received a high-level report of total numbers of episodes and stated, “We do not drill down to specifics.” The committee confirmed only restraint episodes which resulted in an injury or any allegation were reviewed and there was no sample of episodes selected for video review to ensure policy was followed. The committee confirmed that without video review of physical restraint episodes, it was not possible to ensure that verbal de-escalation was appropriately implemented prior to the initiation of physical restraints or that physical restraint was applied safely and according to policy. During a review of the facility’s policy titled, “Proper use and Monitoring of Physical/Chemical Restraints and Seclusion”, signed by the Board of Governors on 10/2025, the policy indicated, “ The organization collects restraint/seclusion data to ... assess and monitor the use of restraints in their facility ... identify opportunities for incrementally improving the rate and the safety of restraint use ... Data is collected on all restraint/seclusion episodes, aggregated, analyzed and reported ... Data includes: shift, staff who initiated the process ...” During a review of the facility’s QAPI Plan dated 2026, the plan indicated, “The QAPI program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care, patient safety, and organizational functions. Data is systematically collected for both improvement priorities and continuing measurement of those processes having the greatest impact on patient care and clinical performance, whether or not problems are suspected.” 48424 2. During an interview on 3/27/26 at 9:30 a.m. with the QAPI committee members, the Director of Pharmacy (DOP) stated the QAPI committee had only seen reports of the number of infections and their category; the effectiveness of antibiotics was not something they focused on in QAPI meetings. The Infection Preventionist (IP) stated the facility would not know if a course of antibiotics was effective or not, the facility was not focused on tracking any data like antibiotic prescription duration, effectiveness, or complications, they were only focused on the number of infections. During a review of the facility’s Policy and Procedure (P&P) titled “Antimicrobial Stewardship”, dated 5/23 indicated, “Metrics, Quality and Performance Improvement (QAPI) 1. Structure, process, and outcome measures are used to assess the effectiveness of [the antimicrobial stewardship program] initiatives and the overall impact on antimicrobial use and resistance patterns. 2. Metrics are developed and used to measure the prevalence of healthcare-associated infections caused by resistant organisms, antimicrobial susceptibilities of common pathogens obtained from antibiograms (A laboratory report that shows how susceptible specific bacteria are to different antibiotics), antimicrobial use patterns, health care costs, and other variables related to health-care associated, antibiotic-resistant infections. a. Data collected using these metrics is analyzed to detect trends. b. Goals are established with an accompanying action plan for QAPI. 3. Results are reported quarterly to the [Pharmacy and Therapeutics Committee], Infection Control and Prevention Committees, and QAPI ...””

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 50852 Based on interview and record review, the facility failed to ensure one medical staff member whose initial appointment was more than two years earlier received the required follow-up appraisal after provisional appointment. This failure had the potential to adversely affect patient care. Findings: During an interview and record review on 3/26/26 at 9:20 a.m. with Executive Assistant (EA), the credential records of Nurse Practitioner (NP) had an appointment date of 11/16/2023 with provisional privileges and no reappraisal after three months for full privileges. EA stated that they did not have a ongoing professional practice evaluation for full privileges for NP. During an interview on 3/26/26 at 1:15 p.m. with the Chief Medical Officer (CMO), CMO stated on initial appointment there is a 90 day period where provisional privileges are granted. During that 90 days the provider should be evaluated for performance, and at the end of the period the provider could be granted active privileges. CMO stated NP should have been evaluated after 90 days for active privileges. During an interview on 3/26/26 at 3:40 p.m. with Chief Executive Officer (CEO), CEO stated that the facility had, “overlooked and missed credentialing deadlines.” During a Review of the facility “Medical Staff Bylaws for River Vista Behavioral Health,” not dated, “In the case of a Provisional appointment, then the appointee must qualify for and be advanced to non-Provisional status or be extended on Provisional status for an additional period not to exceed nine (9) months, at the end of which time he shall be reevaluated for advancement.””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48424 Based on interview and record review, the facility failed to establish an antimicrobial stewardship surveillance process (a program that helps ensure medicines used to treat infections caused by bacteria are used correctly and safely) capable of evaluating program effectiveness. Specifically, the facility did not track or evaluate key elements of antimicrobial use, including the antimicrobial prescribed, duration of therapy, patient response, and treatment outcome. This failure had the potential to result in ineffective treatment, delayed identification of unsuccessful therapy, inappropriate antimicrobial use, and increased risk of antimicrobial resistance. During interview and record review on 3/26/26 at 10:07 a.m., the Infection Preventionist (IP) reviewed the facility’s “2026 Performance Improvement Report: Infection Rates [Hospital Acquired Infections] and [Community Acquired Infection],” dated 2/26. The report listed infection counts by category, but did not include the antimicrobial prescribed, duration of therapy, patient symptoms or response, or whether treatment was effective. The IP stated the report focused on infection counts rather than antimicrobial stewardship effectiveness. The IP explained that the Infection Prevention Committee reported only infection categories, and while antibiotic choices could be found in the electronic system, this information was not included in stewardship reporting. The IP further stated that although the report showed whether infections increased or decreased from one month to the next, it did not explain what actually happened; a more complete report with additional elements would provide a clearer understanding of infection trends. The IP stated the report did not show whether changes in infection rates were due to effective antimicrobial therapy or to factors such as discharges or admissions. During an interview on 3/26/26 at 1:41 p.m. with the Assistant Chief Nursing Officer (ACNO), the ACNO stated it was important to be able to see the effectiveness of antibiotics used in the facility. The ACNO stated having trackable data like the antibiotics perscribed, duration, and patient symptoms allowed the facility to track and trend the effectiveness of atibiotic therapies from month to month. The ACNO stated the current way information was tracked only allowed the staff to be able to see how many infections the facility had in any category, but it did not allow for the ability to interpret what the data meant. During an interview on 3/26/26 at 3:04 p.m. with the Director of Pharmacy (DOP), the DOP stated the effectiveness of antibiotics was not tracked as part of the antibiotic stewardship program in the facility. The DOP stated the facility monitored how many infections of each type they had, but they did not track the effectiveness of the antibiotics given. The DOP stated it was important to track the success and results of the prescribed antibiotics because the facility needed to know if antibiotics were effective during a patient’s stay. During a review of the facility’s Policy and Procedure (P&P) titled, “Antimicrobial Stewardship”, dated 6/25, the P&P indicated, “[Antimicrobial Stewardship] refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial regimen including dosing, duration of therapy, and route of administration. When used in conjunction with infection prevention and control, antimicrobial stewardship also prevents the development of antimicrobial-resistant pathogens ...” “Antimicrobial Stewardship Goals 1. Demonstrate coordination of antibiotic use and factors that lead to antimicrobial resistance ... 2. Document evidence based use of antibiotics in inpatient settings 3. Demonstrate improvements, and sustained improvements in proper antibiotic use, through reductions in antimicrobial consumption ...” During a review of the facility’s P&P titled “Antimicrobial Stewardship Program”, dated 2/23, the P&P indicated, “ ... Antimicrobial Stewardship refers to coordinated interventions designed to improve and measure the use of antimicrobials to reduce potential emergence of multi-drug resistant organisms (MDRO) ... It is the policy of [the facility] to develop and implement an antimicrobial stewardship program that includes: ... The Antimicrobial Stewardship Program’s (AMSP) actions, in collaboration with Infection Prevention and Control, will focus on the prevention of healthcare-associated infections and the emergence of MDRO’s ...Patient Safety and clinical outcome metrics will be used to assess effectiveness of the AMSP and determine its overall impact on the use of antimicrobials and MDRO patterns of emergence ...” During a review of the IP’s “Positions Description”, dated 6/22, the “Position Description” indicated, “[The IP will] Assist with the ongoing review of antibiotic usage as needed, and work with the pharmacy on the facility antimicrobial stewardship program ...””

“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: 47205 Based on observation, interview, and record review, the hospital failed to ensure nurses followed policies and procedures (P&P) when: 1. Licensed Nurses (LNs) did not ensure 1 of 4 emergency carts (a mobile, portable cabinet containing essential medical equipment and medications needed for treating emergencies like cardiac arrest [when the heart stops beating suddenly] or respiratory distress (trouble breathing) was locked on unit 2. 2. LNs did not complete the daily inspection of one (1) of four (4) emergency carts on unit four (4). 3. LNs did not ensure the portable oxygen tank (large metal cylinders that store oxygen under pressure [compressed oxygen]) stored on the crash/emergency cart in unit 1 was filled to/or greater than 500 psi (PSI-pounds per square inch- unit of pressure measurement that indicates the force exerted per square inch of an area) per facility P&P. These failures had the potential for essential supplies and equipment to be unavailable or malfunctioning in a medical emergency, and possibly not address the emergent needs of patients. Findings: 1. During a concurrent observation and interview on 4/8/25 at 2:41 p.m., with Chief Nursing Officer (CNO) on unit four (4) the, “Emergency Medical Equipment Daily Checklist”, dated April 2025 had not been completed for 4/7/25. CNO stated her expectation is that LNs ensure the emergency cart is inspected daily during the night shift. 2. During a concurrent observation and interview on 4/8/25 at 3:22 p.m., with CNO on unit two (2) the emergency cart was observed to be unsecured. CNO stated her expectation is that LNs ensure the emergency cart is kept secured to prevent unauthorized access. 3. During a concurrent observation and interview on 4/8/25 at 3:44 p.m., with CNO on unit one (1), the oxygen tank on the emergency cart was below the 500-psi level, at “443.” CNO stated her expectation is that staff ensure the oxygen tanks are full. CNO clarified a display of any level “below 500 [psi] is considered empty.” During a review of the hospital P&P titled, “Medical Gas Cylinders” dated 1/2025, the P&P indicated “ ... PROCEDURE: ... 5. Empty cylinders shall be labelled as being empty. If cylinders have an integral pressure gauge, your facility must define, by policy, the threshold at which they are considered empty. River Vista policy defines 500 PSI as empty. 6. Partially used cylinders are considered empty and must be treated as such...” A policy for the secure storage of crash carts was requested and was not provided by the end of the survey. During a review of a professional reference titled, “Quick Safety 32: Crash-cart preparedness” (retrieved from https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-32-crashcart-preparedness/crashcart-preparedness/, on 4/18/25, “...Medical emergencies have the tendency to create an uneasiness and a sense of chaos during the event. These feelings may be magnified if the emergency equipment used to rescue the patient is not readily available. The intent of a crash cart is to ensure that the correct emergency equipment, medications and supplies are readily available to manage the emergency... Contributing factors to patient safety events related to crash carts include, but are not limited to: ...Missing, expired, damaged, contaminated, and unavailable equipment or medications, Empty oxygen tanks...Unsecured carts or carts that have been tampered with, Carts not checked or inspected according to policy and procedure...Some of these issues may appear minor, but alone or in combination, they may produce delays in providing care, thereby creating a patient safety risk... The intent of a crash cart is to ensure that the correct emergency equipment, medications and supplies are readily available to manage the emergency...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45929 Based on observations, interviews and record review, the hospital failed to maintain a clean and sanitary environment in accordance with hospital policy and procedures and clinical standards of practice for infection control when: 1. Dust and debris were visible on slanted ledges at least 25 feet above the floor in the gym where patients were playing basketball. This failure had the potential of triggering respiratory illnesses, allergies and asthma (a severe respiratory disease causing narrowing and inflammation of the airways). 2. Three of four sampled employee immunization records had declination forms (documents an individual signs when they refuse a vaccination) and titers (essential blood tests used in healthcare to determine if someone has immunity to specific diseases) that were not completed. This failure had the potential to spread disease causing harm or death. 3. The facility failed to clean and maintain four out of four intake rooms (area located in each, where new patients get interviewed by the nurse and change into appropriate clothing/scrubs). 4. Paper signs posted with scotch tape were found on all patient care units. 5. 85 cardboard boxes of emergency food were stacked directly on the floor in a clean supply room and dust clumps and debris were noted on the floor of the room. These failures had the potential to cause cross contamination (transmission of disease from one patient to another) from the intake rooms not being cleaned after each use. Findings: 1. During a concurrent observation and interview on 4/8/25 at 3:05 p.m. with the Chief Nursing Officer (CNO) in the gym, dust and debris were visible on slanted ledges at least 25 feet above the floor. Marks in the dust were also visible where items had moved the dust around. When asked who cleaned the ledges, the CNO stated we would have to ask the Director of Plant Operations (DPO). During an interview on 4/8/25 at 3:10 p.m. with House Keeping Worker (HKW) 1, HKW 1 stated he knew about the dust in the gym, but did not have the tools to clean that high. HKW 1 stated housekeeping staff have a list of what to clean on every patient unit, but not for the gym. During an interview with the DPO, the DPO stated he did not have staff, until a few days ago, that could get on a ladder to assist the DPO in cleaning the gym’s ledge. The DPO stated the Environmental Services (EVS) personnel were not allowed to get on a ladder. During an interview on 4/11/25 at 2:15 p.m. with the Infection Prevention Registered Nurse (IPRN), the IPRN stated the dust on the ledge of the gym was a risk for patients, as it could contain dust mites (very small, insect-like pests that feed on dead human skin cells and thrive in warm, humid settings, causing respiratory symptoms and rashes to individuals exposed to them) and could fall down triggering allergies and asthma in patients and staff. 2. During a concurrent interview and record review on 4/11/25 at 9:55 a.m. with the Director of Human Resources (DHR), House Supervisor (HS) 1’s “Immunization Record (IR)” (undated) was reviewed. HS 1’s “IR” indicated HS 1 declined a Measles, Mumps and Rubella vaccine (MMR, three highly contagious and serious viral infections) and the varicella (chicken pox, highly contagious viral infection) vaccine. The DHR stated the “IR” had no documentation of measles, mumps, rubella, or varicella titers. During a concurrent interview and record review on 4/11/25 at 10:00 a.m. with the DHR, Milieu Specialist (MS, a specialist in maintaining a safe and therapeutic environment for mental health patients) 1’s “IR” (undated) was reviewed. The “IR” indicated MS 1 had declined vaccinations for varicella, MMR, Hepatitis B (viral infection in the liver), and tDAP or Tdap (a vaccine against three bacterial infections: tetanus [lockjaw], diphtheria [life threatening infection], and pertussis [whooping cough]). The DHR stated the “IR” had no documentation of titers for the previously mentioned diseases. During a concurrent interview and record review on 4/11/25 at 10:25 a.m. with the DHR, the CNO’s “IR” (undated) was reviewed. The “IR” indicated MS 1 had declined vaccinations for varicella, MMR, Hepatitis B, and tDAP. The DHR stated the “IR” had no documentation of Hepatitis B or tDAP titers. During an interview on 4/11/25 at 2:12 p.m. with the IPRN, the IPRN stated employees are asked to provide a copy of their immunizations, and the hospital recommends immunizations. The IPRN stated the hospital offers vaccination to employees but does not draw titers. The IPRN stated she was not aware of the Center for Disease Control & Prevention (CDC, the nation’s leading science-based, data-driven service organization) recommendations for health care workers vaccination, titer guidelines. During a review of the hospital’s policy and procedure titled, “Pre-Placement Health Screening (On-boarding) (PHS)” dated 6/2024, the “PHS” indicated, “ ... Infection Prevention/Employee Health (IP/EH) will provide preventative and healthcare related services ... assures up-to-date health screening for every employee ... pre-employment physical screening is completed for all newly hired staff ... The physical screening includes ... HBV [Hepatitis B Vaccination] screen, MMR vaccination history ... communicable disease and drug screen ... immunization history will be taken from the newly hired employee ... It is recommended that employees should have had at least one (1) Tdap on file ...All immunizations are documented in the employee health file ... Measles, Mumps, and Rubella Screening ... All employees are screened for immunization history at the time of hire ...Patients/Resident must have history of current immunizations at time of admission ...Varicella and Pertussis Screening ... All employees are screened for immunizations at time of hire ...”. During an interview on 4/11/25 at 1550, the CNO stated it was her expectation for hospital policy to follow CDC guidelines. During a review of a professional reference titled, “CDC Immunization of Health-Care Personnel [HCP] (CDCI)”, dated 11/25/11, the “CDCI” indicated, “ ... Summary of main changes from 1997 Advisory Committee ... Infection Control Practices ...recommendations for immunization of health-care personnel (HCP) ... Hepatitis B ...in certain populations at high risk ... should be tested ... to determine infection status ... MMR ...History of disease is no longer considered adequate presumptive evidence of measles or mumps immunity for HCP; laboratory confirmation of disease was added as acceptable presumptive evidence of immunity. History of disease has never been considered adequate evidence of immunity for rubella ...Pertussis ... HCP, regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap ... Tdap can now be administered regardless of interval since last tetanus or diphtheria-containing vaccine ... Varicella ...Criteria for evidence of immunity to varicella were established. For HCP they include ... written documentation with 2 doses f vaccine, laboratory evidence of immunity or laboratory confirmation of disease ...”. 3. During an observation on 4/8/25 at 2:40 p.m. while in Unit 4 intake room, the patient exam table had crunched up paper across the exam table (indicating that someone had sat on the paper because it should be straight with no indents if it is cleaned). During an observation on 4/8/25 at 2:58 p.m. while in Unit 3 intake room, the patient exam table had crunched up paper across the exam table. During an observation on 4/8/25 at 3:25 p.m., while in Unit 2 intake room, the patient exam table had crunched up paper across the exam table. During a concurrent observation and interview on 4/8/25, at 3:48 pm with the Chief Executive Officer (CEO) and the CNO, while in Unit 1’s intake room, the patient exam table had crunched up paper across the exam table. The CEO and CNO stated the intake rooms should be cleaned after each patient use. During an interview on 4/11/25, at 2:12 p.m., with the IPRN, the IPRN stated the exam rooms should have been cleaned immediately after they were used. IPRN stated, “If you don’t have a clean exam room, there could be transmissible disease, lice ...”. During a review of a professional reference from the CDC titled, “Healthcare-Associated Infections (HAIs)” Considerations for Reducing Risk: Surfaces in Healthcare Facilities, dated 4/15/24 indicated, “ ... Hospitals must maintain a clean environment and reduce germ exposure to keep patients, visitors and healthcare personnel safe. There are six Core Components to creating and sustaining a clean, safe environment ... 1. Integrate environmental services into the hospital’s safety culture. 2. Educate and train all personnel responsible for cleaning and disinfecting patient care areas. 3. Select appropriate cleaning and disinfection technologies and products. 4. Standardize setting-specific cleaning and disinfection protocols. 5. Monitor effectiveness and adherence to cleaning and disinfection protocols. 6. Provide feedback on the adequacy and effectiveness of cleaning and disinfection to staff and stakeholders ... All personnel who clean and disinfect reusable patient care equipment and environmental surfaces in patient care areas must understand their roles and responsibilities ...”. https://www.cdc.gov/healthcare-associated-infections/hcp/infection-control/index.html 4. During an observation on 4/8/25 at 2:20 p.m. on Unit 4, multiple paper signs hung with scotch tape were posted in the medication room and hallways. During an observation on 4/8/25 at 2:50 p.m. on Unit 3, multiple paper signs hung with scotch tape were posted in the medication room and hallways. During an observation on 4/8/25 at 3:20 p.m. on Unit 2, multiple paper signs hung with scotch tape were posted in the medication room and hallways. During an observation on 4/8/25 at 3:40 p.m. on Unit 1, multiple paper signs hung with scotch tape were posted in the medication room and hallways. During an interview on 4/11/25 at 2:15 p.m. with the IPRN, the IPRN stated paper signage on the walls was a “ ... no-no ...” because it “ ... can’t be cleaned ...”. The IPRN stated acceptable signage should be laminated or kept in a clear sleeve that could be cleaned. 5. During a concurrent observation and interview on 4/8/25 at 2:55 p.m. with the CEO in a clean supply room, 85 cardboard boxes of emergency food were stacked on the floor and clumps of dust and debris were on the floor. The CEO stated the room was usually cleaned daily. During an interview on 4/11/25 at 2:18 p.m. with the IPRN, the IPRN stated the cardboard boxes of food could harbor bugs and if the boxes got wet, the food could mold easily and cause a risk of infection if consumed. The IPRN stated the debris and dust clumps on the clean supply room floor was “ ... definitely not clean ...”. During a review of a professional reference titled, “Why carboard boxes attract pests (CB)”, dated 4/7/24, “CB” indicated, “ ... Cardboard can absorb and retain moisture from the environment, which creates an inviting habitat for pests ... The corrugated structure of cardboard offers an ideal hiding spot for pests ... making it difficult to detect their presence until an infestation has occurred ... Cockroaches ... are attracted to the glue used in cardboard, which often contains starch, a food source for these pests ... Silverfish ... are particularly fond of damp cardboard, which provides both a food source and a humid environment ...”.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40644 Based on observation, interview and record review, the hospital failed to ensure patients received care in a safe setting for 71 out of 71 patients when: 1. Landscaping plants in four of six courtyards included one plant variety that is poisonous if eaten. This failure had the potential to put all patients who have access to the courtyards at risk of poisoning. 2. Three of four sampled employee records did not contain proof of an annual abuse prevention (proactive steps to create safe environments and prevent harm to vulnerable populations) and reporting (when a person either knows or has a reasonable suspicion a person is being or has been abused and reports to the proper authorities) education completion. This failure had the potential to place all patients at risk for unreported abuse. Findings: 1. During a concurrent observation, interview, and document review on 4/10/25 at 9:00 a.m. in courtyard 1 with the Director of Plant Maintenance (DPM) and the Chief Executive Officer (CEO) the courtyard was observed as an outdoor area surrounded by hospital buildings, creating an enclosed outdoor space for patients to sit or engage in activities. The central area of the courtyard was concrete, and around the perimeter there were landscape plants. Six Nandina domestica shrubs (Nandina, often called heavenly bamboo or sacred bamboo, is a common shrub used in landscaping that produces bright red berries) were noted. The shrubs were not in bloom or producing berries at the time of the observation. The DPM was provided a print-out of reference from https://en.wikipedia.org/wiki/Nandina#:~:text=Nandina%20can%20take%20heat%20and,off%20by%20hand%20in%20spring for review. The reference indicated, “ ... Toxicity: All parts of the plant are poisonous, containing compounds that decompose to produce hydrogen cyanide, and could be fatal if ingested.” The DPM observed the bright berries in the picture of the shrub, and stated he could see that the berries on the plant looked like cherries and could be tempting to children and adults. The CEO stated she was not familiar with the plant. During a tour of courtyards 2, 3, and 4, the courtyards were identical with the same landscape plants, including Nandina. During a tour of courtyards 5 and 6, the areas were noted to be smaller and did not contain Nandina shrubs. During an interview on 4/11/25 with the Chief Nursing Officer (CNO), the CNO stated she was not familiar with Nandina bushes, and stated, “We don’t want anyone to get poisoned.” During a review of hospital policy titled, “Patient Rights and Responsibilities” dated 6/2024, the policy indicated, “ ...1. Humane Psychological and Physical Environment: Each patient at [name of hospital] has the right to a humane psychological and physical environment. The facility has been, and shall continue to be, designed to positively contribute to patient treatment by affording patients with comfort and safety ...” During a review of an article from Human and Experimental Toxicology titled, “Pediatric Nandina domestica ingestions reported to poison centers” dated April 19, 2018, retrieved from https://pubmed.ncbi.nlm.nih.gov/28421827/#:~:text=Abstract,outside%20of%20a%20healthcare%20facility, the article indicated, “ ... Nandina domestica is grown as an ornamental plant in the United States but has also been reported as an invasive plant in a number of states. Parts of the plant, particularly the berries, contain cyanogenic glycosides that convert to hydrogen cyanide when ingested ...” During a review of an article titled, “A Comprehensive Guide To Hazardous & Poisonous Plants In Therapeutic Settings” (undated) retrieved from https://rootinnature.ca/growth-network/ the article indicated, “ ... An integral part of creating this therapeutic environment is ensuring the garden’s safety. It is not merely about preventing inadvertent brushes with poison ivy or the prick of a thorny rose. It is about safeguarding the sanctity of the garden experience ...” 45929 2. During a concurrent interview and record review on 4/11/25 at 10:00 a.m. with the Director of Human Resources (DHR) and the CNO, House Supervisor (HS) 1’s “Education History (EH)”, dated 2024-2025, was reviewed. The DHR stated she was not able to locate documentation of abuse prevention and reporting education completed by HS 1 within the previous year. The CNO stated HS 1 received repeat training in Crisis Prevention Institute (CPI, a de-escalation and crisis intervention program for staff working with individuals with mental health needs) after a recent video camera review of an incident of a patient encounter on a patient care unit. During a concurrent interview and record review on 4/11/25 at 10:10 a.m. with the DHR, the DHR reviewed Milieu Specialist (MS, a specialist in maintaining a safe and therapeutic environment for mental health patients) 1’s “EH”, dated 2024-2025. The DHR stated she could not locate documentation of abuse prevention and reporting education completed by MS 1 in the previous year. During a concurrent interview and record review on 4/11/25 at 10:40 a.m. with the DHR, the DHR reviewed the CNO’s “EH”, dated 2024-2025. The DHR stated she could not locate documentation of abuse prevention and reporting education completed by the CNO in the previous year. During an interview on 4/11/25 at 3:36 p.m. with the CNO, the CNO stated Abuse prevention and reporting education is important because abuse of a patient was more likely to occur with patients with mental health issues. During a review of the hospital’s policy and procedure titled, “Staff Competency and Training (SCT)”, dated 6/2024, “SCT” indicated, “ ... Purpose: To assure compliance with all laws, rules and regulations relating to federal and state health care programs ... Annual Retraining ... On an annual basis, each employee is required to complete refresher training on the following topics ... Abuse/Neglect Identification and Reporting ...”. During a review of a professional reference titled, “Patient safety in inpatient psychiatry: a reaming frontier health policy (PS)”, dated 5/2/23, “PS” indicated, “ ... Behavioral health care has been slow to take up robust efforts to improve patient safety. This lag is especially apparent in inpatient psychiatry, where there is risk for physical and psychological harm. Recent investigative journalism has provoked public concern about instances of alleged abuse, negligence ... sexual assault, inappropriate medication use ... inappropriate restraint and seclusion ... Several processes must be in place to ensure safety within psychiatric facilities. Safe environments require that staff members be proactive and intervene quickly in tense and escalating situations. Their ability to notice and mindfully intervene at these flash-point moments can result in the reduced use of containment measures (that is, chemical and physical restraint and close-door seclusion) that in some instances can be harmful to patients ...”.”

“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: 47205 Based on observation, interview, and record review, the hospital failed to ensure nurses followed policies and procedures (P&P) when: 1. Licensed Nurses (LNs) did not ensure 1 of 4 emergency carts (a mobile, portable cabinet containing essential medical equipment and medications needed for treating emergencies like cardiac arrest [when the heart stops beating suddenly] or respiratory distress (trouble breathing) was locked on unit 2. 2. LNs did not complete the daily inspection of one (1) of four (4) emergency carts on unit four (4). 3. LNs did not ensure the portable oxygen tank (large metal cylinders that store oxygen under pressure [compressed oxygen]) stored on the crash/emergency cart in unit 1 was filled to/or greater than 500 psi (PSI-pounds per square inch- unit of pressure measurement that indicates the force exerted per square inch of an area) per facility P&P. These failures had the potential for essential supplies and equipment to be unavailable or malfunctioning in a medical emergency, and possibly not address the emergent needs of patients. Findings: 1. During a concurrent observation and interview on 4/8/25 at 2:41 p.m., with Chief Nursing Officer (CNO) on unit four (4) the, “Emergency Medical Equipment Daily Checklist”, dated April 2025 had not been completed for 4/7/25. CNO stated her expectation is that LNs ensure the emergency cart is inspected daily during the night shift. 2. During a concurrent observation and interview on 4/8/25 at 3:22 p.m., with CNO on unit two (2) the emergency cart was observed to be unsecured. CNO stated her expectation is that LNs ensure the emergency cart is kept secured to prevent unauthorized access. 3. During a concurrent observation and interview on 4/8/25 at 3:44 p.m., with CNO on unit one (1), the oxygen tank on the emergency cart was below the 500-psi level, at “443.” CNO stated her expectation is that staff ensure the oxygen tanks are full. CNO clarified a display of any level “below 500 [psi] is considered empty.” During a review of the hospital P&P titled, “Medical Gas Cylinders” dated 1/2025, the P&P indicated “ ... PROCEDURE: ... 5. Empty cylinders shall be labelled as being empty. If cylinders have an integral pressure gauge, your facility must define, by policy, the threshold at which they are considered empty. River Vista policy defines 500 PSI as empty. 6. Partially used cylinders are considered empty and must be treated as such...” A policy for the secure storage of crash carts was requested and was not provided by the end of the survey. During a review of a professional reference titled, “Quick Safety 32: Crash-cart preparedness” (retrieved from https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-32-crashcart-preparedness/crashcart-preparedness/, on 4/18/25, “...Medical emergencies have the tendency to create an uneasiness and a sense of chaos during the event. These feelings may be magnified if the emergency equipment used to rescue the patient is not readily available. The intent of a crash cart is to ensure that the correct emergency equipment, medications and supplies are readily available to manage the emergency... Contributing factors to patient safety events related to crash carts include, but are not limited to: ...Missing, expired, damaged, contaminated, and unavailable equipment or medications, Empty oxygen tanks...Unsecured carts or carts that have been tampered with, Carts not checked or inspected according to policy and procedure...Some of these issues may appear minor, but alone or in combination, they may produce delays in providing care, thereby creating a patient safety risk... The intent of a crash cart is to ensure that the correct emergency equipment, medications and supplies are readily available to manage the emergency...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45929 Based on observations, interviews and record review, the hospital failed to maintain a clean and sanitary environment in accordance with hospital policy and procedures and clinical standards of practice for infection control when: 1. Dust and debris were visible on slanted ledges at least 25 feet above the floor in the gym where patients were playing basketball. This failure had the potential of triggering respiratory illnesses, allergies and asthma (a severe respiratory disease causing narrowing and inflammation of the airways). 2. Three of four sampled employee immunization records had declination forms (documents an individual signs when they refuse a vaccination) and titers (essential blood tests used in healthcare to determine if someone has immunity to specific diseases) that were not completed. This failure had the potential to spread disease causing harm or death. 3. The facility failed to clean and maintain four out of four intake rooms (area located in each, where new patients get interviewed by the nurse and change into appropriate clothing/scrubs). 4. Paper signs posted with scotch tape were found on all patient care units. 5. 85 cardboard boxes of emergency food were stacked directly on the floor in a clean supply room and dust clumps and debris were noted on the floor of the room. These failures had the potential to cause cross contamination (transmission of disease from one patient to another) from the intake rooms not being cleaned after each use. Findings: 1. During a concurrent observation and interview on 4/8/25 at 3:05 p.m. with the Chief Nursing Officer (CNO) in the gym, dust and debris were visible on slanted ledges at least 25 feet above the floor. Marks in the dust were also visible where items had moved the dust around. When asked who cleaned the ledges, the CNO stated we would have to ask the Director of Plant Operations (DPO). During an interview on 4/8/25 at 3:10 p.m. with House Keeping Worker (HKW) 1, HKW 1 stated he knew about the dust in the gym, but did not have the tools to clean that high. HKW 1 stated housekeeping staff have a list of what to clean on every patient unit, but not for the gym. During an interview with the DPO, the DPO stated he did not have staff, until a few days ago, that could get on a ladder to assist the DPO in cleaning the gym’s ledge. The DPO stated the Environmental Services (EVS) personnel were not allowed to get on a ladder. During an interview on 4/11/25 at 2:15 p.m. with the Infection Prevention Registered Nurse (IPRN), the IPRN stated the dust on the ledge of the gym was a risk for patients, as it could contain dust mites (very small, insect-like pests that feed on dead human skin cells and thrive in warm, humid settings, causing respiratory symptoms and rashes to individuals exposed to them) and could fall down triggering allergies and asthma in patients and staff. 2. During a concurrent interview and record review on 4/11/25 at 9:55 a.m. with the Director of Human Resources (DHR), House Supervisor (HS) 1’s “Immunization Record (IR)” (undated) was reviewed. HS 1’s “IR” indicated HS 1 declined a Measles, Mumps and Rubella vaccine (MMR, three highly contagious and serious viral infections) and the varicella (chicken pox, highly contagious viral infection) vaccine. The DHR stated the “IR” had no documentation of measles, mumps, rubella, or varicella titers. During a concurrent interview and record review on 4/11/25 at 10:00 a.m. with the DHR, Milieu Specialist (MS, a specialist in maintaining a safe and therapeutic environment for mental health patients) 1’s “IR” (undated) was reviewed. The “IR” indicated MS 1 had declined vaccinations for varicella, MMR, Hepatitis B (viral infection in the liver), and tDAP or Tdap (a vaccine against three bacterial infections: tetanus [lockjaw], diphtheria [life threatening infection], and pertussis [whooping cough]). The DHR stated the “IR” had no documentation of titers for the previously mentioned diseases. During a concurrent interview and record review on 4/11/25 at 10:25 a.m. with the DHR, the CNO’s “IR” (undated) was reviewed. The “IR” indicated MS 1 had declined vaccinations for varicella, MMR, Hepatitis B, and tDAP. The DHR stated the “IR” had no documentation of Hepatitis B or tDAP titers. During an interview on 4/11/25 at 2:12 p.m. with the IPRN, the IPRN stated employees are asked to provide a copy of their immunizations, and the hospital recommends immunizations. The IPRN stated the hospital offers vaccination to employees but does not draw titers. The IPRN stated she was not aware of the Center for Disease Control & Prevention (CDC, the nation’s leading science-based, data-driven service organization) recommendations for health care workers vaccination, titer guidelines. During a review of the hospital’s policy and procedure titled, “Pre-Placement Health Screening (On-boarding) (PHS)” dated 6/2024, the “PHS” indicated, “ ... Infection Prevention/Employee Health (IP/EH) will provide preventative and healthcare related services ... assures up-to-date health screening for every employee ... pre-employment physical screening is completed for all newly hired staff ... The physical screening includes ... HBV [Hepatitis B Vaccination] screen, MMR vaccination history ... communicable disease and drug screen ... immunization history will be taken from the newly hired employee ... It is recommended that employees should have had at least one (1) Tdap on file ...All immunizations are documented in the employee health file ... Measles, Mumps, and Rubella Screening ... All employees are screened for immunization history at the time of hire ...Patients/Resident must have history of current immunizations at time of admission ...Varicella and Pertussis Screening ... All employees are screened for immunizations at time of hire ...”. During an interview on 4/11/25 at 1550, the CNO stated it was her expectation for hospital policy to follow CDC guidelines. During a review of a professional reference titled, “CDC Immunization of Health-Care Personnel [HCP] (CDCI)”, dated 11/25/11, the “CDCI” indicated, “ ... Summary of main changes from 1997 Advisory Committee ... Infection Control Practices ...recommendations for immunization of health-care personnel (HCP) ... Hepatitis B ...in certain populations at high risk ... should be tested ... to determine infection status ... MMR ...History of disease is no longer considered adequate presumptive evidence of measles or mumps immunity for HCP; laboratory confirmation of disease was added as acceptable presumptive evidence of immunity. History of disease has never been considered adequate evidence of immunity for rubella ...Pertussis ... HCP, regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap ... Tdap can now be administered regardless of interval since last tetanus or diphtheria-containing vaccine ... Varicella ...Criteria for evidence of immunity to varicella were established. For HCP they include ... written documentation with 2 doses f vaccine, laboratory evidence of immunity or laboratory confirmation of disease ...”. 3. During an observation on 4/8/25 at 2:40 p.m. while in Unit 4 intake room, the patient exam table had crunched up paper across the exam table (indicating that someone had sat on the paper because it should be straight with no indents if it is cleaned). During an observation on 4/8/25 at 2:58 p.m. while in Unit 3 intake room, the patient exam table had crunched up paper across the exam table. During an observation on 4/8/25 at 3:25 p.m., while in Unit 2 intake room, the patient exam table had crunched up paper across the exam table. During a concurrent observation and interview on 4/8/25, at 3:48 pm with the Chief Executive Officer (CEO) and the CNO, while in Unit 1’s intake room, the patient exam table had crunched up paper across the exam table. The CEO and CNO stated the intake rooms should be cleaned after each patient use. During an interview on 4/11/25, at 2:12 p.m., with the IPRN, the IPRN stated the exam rooms should have been cleaned immediately after they were used. IPRN stated, “If you don’t have a clean exam room, there could be transmissible disease, lice ...”. During a review of a professional reference from the CDC titled, “Healthcare-Associated Infections (HAIs)” Considerations for Reducing Risk: Surfaces in Healthcare Facilities, dated 4/15/24 indicated, “ ... Hospitals must maintain a clean environment and reduce germ exposure to keep patients, visitors and healthcare personnel safe. There are six Core Components to creating and sustaining a clean, safe environment ... 1. Integrate environmental services into the hospital’s safety culture. 2. Educate and train all personnel responsible for cleaning and disinfecting patient care areas. 3. Select appropriate cleaning and disinfection technologies and products. 4. Standardize setting-specific cleaning and disinfection protocols. 5. Monitor effectiveness and adherence to cleaning and disinfection protocols. 6. Provide feedback on the adequacy and effectiveness of cleaning and disinfection to staff and stakeholders ... All personnel who clean and disinfect reusable patient care equipment and environmental surfaces in patient care areas must understand their roles and responsibilities ...”. https://www.cdc.gov/healthcare-associated-infections/hcp/infection-control/index.html 4. During an observation on 4/8/25 at 2:20 p.m. on Unit 4, multiple paper signs hung with scotch tape were posted in the medication room and hallways. During an observation on 4/8/25 at 2:50 p.m. on Unit 3, multiple paper signs hung with scotch tape were posted in the medication room and hallways. During an observation on 4/8/25 at 3:20 p.m. on Unit 2, multiple paper signs hung with scotch tape were posted in the medication room and hallways. During an observation on 4/8/25 at 3:40 p.m. on Unit 1, multiple paper signs hung with scotch tape were posted in the medication room and hallways. During an interview on 4/11/25 at 2:15 p.m. with the IPRN, the IPRN stated paper signage on the walls was a “ ... no-no ...” because it “ ... can’t be cleaned ...”. The IPRN stated acceptable signage should be laminated or kept in a clear sleeve that could be cleaned. 5. During a concurrent observation and interview on 4/8/25 at 2:55 p.m. with the CEO in a clean supply room, 85 cardboard boxes of emergency food were stacked on the floor and clumps of dust and debris were on the floor. The CEO stated the room was usually cleaned daily. During an interview on 4/11/25 at 2:18 p.m. with the IPRN, the IPRN stated the cardboard boxes of food could harbor bugs and if the boxes got wet, the food could mold easily and cause a risk of infection if consumed. The IPRN stated the debris and dust clumps on the clean supply room floor was “ ... definitely not clean ...”. During a review of a professional reference titled, “Why carboard boxes attract pests (CB)”, dated 4/7/24, “CB” indicated, “ ... Cardboard can absorb and retain moisture from the environment, which creates an inviting habitat for pests ... The corrugated structure of cardboard offers an ideal hiding spot for pests ... making it difficult to detect their presence until an infestation has occurred ... Cockroaches ... are attracted to the glue used in cardboard, which often contains starch, a food source for these pests ... Silverfish ... are particularly fond of damp cardboard, which provides both a food source and a humid environment ...”. 47205”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33126 Based on observation, interview and record review, the hospital failed to protect and promote each patient’s rights for 4 of 22 sampled patients ( PT-1, PT-2, PT-4 and PT-20) when: 1. Staff did not safeguard their electronic badge in accordance with hospital policies and procedures, and nursing staff did not assign the appropriate level of supervision for PT-1 in accordance with assessment of risk of elopement. Staff did not assess and address staffing levels and environmental factors that could have prevented elopement. These failures resulted in PT-1 accessing staff’s unattended electronic badge, traversing several restricted access doors and exiting and eloping the physical safety of the hospital to the outside unnoticed and unsupervised. PT-1 eloped at approximately 8:06 a.m. on 9/20/24 and staff were not aware of the elopement until 8:25 a.m., on 9/20/24. Local Police notified the hospital PT-1 was charged with unlawfully taking a van from a property next to the hospital and brought PT-1 back to the hospital for admission later the same day 9/20/24. (Refer to A144) Because of the serious potential harm to PT-1 and all patients related to not having the level of supervision needed and not having a system to keep patients from eloping, an Immediate Jeopardy (IJ) was called for CFR 482.13(c)(2), A-0144 on 11/8/24 at 2:03 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO). The IJ Template was provided to the hospital and instructed to submit an acceptable Plan of Removal which lists actions to remove the IJ. The hospital submitted Version 3.1 (previous 3 submission not acceptable) which was accepted on 11/14/24 at 5:33p.m.Version 3.1 indicated the following actions were to be implemented: the involved staff who left the electronic badge unattended was placed on administrative leave, an investigation to determine factors that led to the elopement commenced, reinforcement and inservices to all staff in regards to keeping electronic badges safe and secure and not left unattended, the level of supervision was addressed for all patients and staffing was evaluated provided to support a safe environment and a monitoring system was put into place to ensure all actions were implemented. The survey team validated all actions were implemented and the IJ was removed on 11/15/24 at 11:15 a.m. with the CNO and CEO. Condition level non-compliance remained after the IJ was removed. 2. Hospital staff witnessed and Mental Health Technician (MHT)-14 admitted to verbally taunting, verbally abusing and threatening PT-20. The hospital failed to effectively investigate the situation and did not immediately address the abusive practices of MHT-14. PT-2 was in seclusion at the time of the abuse. The hospital failed to report the threatening behavior of MHT-14 to local law enforcement. MHT-14 was not placed on administrative leave as indicated by standards of practice for abuse and was permitted to continue to work. The hospital failed to report the abuse to the state agency. These failures resulted in PT-2’s unnecessary and avoidable emotional and mental anxiety that required administration of medication to calm PT-2’s symptoms. (refer to A145, Finding 1) 2. Hospital staff witnessed Licensed Vocational Nurse (LVN) 1 physically push and physically remove PT-4 from the group room and LVN 1 did not utilize de-escalating and non-confrontational techniques to address the situation in accordance with professional standards of practice and hospital policies and procedures. These failures resulted in PT-4 suffering unnecessary and avoidable physical abuse and mental anguish and possibly negatively affected the mental health status of PT-4’s. (Refer to A145, Finding 2) 3. Hospital staff physically restrained and took down PT-20 to the floor, physically pushing PT-20’s face to the floor without first utilizing de-escalating and non-confrontational techniques in accordance with professional standards of practice and hospital policies and procedures. Subsequently, PT-20 was placed in seclusion inappropriately without first determining the best method to address PT-20’s behavior. While in seclusion the hospital staff did not effectively address self-injurious behavior of PT-20 striking her head against the concrete wall. (refer to A145, Finding 3) These failures resulted in not protecting PT-20’s right to be free from physical abuse and suffered avoidable closed head trauma; and possibly resulted in negatively affecting the mental health status of PT-20. Because of the avoiable serious emotional, mental, and physical harm to PT-2, PT-4 and PT-20 and not utilizing de-escalating and non-confrontational techniques and not having a system to ensure patients are free from abuse an Immediate Jeopardy (IJ) was called for CFR 482.13(c)(3) A-145 on 11/8/24 at 2:03 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO). The IJ Template was provided to the hospital and instructed to submit an acceptable Plan of Removal which lists actions to remove the IJ. The hospital submitted Version 3.1 which was accepted on 11/14/24 at 5:33p.m. The hospital actions to address the IJ situation included: terminating employment of MHT-14, inservice of staff on expectations on preventing abuse and harassment, training related to appropriately escalating situations to charge nurse and hospital leadership, inservice of de-escalating and non-confrontational techniques, inservice on when seclusion is appropriate and not appropriate, and evaluated and implemented staffing levels to better mee the needs of patients. The survey team validated all actions were implemented and the IJ was removed on 11/15/24 at 11:15 a.m. with the CNO and CEO . Condition level non-compliance remained after the IJ was removed. The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 11090 Based on observation, interview and record review, the hospital failed to have a well-organized and effective 24- hour nursing services when: 1. The routine registered nurse staffing assignment per unit of 30 patient capacity was 1-2 RNs per unit. Vital signs were not done in accordance with hospital policies and procedures due to inadequate staffing numbers. The number of nursing personnel was not adequate to provide the level of nursing care needed to meet Patient (PT) 3’s needs, when PT-3 was observed pacing around the millieu, unkempt, malodorous, and wearing dirty clothes The hospital used a formula for staffing that did not include the assessed level of nursing care needed for patients. (Refer to A392, Finding 1); 2. Unlicensed Mental Health Technicians (MHTs) who routinely conduct group therapy sessions were not trained to do so in in three randomly sampled MHT personnel files and three selected MHT personnel files of MHT staff providing group therapy during the survey (MHT1, MHT2, MHT3, MHT4, MHT7, MHT8). (Refer to A-392, Finding 2 and A-395, Finding 2) and 3. There were no Registered Nurses (RN) on duty for Unit 3 on 10/4/24, 10/8/24 and 10/27/24. (Refer to A-392, A-393 Finding 1, and A-395, Finding 1) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe environment.”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 11090 Based on observation, interview and record review, the facility failed to ensure that the facility was adequately staffed with qualified mental health professionals and supportive staff to provide individualized comprehensive treatment and discharge planning for patients when: 1. Ongoing Discharge Planning was not done for seven of 22 sampled patients (PT-2, PT-3, PT-9, PT-10, PT-11, PT-14, PT-22); (Refer to A-1688) 2. The Psychosocial Assessments (PSA) were not completed within 72 hours of admission by social service staff for eight of 22 sampled patients (PT-1, PT-3, PT-6, PT-7, PT-8, PT-9, PT-12, PT-13) (Refer to A-1717) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe environment.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 11090 Based on observation, interview and record review, the hospital failed to ensure patients received care in a safe setting for one of 22 sampled patients, Patient (PT) 1, when staff did not safeguard their electronic badge in accordance with hospital policies and procedures, and nursing did not assign the appropriate level of supervision for PT-1 in accordance with assessment of risk of elopement. Staff did not assess and address staffing levels and environmental factors that could have prevented elopement. These failures resulted in PT-1 accessing staff’s unattended electronic badge, traversing several restricted access doors and exiting and eloping the physical safety of the hospital to the outside unnoticed and unsupervised. PT-1 eloped at approximately 8:06 a.m. on 9/20/24 and staff were not aware of the elopement until 8:25 a.m. on 9/20/24. Local Police notified the hospital PT-1 was charged with unlawfully taking a van from a property next to the hospital and brought PT-1 back to the hospital for admission later the same day 9/20/24. Because of the serious potential harm to PT-1 and all patients related to not having the level of supervision needed and not having a system to keep patients from eloping, an Immediate Jeopardy (IJ) was called for CFR 482.13(c)(2), A-0144 on 11/8/24 at 2:03 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO). The IJ Template was provided to the hospital and instructed to submit an acceptable Plan of Removal which lists actions to remove the IJ. The hospital submitted Version 3.1 (previous 3 submission not acceptable) which was accepted on 11/14/24 at 5:33p.m.Version 3.1 indicated the following actions were to be implemented: the involved staff who left the electronic badge unattended was placed on administrative leave, an investigation to determine factors that led to the elopement commenced, reinforcement and inservices to all staff in regards to keeping electronic badges safe and secure and not left unattended, the level of supervision was addressed for all patients and staffing was evaluated provided to support a safe environment and a monitoring system was put into place to ensure all actions were implemented. The survey team validated all actions were implemented and the IJ was removed on 11/15/24 at 11:15 a.m. with the CNO and CEO. Condition level non-compliance remained after the IJ was removed. Findings: An anonymous complaint was received on 9/23/24 alerting the California Department of Public Health that an elopement had occurred at the hospital on 9/20/24. During an interview on 11/6/24, at 10:50 a.m. with the Director of Performance Improvement/Risk Manager (RM), the RM stated, PT-1 was an involuntary patient admitted on 9/16/24, for suicidal ideation (thinking about or plans for suicide). PT-1 was in Unit 3, a locked, secured patient care unit in the hospital. The unit is only accessible with electronic badge access and electronic badge access is also needed to open the fire escape doors. RM stated he viewed a video recording of the incident which showed on 9/20/24, at approximately 8:06 a.m. a Mental Health Technician (MHT-10), (an unlicensed healthcare worker who provides care and support to people with mental health issues) was obtaining patient vital signs in the Unit 3 Group Room (a common area where patients can congregate for group therapy, meals, activities). MHT-10 took off his badge containing hospital identification card with secure access badge, placed it on the table in the group room then left the room proceeding out to the patient corridor. PT-1 picked up the hospital identification card and secure access badge, placed them in his pocket, walked out of the group room, and quickly walked down the main hallway to the secured fire escape door. PT-1 used the secure access badge to open the fire escape door allowing access to the exit stairwell, walked down the exit stairwell, used the secure badge access to exit an unalarmed exterior door on the first floor and PT-1 eloped from the hospital. The RM stated the fire escape door did not have an alarm to alert staff it had been opened without authorization from the patient care corridor accessing the exit stairwell. The RM stated PT-1 eloped at 9/20/24, at 8:06 a.m. and the elopement was not detected until 9/20/24, at 8:25 a.m.. RM stated the hospital does not use Security Guards. Law enforcement was called, PT-1 was apprehended by police after stealing a van from a nearby hospital, and returned to the facility on 9/20/24, at 1:00 p.m. The RM stated, it is the expectation that all staff who have hospital identifications and secure access badges keep them always secured and on their person. The RM stated MHT-10 was negligent when he left his Hospital ID and secure access badge unattended on a table. RM stated, “PT-1 was resistive and running from the police officers and resisting coming in to the hospital prior to his admission. Staff should have identified PT-1 was a flight elopement risk and the elopement should never have happened.” PT 1 was able to elope from the hospital and run to a nearby hospital parking lot where he stole a van and drove off the premises. PT-1’s elopement and theft of a van put him at risk of personally becoming injured or causing severe injury to others. During a record review on 11/6/24 at 11 a.m., PT-1’s demographic page indicated the patient was an 18-year-old male admitted on 9/16/24, at 8:20 p.m. on an involuntary basis, with a primary diagnosis of unspecified psychosis (a diagnosis used when there is not enough information to classify a patient’s psychotic symptoms into a specific disorder). PT-1’s psychiatric evaluation dated 9/17/2024, indicated, “history of present illness: patient was very confused, talking nonsensical. As per the intake notes PT-1 was an, 18-year-old male who was made 5150 (Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for danger to self and danger to others, ran away from the officers. The patient states that he is Jesus Christ. He was very combative with the Emergency Medical Services (EMS) staff and there was great difficulty in bringing him to the facility.” During a review of the daily staffing sheets for Unit 3 for the date of 9/20/24, the staffing during the elopement of PT-1 consisted of 1 Registered Nurse (RN) and 1 Licensed Vocational Nurse (LVN) for 28 patients. During an interview on 11/5/2024 at 10 a.m., RN1 and RN2 stated with the current staffing schedules, there is no time to fully address each patient’s individual needs and to coordinate care to meet each patient’s care plan. During a concurrent interview and document review on 11/12/24 at 9:15 a.m., of the” General Adult Core Staffing Guidelines”, the SC stated the document was used to determine the number of RNs to be assigned to each unit. The document listed the following: Census 17-23, two RNs per shift, census 24-28, three RNs per shift, census 29-35 three RNs per shift. Licensed Practical Nurses (LVNs) were not included in the staffing plan. As the census increased, mental health technicians (MHT)s were added. The SC stated he completes all schedules according to the facility Core Staffing Guidelines for the three adult and one adolescent patient units. The SC stated he submits the staffing schedules to Administration by 3 p.m. The SC stated Administration makes the staffing assignment changes, cuts and adjustments after the SC leaves the facility for the day. During a tour of all patient units on 11/15/24 at 9:30 a.m., with the RM, all inpatient hallway corridor exit doors were checked for what the hospital had indicated were the installation of “high pitched” alarms. All alarms had been installed (per the facility’s Plan of Removal for IJ) but the survey team observed, the volume of the alarms was not “high pitched” and not loud enough to be heard at the nurses stations if staff were talking or answering the telephone. When the exit door was opened, the alarm sounded, but when the door was closed, the alarm quickly stopped. In testing the alarm, a staff member opened the door, walked out into the stairwell and closed the door behind him. This test of opening the door, walking into the stairwell landing, and closing the door lasted no more than 3 seconds. The alarm only sounded during the time when the door was open and stopped when the door was closed. The RM stated the hospital does not provide security guards which would help in monitoring elopements. The RM stated the hospital does not provide real time monitoring of video surveillance cameras. During a concurrent interview and record review on 11/16/24 at 11:00 a.m., PT-1’s discharge summary dated 9/26/24 indicated PT-1 was an 18-year-old male, “Admitted for being grandiose, talking nonsensical. Grandmother called the police against him for yelling and screaming episode. He went AWOL (absent with-out leave) from our program in a vendor’s car but we brought him back.” The RM verbally corrected the above documentation and stated PT-1 “was found in the community after the elopement and was returned to the facility by law enforcement.” During a review of facility’s document Titled, “Master Treatment Plan Review and Individual Treatment Problem Sheet” dated 9/20/24, indicated ,”Problem: Elopement, patient took employee badge and keys and eloped from the building but was found in the community by law enforcement and brought back.” The Individual Treatment Problem Sheet dated 9/20/24, identified Elopement as a problem with interventions listed as “1:1 assess effectiveness and side effects of medications and verbalize his needs and wants.” There was no documentation to support additional monitoring of the location of PT-1 as an intervention. During a review of the facility’s policy and procedure (P&P) titled, “Elopement Prevention and Precaution”, dated 2023, indicated, “Policy, it is the policy of the facility to provide a safe, therapeutic environment of care includes the prevention of patient elopement from the facility or activities on or off grounds. To provide a plan for prevention of elopement from the hospital by identifying early warning signs of elopement risk, monitoring the patient with a suspected potential for an attempt to elope, and implementing intervention steps to minimize the risk of elopement. To provide a response and notification plan in the event of an elopement incident including the process for calling an elopement in order to return the patient to the facility... 2. Observation, Staff assigned to monitor patients on elopement precautions shall be vigilant for identification of elopement risks, behaviors and immediately communicate, document significant signs of concern... 3. Interventions...Monitor patient behaviors near doors and exits, and redirect patient away from doors and exits. During a review of the facility’s policy titled, “Plan for the Provision of Inpatient Care policy #14339983” on 11/12/24 at 10:00 a.m., policy effective 9/2023, page 17 under Nursing Staffing, indicated, “Nursing care is planned, delegated, and coordinated by registered nurses. Members of nursing staff include registered nurses, licensed practical nurses, and mental health technicians. Unit staffing includes at least one RN at all times. Assignments for nursing care are made according to programmatic and patient care needs as defined in the Plan for Nursing Care. Adjustments to the core staffing levels are made on the basis of identified patient needs. Such adjustments for planned staffing are made daily by the CNO or designee based on the individualized needs of patients on the units.” During a review of a professional reference from The Agency for Healthcare Research and Quality sites in a case study conducted by L.M. Cascella, titled “Lapses in elopement policies have grave consequences for behavioral health patient” indicated that “Breakdowns in patient assessment and team communication are top contributing factors in elopement. Risk strategies include conducting a risk assessment for each patient upon admission and periodically throughout the patient’s entire stay to determine elopement risk, and to consider using a decision-making tool or aid to facilitate elopement assessments, such as a decision tree or check list.””

“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: 11090 34448 Based on observation, interview and record review, the hospital failed to ensure three of 22 patients, Patient (PT) -2, PT-4 and PT-20, were free from abuse or harassment when: 1. Hospital staff witnessed and Mental Health Technician (MHT)-14 admitted to verbally taunting, verbally abusing and threatening PT-20. The hospital failed to effectively investigate the situation and did not immediately address the abusive practices of MHT-14. PT-2 was in seclusion at the time of the abuse. The hospital failed to report the threatening behavior of MHT-14 to local law enforcement. MHT-14 was not placed on administrative leave as indicated by standards of practice for abuse and was permitted to continue to work. The hospital failed to report the abuse to the state agency. These failures resulted in PT-2’s unnecessary and avoidable emotional and mental anxiety that required administration of medication to calm PT-2’s symptoms. 2. Hospital staff witnessed Licensed Vocational Nurse (LVN) 1 physically pushed and physically removed PT-4 from the group room and LVN 1 did not utilize de-escalating and non-confrontational techniques to address the situation in accordance with professional standards of practice and hospital policies and procedures. These failures resulted in PT-4 suffering unnecessary and avoidable physical abuse and mental anguish and possibly negatively affected the mental health status of PT-4’s. 3. Hospital staff physically restrained and took down PT-20 to the floor, physically pushing PT-20’s face to the floor without first utilizing de-escalating and non-confrontational techniques in accordance with professional standards of practice and hospital policies and procedures. Subsequently, PT-20 was placed in seclusion inappropriately without first determining the best method to address PT-20’s behavior. While in seclusion the hospital staff did not effectively address self-injurious behavior of PT-20 striking her head against the concrete wall. These failures resulted in not protecting PT-20’s right to be free from physical abuse and suffered avoidable closed head trauma; and possibly resulted in negatively affecting the mental health status of PT-20. Because of the avoiable serious emotional, mental,and physical harm to PT-2, PT-4 and PT-20 and not utilizing de-escalating and non-confrontational techniques and not having a system to ensure patients are free from abuse an Immediate Jeopardy (IJ) was called for CFR 482.13(c)(3) A-145 on 11/8/24 at 2:03 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO). The IJ Template was provided to the hospital and instructed to submit an acceptable Plan of Removal which lists actions to remove the IJ. The hospital submitted Version 3.1 which was accepted on 11/14/24 at 5:33p.m. The hospital actions to address the IJ situation included: terminating employment of MHT-14, inservice of staff on expectations on preventing abuse and harassment, training related to appropriately escalating situations to charge nurse and hospital leadership, inservice of de-escalating and non-confrontational techniques, inservice on when seclusion is appropriate and not appropriate, and evaluated and implemented staffing levels to better mee the needs of patients. The survey team validated all actions were implemented and the IJ was removed on 11/15/24 at 11:15 a.m. with the CNO and CEO. Condition level non-compliance remained after the IJ was removed. Findings: 1. During a tour of Units 1, 2, and 3 on 11/5/2024 at 10:00 a.m., unit staff identified the locations of each unit’s seclusion room area. Each seclusion area was located behind a restricted access door. Two individual seclusion rooms were observed beyond the controlled entrance door. Each seclusion room had its own additional restricted access door with a window for observation, hard cement floors, hard cement walls and a drain in the middle of the floor. During a concurrent interview and clinical record review,with MHT-13, on 11/6/2024 at 2:00 p.m., the clinical record indicated PT-2 was a 24-year-old male admitted on 10/2/2024 with diagnosis of a major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities that once brought joy), who was identified as a suicide risk. PT-1 was discharged on 10/7/2024. MHT-13 stated that he had witnessed an event on 10/6/2024 involving PT-2 on Unit 3. MHT-13 stated on 10/6/2024 on Unit 3 during the day, he had been working with patients in the Day Room when MHT-14 stated loud verbal comments of, “Yeah, we’ll see, we’ll see” directed at PT-2. PT-2 had been placed in a Unit 3 Seclusion Room. As MHT-13 came out of the day room, MHT-13 stated Registered Nurse (RN) 4 requested MHT-13 trade places with MHT-14 who had been monitoring PT-2 in seclusion. According to MHT-13 PT-2 told him that MHT-14 threatened PT-2 stating that MHT-14 was going to, “Get in your chart, get the address of where you live and go hurt you and your family.” MHT-13 stated PT-2 was administered a medication to calm him down during this altercation with MHT-14. PT-2’s clinical record indicated that PT-2’s physician (PSY2) ordered a haloperidol (Haldol-an antipsychotic medication used to treat emotional and mental conditions) injection 50 mg and diphenhydramine (Benadryl-often given with Haldol to prevent unwanted side effects of Haldol) 50 mg injection to be administered on 10/6/2024 at 3:00 p.m.. MHT-13 stated PT-2 stated he was going to file a grievance against MHT-14 after he got out of seclusion. MHT-13 stated he spoke with MHT-14 about PT-2’s allegation that MHT-14 was going to get his address and harm him and his family. MHT-13 stated MHT-14 laughed and stated, “f_ck that faggot”, and admitted that he did indeed tell PT-2 that he was, “Going to get the patient’s address and harm the patient and his family.” MHT-13 stated RN4 was able to coordinate moving MHT-14 to Unit 4 by trading with another MHT for the remainder of the shift. MHT-13 was told by RN4 that an Incident Report on the altercation had been filed. MHT-13 stated he gave PT-2 the complaint form to complete and saw him place it in the grievance box. MHT-13 stated on 10/7/2024, MHT-14 was not assigned to a different floor and was again assigned to Unit 3. MHT-14 continuously followed PT-2 in the hallway and the nursing station calling him “faggot.” The Charge Nurse told him to stop and asked MHT-14 if he needed to switch units. MHT-13 stated at first, MHT-14 agreed to switch units but MHT-14 did not leave. MHT-13 stated MHT-14 continued following PT-2 saying “I’m just waiting for him to make a move” indicating he was waiting for the opportunity to get physical with PT-2. MHT-14 eventually left the unit and was replaced by another MHT. MHT-13 stated later that same day, MHT-14 came on the unit with the Chief Nursing Officer (CNO) to speak with MHT-13 and the Charge Nurse (RN4). RN4 was trying to explain the verbal abuse and threats MHT-14 made to PT-2, to the CNO, but the only thing the CNO was concerned about was that RN4 had no right to trade MHT-14 to another floor. There was no mention of the verbal abuse and threats made to PT-2. The CNO told MHT-13 that MHT-14’s behavior had been “triggered” by PT-2. MHT-13 stated CNO stated “MHT-14 was not at fault.” During an interview on 11/15/2024 at 8:45 a.m., with the Care Navigator (CN), CN stated she teaches staff Crisis Prevention Intervention (CPI, program that teaches how to safely de-escalate potentially dangerous situations) training. CN stated CPI taught staff how to identify distressed patient behavior and how to de-escalate the situation. CN further stated, “We don’t teach holding a patient up against a wall. Don’t push them, don’t shove. Continue to be supportive and keep talking to the patient.” During an interview on 11/6/2024 at 2:00 p.m., with the CNO, a review of the event of PT-2 being placed in seclusion, and the taunting by MHT-14 was discussed. The CNO stated he investigated the event and identified it as “verbal taunting” but did not substantiate the event as “abuse”. The CNO stated the patient (PT-2) called MHT-14 a “racial slur”. The CNO stated that the hospital’s patient population was at high risk for making verbal statements because they are inpatient psychiatric patients, but there is no excuse for staff retaliation. The CNO stated he determined the incident between PT-2 and MHT-14 did not rise to the level of being considered “abuse” The CNO stated this decision was supported as such by the facility’s Corporate Risk Department. The CNO did not respond when asked by the survey team,”Then what does constitute abuse?” CNO did not address MHT-14s behavior that was witnessed by staff. CNO did not address the expectation to effectively utilize de-escalating and non-confrontational techniques. The CNO did not discuss the difference between “taunting” and “verbal abuse”. The CNO did not discuss witnesses hearing MHT-14’s use of derogatory names in speaking to PT-2. During an interview and document review on 11/7/2024 at 7:45 a.m. with the Risk Manager (RM), the Incident Report Log 24-270195 was reviewed concerning PT-2’s altercation with MHT-14. The log identified the event as aggression of a, “patient towards staff.” The RM claimed there was no video of the event. The RM stated PT-2 had been speaking on the telephone, became agitated, used a loud voice, and MHT-14 attempted to intervene to calm PT-2 down. PT-2 called MHT-14 a “racial slur” which “triggered” MHT-14’s response. The RM stated the CNO intervened and determined the event did not constitute “abuse” and therefore was not reported to the California Department of Public Health (CDPH). The RM stated MHT-14 was never disciplined but resigned on 10/13/2024. The threat by MHT-14 of obtaining PT-2’s address and harming PT-2 and his family was not reported to the local police department until 11/9/2024 after the event was identified by the California Deprtment of Public Health (CDPH). During a review of the Facility’s Policy titled, “Reporting of Abuse and/or Neglect policy #13149299” effective 4/2023 indicated, “It is the policy of [facility] to report any suspected abuse and/or neglect when there is reasonable cause to suspect that an individual who meets the definition of victim under the various Protective Service Acts has been abused. The [facility] follows all required State of California mandatory reporting standards and regulations.” During a reivew of the facility’s policy titled, “Abuse/Neglect Response Plan”, undated, outlining investigation actions to be taken by the hospital when an allegation is made. Under the category of Response and Notification, the document indicated, “If allegation is toward an employee: Remove the employee from the unit immediately. Interview staff member and document the employee’s description of events. Place the employee on administrative leave pending investigation of the incident.” During a review of the Facility’s Policy Titled, “Caregiver Misconduct Management policy ID 131494955”, documented under Definitions, K, 4, “examples of abuse include but are not limited to: Verbal abuse-threats of harm, saying things to intentionally frighten a client.” Under Procedure, D, 1., “Employees will be placed on administrative suspension during an investigation into potential major work rule violations such as alleged abuse. Supervisors are required to notify the HR Director or designee prior to suspending an employee.” 2. During a record review on 11/6/24 at 9:30 am of PT-4’s “Interdisciplinary Progress Note (IDN),” dated 10/30/2024 at 1:30 p.m., completed by the Patient Right’s Advocate, the IDN indicated, “Met with [PT 4] to discuss her grievance that she filed regarding excessive force from a staff member.” The IDN further indicated, on 10/27/2024, a patient in the group room started yelling at PT-4 to get out of the room. Review of the IDN indicated PT-4 started yelling back. LVN 1 entered the group room and “pushed” PT-4 towards the doorway. Further review of the IDN indicated, once outside the group room, LVN 1 “shoved” PT- 4 up against the hallway window. During a concurrent interview and record review 11/6/24 at 10:00 a.m., with the Director of Performance Improvement and Risk Management (RM), the facility’s document titled, “INVESTIGATION-PT- 4’s Grievance,” dated 10/29/2024, was reviewed. The “INVESTIGATION” indicated on 10/27/2024 at 12:52 p.m., PT-4 alleged, “Staff used excessive force during incident... PT-4 alleged she was slammed against the window.” The “INVESTIGATION,” further indicated that after documentation review and witness interviews, the facility substantiated the excessive force allegation. RM stated a video surveillance of the event had also been reviewed and confirmed that LVN 1 “grabbed” Pt-4 and removed her from the group room. RM further stated once outside the group room LVN 1, “Pushed [PT-4] up against the wall.” RM stated, “We did feel it was excessive force and placed LVN 1 on administrative leave on 10/30/2024.” RM further stated, staff had not been in-serviced on abuse prevention and de-escalation (decrease the level of intensity) techniques since the incident and LVN 1 is still employed by the facility. During a record review on 11/7/2024 at 9 a.m., of PT-4’s “PATIENT DEMOGRAPHIC PROFILE,” [undated], the “PATIENT DEMOGRAPHIC PROFILE,” indicated, PT-4 was admitted to the facility on, 10/23/2024. PT-4’s admitting diagnosis was listed as “unspecified psychosis (loss of touch with reality) not due to a substance”. During a review on 11/7/24 at 10:30 a.m., of the facility’s video surveillance of the incident involving PT-4, with the survey team and the RM in attendance, the video surveillance dated 10/27/2024 at 12:51 p.m. showed Mental Health Technician 11 (MHT -11) and MHT-12 walking PT-4 towards the group room door. LVN 1 entered the group room, walked up to PT-4 and pushed PT-4 out the group room door into the hallway. The video surveillance then showed LVN 1 push PT-4 a second time into a window in the hallway and held PT-4 against the wall. PT-4 was subsequently escorted to the seclusion room by LVN 1, MHT-11, and MHT-12. During an interview on 11/12/2024 at 8:12 a.m., with PT-4, on Unit 3, PT-4 stated she had filed a grievance against LVN 1. PT-4 stated, “[LVN 1] dragged me and pushed my head against the window, threw me in the seclusion room.” PT-4 further stated, “[LVN 1] shouldn’t have put her hands on me, if she would have asked me nicely to leave the group room I would have.” During an interview on 11/12/2024 at 3:43 p.m., with MHT-11, MHT-11 stated she was in the nurse’s station when she heard PT-4 yelling and being verbally abusive to another patient in the group room. MHT-11 stated she and MHT-12 went into the group room and were escorting PT-4 towards the doorway when LVN 1 entered the group room. MHT-11 stated, “[LVN 1] placed hands on PT-4, turned her towards the door and forcibly removed her from the group room. [LVN 1] pushed PT-4 into the window. The charge nurse said to put PT-4 in seclusion.” During an interview on 11/15/2024 at 8:45 a.m., with the Care Navigator (CN), CN stated she teaches staff Crisis Prevention Intervention (CPI, program that teaches how to safely de-escalate potentially dangerous situations) training. CN stated CPI taught staff how to identify distressed patient behavior and how to de-escalate the situation. CN further stated, “We don’t teach holding a patient up against a wall. Don’t push them, don’t shove. Continue to be supportive and keep talking to the patient.” During a review of the facility’s policy and procedure (P&P) titled, “Caregiver Misconduct Management,” dated April 2023, the P&P indicated, “Staff and all other persons with whom clients/patients come in contact shall treat the patient with courtesy, respect, with full recognition of their dignity and individuality, and shall provide them considerate care and treatment at all times. Clients/Patients... can expect trauma sensitive care which incorporates a collaborative and respectful approach with individuals who have experienced trauma, to promote personal healing and recover... Abuse is any of the following acts committed by a caregiver: 1. An act or repeated acts by a caregiver... when not part of the patient’s treatment plan, and when done intentionally to cause harm does any of the following: a. Causes or could reasonably be expected to cause pain, injury or death to a client...b. Substantially disregards clients right under State Regulations, or a caregivers duties and obligations to a client. c. Causes or could reasonably be expected to cause mental or emotional damage to a client... 4. Examples of abuse include but are not limited to: a. Physical abuse - hitting, slapping, pinching and kicking.” 3. During a concurrent interview and review of video recording on 11/13/24 at 2:48 p.m., the CNO stated PT-20 became agitated and had a verbal altercation with Mental Health Technician (MHT-11). Video recording shows PT-20 walked down the main hallway to the nurse’s station, found a water bottle on the nurse’s desk, picked up and threw the water bottle at Mental Health Technician (MHT-12). MHT-12 exited the nurse’s station, physically placed his hands on PT-20’s arms and pushed PT-20 backwards. Subsequently, MHT-11 and MHT-12 immediately forced PT-20 to the floor and forcibly held PT-20’s extremities and head against the floor.(This maneuver is called a take down) PT-20 bit MHT-12 on the finger while she was being held down on the floor. PT-2 was then taken to the seclusion room and held down on the hard cement floor by three staff members. The seclusion room PT-20 was placed in was a room with hard cement floor and cement walls located adjacent to the nurses’ station. PT-20 was observed in the seclusion room banging her head against the wall and floor. As an intervention to banging her head against the wall, PT-20 was provided a pillow and directed to place the pillow between her head and the wall to avoid injury. Staff then left the seclusion room. PT-20 did not comply after staff exited and continued banging her head against the cement wall. Staff re-entered the seclusion room and PT-20 was then offered a pillow wedge and directed to place the pillow wedge between her head and the floor, Staff again left the room. PT-20 did not use the pillow wedge provided and continued to bang her head against the cement wall. Staff did not stay in the room with PT-20 after attempts to de-escalate to prevent PT-20 from continuing to bang her head against the cement wall. The CNO stated PT-20 was sent to an outside hospital on 11/12/24 at 2 p.m. for further evaluation. The CNO stated he met with “staff involved in the incident” on 11/12/24 and he determined that an allegation of abuse was “not substantiated.” The CNO stated he made that decision without reviewing the video. During a concurrent observation and interview on 11/13/24, at 4:50 p.m., with PT-20, PT-20 stated, MHT-11 entered her room abruptly, pushing the door loudly against the wall, and the light from the flashlight flashing on her face woke her up. PT-20 asked MHT-11 to stop entering her room and that he could check on her from the door. PT-20 stated, MHT-11 responded, “This will be how it is”. PT-20 stated she became angry and walked to the nurse’s station. MHT-12 was behind the counter in the nurse’s station telling PT-20 she must comply and return to her room. PT-20 picked up a water bottle from the counter and threw the bottle toward MHT-12, missing him. MHT-11 and MHT-12 took her down to the ground in front of the nurses’ station and during the take down PT-20 stated she was struck by an unknown staff member in the right eye and hit in the face. PT-20 stated she was placed in seclusion and was hitting her head on the floor and wall. PT-20 stated she told staff she was injured during the incident. During the interview PT-20 was observed to have visible redness around her right eye and visible bruising and swelling to her nose. During an interview with MHT-11 on 11/14/24 at 8:50 a.m., MHT-11 indicated, PT-20 was aggressive towards other patients on 11/11/24. “Once the lights were lowered for sleep, I entered the room to check on the patient. The patient told me to get out of the room. “Don’t come all the way in the room during checks.” MHT- 11 stated to PT-20, “This is the way it will be for tonight.” MHT-11 stated PT-20 then came to the nurse’s station and told MHT-11 PT-20 “was going to beat him up, break his face”. MHT-11 stated PT-20 spit in his face. MHT-11 stated PT-20 was at the nurse’s station when she confronted MHT-12. PT-20 picked up a water bottle from the nurse’s station and threw the water bottle toward MHT-12. MHT-11 stated he knew PT-20 was going to escalate and attack staff so the seclusion room was opened. MHT-11 stated PT-20 “began to have a panic attack and attack staff while on the ground during the hold”. PT-20 was then placed in seclusion and began banging her head in against the wall (non-padded cement). MHT-11 stated, “We were trying to get her to stop, she kept rotating her head and banging her head. We provided her with a pillow to pad her head, she had a bump on her head after the incident, was returned to her room, was not offered an ice pack or other aid. The patient had a bruised lip, but she was spitting and biting at staff.” During a record review of PT-20’s demographic page on 11/13/24 at 10:00 a.m., indicated PT-20 was a 30-year-old female admitted to the hospital on 11/6/24, at 9:20 a.m., on an involuntary hold from [Outside Hospital] with a primary diagnosis of major depressive disorder (a serious but treatable clinical depression). During a record review of PT-20’s psychiatric evaluation at 11/13/24 at 10:15 a.m., dated 11/7/24 at 6:23 a.m., indicated : “Justification for hospitalization: suicidal ideation (the thoughts and or plan to commit suicide), Chief complaint: I jumped in front of a car (slow moving) and I regret it. History of present illness, PT-20 was a 30-year-old female who initially presented to the [Outside Hospital] emergency room with nausea and vomiting and feeling as if she was going to have a seizure. PT-20 eloped from the emergency room when she was hit by a car at 10 miles an hour in a suicide attempt. Patient was making suicidal statements to be with her grandmother who recently passed away. PT-20 had been fighting Emergency Medical Services staff and spitting on them.. Patient had been diagnosed with bipolar disorder (mental health disorder that causes extreme mood swings).” During a record review of PT-20’s daily nursing note on 11/13/24 at 10:15 a.m., the daily nursing note dated, 11/12/24, at 2:00 p.m. indicated, “PT-20 was aggressive toward staff during room checks with two different mental health technicians. Nurses offered oral medication, but patient refused. House Supervisor informed and came to assist PT-20 during rounds. Patient threw staff water bottle toward staff and then punched staff in the face.” A review of the Seclusion/Restraint/Chemical Restraint Order form on 11/13/24 at 10:00 a.m., the form dated 11/11/24 at 10:30 p.m., indicated PT-20’s physician (PHY3) was notified by telephone on 11/11/24 at 10:30 p.m. of the PT-20’s status and PHY3 ordered PT-20 be placed in seclusion and be administered a chemical restraint. Pt-20 was administered a “one time only” of Haldol 5mg and Benadryl 50mg IM (intramuscular) on 11/11/24 at 10:50 p.m... The Termination/Post Intervention documented PT-20 sent into seclusion at 10:45 p.m. and was returned to her room and out of seclusion at 11:44 p.m. During a record review of the Termination/Post Intervention Nursing Summary and Notifications on 11/13/24 at 10:00 a.m., (document completed when patient leaves seclusion) indicated that PT-20 left seclusion with “bruises, lacerations, and a bump on the head “ at 11/11/24 at 11:55 p.m. PT-20’s Daily Nursing Note dated, 11/12/24, at 2:15 p.m., documented “patient complaining of headache and dizziness, patient on every two-hour neuro checks due to trauma to forehead from self-inflicted banging on the cement wall in seclusion, provider notified. Received orders to send patient out to the emergency room (greater than 12 hours after PT-20 was forcibly placed in restraint and seclusion).” The daily nursing note documented on 11/12/24 at 2:20 p.m., “EMS arrived, patient transported to the emergency room via ambulance.” During a record review on 11/13/24 at 10:00 a.m., PT-20’s outside hospital’s clinical record indicated, PT-20 presented to the Emergency Department with a history of present illness as “ A 30-year-old female with a history of psychiatric issue, who presents to the emergency department with headache, forehead, contusion after slamming her head into a concrete wall during a confrontation with staff at a behavioral health facility. Denies loss of consciousness, or other injuries ... clinical impression, closed head injury.” The ED provider notes indicated PT-20 with a, “contusion to left forehead and small conjunctival hemorrhage lateral right eye.” A CT (computerized tomography) scan indicated “No acute intracranial process, forehead small contusion.” Discharge ED physician note on 11/12/24 indicated, “Due to mechanism of injury and concern for possible intracranial bleed, skull fracture CT was ordered which was negative. Informed patient she may have a mild concussion from her injury and if symptoms return to return to the ED.” Clinical impression at discharge indicated “Closed head injury, initial encounter.” PT-20 was transferred back to the facility at on 11/12/2024 at 6:30 p.m.” During an interview on 11/15/2024 at 8:45 a.m., with the Care Navigator (CN), CN stated she teaches staff Crisis Prevention Intervention (CPI, program that teaches how to safely de-escalate potentially dangerous situations) training. CN stated CPI taught staff how to identify distressed patient behavior and how to de-escalate the situation. CN further stated, “We don’t teach holding a patient up against a wall. Don’t push them, don’t shove. Continue to be supportive and keep talking to the patient.” During a review of the facility’s policy titled “Patient’s Bill of Rights” undated indicated,” ...3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to your personal needs, and are treated with respect and dignity.” During a review of the facility’s Policy and Procedure (P&P) titled, “Assault / Homicide Prevention and Precautions” dated, 4/23 indicated, “Policy, it is the policy of the facility to provide a safe, therapeutic environment of care that includes the prevention of assault and homicide incidents, as well as threats of assault or homicide. To provide a plan for monitoring potentially aggressive / violent patients via assault / homicide precautions, identifying early warning signs, and implementing interventions to prevent assault / homicide incidents, while establishing guidelines for the use of the code green (a code used to alert staff of patient aggressive behaviors) and to minimize the disruption of the therapeutic milieu, as well as ensure the safety of all patients and staff.” During a review of the professional reference article from The Joint Commission, titled,”De-escalation in Health Care”, dated January 28, 2019, indicated, “...De-escalation is a first-line response to potential violence and aggression in health care settings...some de-escalation studies have concluded that the positive consequences of de-escalation include: Preventing violent behavior, avoiding the use of restraint, reducing patient anger and frustration, maintaining the safety of staff and patients, improving staff-patient connections, enabling patients to manage their own emotions and to regain personal control, helping patients to develop feelings of hope, security and self-acceptance...” During a review of the professional reference article from the AMA Journal of Ethics titled, “How Should Clinicians Execute Critical Force Interventions With Compassion, Not Just Harm Minimization, as a Clinical and Ethical Goal?” dated April 2021, indicated, “...In psychiatry, forced treatment should generally align with a patient’s values in order to neither exacerbate existing trauma nor alienate a patient from future treatment engagement. Force can have significant and lasting negative impact on a patient’s treatment experience and,... can be considered ‘toxic’ in its impact on patient attitudes towards treatment...””

“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: 11090 Based on observation, interview and record review, the hospital failed to ensure adequate numbers of licensed nurses and other personnel to provide nursing care to meet each patient’s needs when: 1. The routine registered nurse staffing assignment per unit of 30 patient capacity was 1-2 RNs per unit. Vital signs were not done in accordance with hospital policies and procedures due to inadequate staffing numbers. The number of nursing personnel was not adequate to provide the level of nursing care needed to meet Patient (PT) 3’s needs,when PT-3 was observed pacing around the millieu, unkempt, malodorous, and wearing dirty clothes The hospital used a formula for staffing that did not include the assessed level of nursing care needed for patients. 2. Unlicensed Mental Health Technicians (MHTs) who routinely conduct group therapy sessions were not trained to do so in in three randomly sampled MHT personnel files and three selected MHT personnel files of MHT staff providing group therapy during the survey (MHT1, MHT2, MHT3, MHT4, MHT7, MHT8). These failures resulted in PT-3 not being provided the level of supervision and opportunities to address basic hygiene needs and did not provide the support for RNs to assign other personnel according to the needs of each patient on each unit of the hospital. Findings: 1. During the initial observation and facility tour of Unit 1 and concurrent interview on 11/5/2024 at 10:00 a.m. with Registered Nurses (RN1, RN2), PT-3 was observed pacing the hallway, not communicating with other residents or staff, and not attending group activities. PT-3 was malodorous, hair uncombed and he was wearing soiled clothing (facility supplied hospital scrubs). PT-3 had been admitted to the facility on 9/18/24. The physician’s (MD1) history and physical dated 9/18/24 identified PT-3 with diagnoses of “schizophrenia (a serious mental condition involving a breakdown in the relation between thought,emotion,and behavior leading to faulty perception, inapproopriate actions and feelings,withdrawal from reality and personal relationships into fantasy and delusion) bipolar type(characterized by both manic and depressive episodes), unspecified psychotic disorder and rule out catatonic(Catatonia- a collection of signs and symptoms where the brain doesn’t manage muscle movement signals as it should).” RN1 and RN2 stated the current census on their unit was 26, and the capacity of the unit was 30 patients, there were two Registered Nurses (RN1, RN2) and three unlicensed mental health technicians (MHT) to care for those 26 patients. RN1 and RN2 stated the number of licensed nurses scheduled is the same whether they have 25 or more patients. RN1 acknowledged that there were patients on Unit 1 needing 1:1 (individual) supervision to redirect behaviors, when showering, ensuring that patients put on clean clothes, attend group therapy sessions or individual treatment sessions, but the current plan for staffing prohibits the RNs from providing that care. RN1 and RN2 stated with the current staffing schedules, there is no time to fully address each patient’s individual needs and to coordinate care to meet each patient’s care plan. During an interview on 11/5/24 at 10:05 a.m., RN1 and RN2 acknowledged that Unit 1 had a higher acuity of patients and there were patients on Unit 1 needing more 1:1 (individual) supervision to redirect. RN1 and RN2 stated PT-3 needed 1:1 assistance and direction showering and putting on clean clothes, but limited staffing prohibited providing that care. During a concurrent observation, staff interview, and facility tour of Unit 1 on 11/9/24 at 9:00 a.m., with Registered Nurse (RN3) and RN 4, RN3 and RN4 stated they had 26 patients on the unit and only two MHTs to assist. RN3 stated Unit 1 had been scheduled to have three MHTs on the unit, but one was sent to another unit due to staffing shortage. The MHT who was reassigned to another unit had not completed taking morning vital signs for his patient assignment before leaving Unit 1. This resulted in vital signs not being completed on 15 of 26 patients. RN 3 and RN 4 stated the two remaining MHTs on the unit were not re-assigned to complete the vital signs for the 15 patients that needed vital signs. Instead, RN3 and RN4 stated they decided to administer the psychoactive medications that were due without first obtaining vital signs. In addition, RN3 and RN4 stated they decided to delay administering physician-ordered blood pressure medications until later in the day after the vital signs were obtained and did not first notify the ordering physician of the late administration of medications. During a concurrent interview and document review on 11/12/24 at 9:15 a.m. with the Staffing Coordinator (SC), the SC stated he completes all schedules according to the facility “Core Staffing Guidelines” for the three adult and one adolescent patient units. The SC stated he submits the staffing schedules to Administration by 3 p.m. each day for the following day’s schedule. The SC stated Administration makes the staffing assignment changes and cuts after the SC leaves the facility for the day. The staffing assignments are made according to the hospital “Adult Facility General Core Staffing Guidelines” sheet which recommends two RNs and no licensed vocational nurses (LVNs) for a patient census of 12 through 23 and three RNs and no LVNs for a patient census of 24 through 35, and the Adolescent General Core Staffing Guidelines which recommends one RN and no LVNs for a census of 1 through 11, two RNs and no LVNs for a census of 12-23, three RNs and no LVNs for a census of 24-28, and no LVNs. A review of the daily staff assignment sheets for October 2024, indicated that there was no Registered Nurse on duty and only one Licensed Vocational Nurse (LVN) on duty 10/4/24 on Unit 3 between the hours of 2 p.m. to 7 p.m. for 20 patients. On 10/8/24 on Unit 3 there was only one LVN on duty between the hours of 7 p.m. to 7 a.m. for 17 patients. On 10/27/24 on Unit 3 only one LVN and one RN orientee (newly hired RN orienting to new job) were on duty between the hours of p.m. to 7 a.m. for 24 patients. The SC acknowledged the lack of RN coverage on Unit 3 for 10/4/24, 10/8/24 and 10/27/24. On 10/27/24, the staffing sheet counted an RN orientee (newly hired RN undergoing orientation) as licensed staff. The SC clarified that an RN orientee cannot be counted in meeting the RN staffing requirement. The SC also clarified that MHTs are not licensed nursing staff. During a concurrent interview and document review on 11/12/24 at 9:15 a.m. of the “General Adult Core Staffing Guidelines”, the SC stated the document was used to determine the number of RNs to be assigned to each unit. The document listed the following: Census 17-23, two RNs per shift, census 24-28, three RNs per shift, census 29-35 three RNs per shift. Licensed Practical Nurses (LVNs) were not included in the staffing plan. As the census increased, mental health technicians (MHT)s were added. The SC clarified that MHTs are not licensed nursing staff During a concurrent interview and document review with the Director of Pharmacy (DP) on 11/14/2024 at 11 a.m. the DP stated, the “Medication Administration policy ID 15786006”, effective 6/2024 does not require physician notification if medications are administered late or that vital signs must be reviewed prior to administering certain medication classifications. The DP indicated he had identified the policy needed additional guidance in ensuring that blood pressures were taken prior to the administration of certain medication categories and has recently communicated that recommendation to the CEO and CNO on the needed policy update. During a review of the facility’s policy titled, “Plan for the Provision of Inpatient Care policy #14339983”, effective 9/2023, page 17 under Nursing Staffing documented “Nursing care is planned, delegated, and coordinated by registered nurses. Members of nursing staff include registered nurses, licensed practical nurses, and mental health technicians. Unit staffing includes at lest one RN at all times. Assignments for nursing care are made according to programmatic and patient care needs as defined in the Plan for Nursing Care. Adjustments to the core staffing levels are made on the basis of identified patient needs. Such adjustments for planned staffing are made daily by the CNO or designee based on the individualized needs of patients on the units.” During a concurrent interview and document review with the Staffing Coordinator (SC), on 11/12/2024 at 9:15 a.m., of the daily staff assignment sheets selected for the month October 2024 for Unit 3, the daily staffing assignments sheets indicated that there was no Registered Nurse on duty and only one Licensed Vocational Nurse (LVN) on duty 10/4/24 on Unit 3 between the hours of 2 p.m. to 7 p.m. for 20 patients. On 10/8/24 on Unit 3 there was only one LVN on duty between the hours of 7 p.m. to 7 a.m. for 17 patients. On 10/27/24 on Unit 3 only one LVN and one RN orientee (newly hired RN orienting to new job) were on duty between the hours of 7 p.m. to 7 a.m. for 24 patients. The SC acknowledged the lack of RN coverage on Unit 3 for 10/4/24, 10/8/24 and 10/27/24. On 10/27/24, the staffing sheet counted an RN orientee (newly hired RN undergoing orientation) as licensed staff. The SC clarified that an RN orientee cannot be counted in meeting the RN staffing requirement. (SC), the SC stated he completes all schedules according to the facility Core Staffing Guidelines for the three adult and one adolescent patient units. The SC indicated he submits the staffing schedules to Administration by 3 p.m. The SC stated Administration makes the staffing assignment changes, cuts and adjustments after the SC leaves the facility for the day. The staffing assignments are made according to the facility Core Staffing Guidelines sheet. During a concurrent interview and document review on 11/12/24 at 9:20 a.m., of the” General Adult Core Staffing Guidelines”, the SC stated the document was used to determine the number of RNs to be assigned to each unit. The document listed the following: Census 17-23, two RNs per shift, census 24-28, three RNs per shift, census 29-35 three RNs per shift. Licensed Practical Nurses (LVNs) were not included in the staffing plan. As the census increased, mental health technicians (MHT)s were added. The SC clarified that MHTs are not licensed nursing staff. During a review of the facility’s policy titled, “Plan for the Provision of Inpatient Care policy #14339983” on 11/12/24 at 10:00 a.m., policy effective 9/2023, page 17 under Nursing Staffing, indicated, “Nursing care is planned, delegated, and coordinated by registered nurses. Members of nursing staff include registered nurses, licensed practical nurses, and mental health technicians. Unit staffing includes at lest one RN at all times. Assignments for nursing care are made according to programmatic and patient care needs as defined in the Plan for Nursing Care. Adjustments to the core staffing levels are made on the basis of identified patient needs. Such adjustments for planned staffing are made daily by the CNO or designee based on the individualized needs of patients on the units.” During a review of professional reference article from the American Psychiatric Nurses Association (APNA) titled, “APNA Position: Staffing Inpatient Psychiatric Units”, undated, the article indicated, “...staffing decisions demand consideration of several distinct aspects which impact how care is organized: consumer needs, staff capacities/capabilities, unit culture, practice environment, and staffing evaluation model. In this way, staffing is not an external calculation, but a participatory process that requires ongoing systematic evaluation and monitoring of select patient, staff, and system outcomes (ANA-American Nurses Association), 2020)... This requires that front-line staff, management, and psychiatric-mental health care consumers work together, with a shared understanding of patient needs and their complexity as well as how these needs are met by Psychiatric Mental Health (PMH) nurses with specific skills and experience levels...It is the position of the American Psychiatric Nurses Association that when PMH nurse staffing is appropriate, adverse events decline and overall outcomes improve.. During a review of the Staff Nurse (registered nurse) (RN), job code 650, Position Description, the RN Position Summary defines the position as: The Staff Nurse (R.N.) is a registered professional nurse who prescribes, coordinates, and evaluates patient care through collaborative efforts with health team members in accordance with the nursing process and the standards of care and practices. Essential Job Function categories listed as: Assessment, Intervention, Treatment Planning, Milieu, Teaching and Performance. Assessment: Document patient information and nursing care, document and reassess any significant changes in the patient’s condition in compliance with facility policy, report any signs of symptoms of infection to the Infection Control Nurse (ICN), and to verify the accuracy of patient records. Intervention: Employ principles of communication, interviewing techniques, problem solving and crisis intervention when performing psychotherapeutic interventions, accurately administer medications to patients, transcribe and carry out physicians treatment orders, utilize appropriate interventions in psychiatric medical emergencies. Treatment Planning: Prioritize and formulate a plan of care based on patient assessment, participate in development of an interdisciplinary treatment plan with measurable goals and objectives and interventions, update and revise the plan as goals and objectives are met or when patient condition changes, document both the nursing interventions on the treatment plan and the patient’s response to the intervention. Milieu: Assure patients are adequately oriented to the program, monitor program activity and encourage patient participation, prescribe and coordinate nursing care to patients, provide structured, monitor program activity and encourage patient participation, consistently utilize universal precautions and environmental safety guidelines, conduct structured didactic groups with patients and families, and utilize “self” as a role model to promote health communication. Teaching: Provide education to patients and families based on their identified needs and limitations, provide and document discharge instructions including food and drug interactions, diets and activities as appropriate, evaluate and document the effectiveness of all patient teaching, provide opportunities for patients and families to question, discuss and explore their feelings about prescribed therapies/interventions/diagnosis. During a review of the LVN/LPT (licensed vocational nurse, licensed psychiatric technician), job code 435, Position Description at 11/12/24 at 3:00 p.m., the Job Description defines the position: The LVN/LPN/LPT administers nursing care to designated patients under the direction and supervision of a Registered Nurse and performs a variety of direct and indirect patient care duties. Primary Criteria/Responsibilities: Assists in the delivery of patient care in an acute psychiatric setting for patients experiencing a wide rate of psychiatric conditions, provides nursing care within the scope of practice to meet the unique needs of each patient, assists Charge/Staff Nurse by collecting data related to the patient’s condition, reports data findings related to patient’s condition to the Charge Nurse, assists the RN in assessing for pain using pain scale and documents accordingly, assists the Charge/Staff Nurse to organize and deliver patient care and to supervise staff, documents patient activity and behavior in an accurate, timely and legible manner, recognizes when patient is in need of 1:1 intervention and interacts therapeutically and informs Charge/Staff Nurse of significant developments and documents in progress note, provides 1:1 intervention as directed, assists the Charge/Staff Nurse in assessing patient’s response to interventions and communicates these findings to other team members....., transcribes and administers medications and treatments accurately and documents on medication record..., keeps Charge/Staff Nurse informed of events that may change staffing needs such as admissions, discharges, transfers and patients in crisis, provides education to patients on medications and disease management and coping mechanisms,,,, notifies Charge/Staff Nurse of patients with potential risk for injury due to falls or self-destructive or assaultive behavior and implements fall precautions..., demonstrates effective management of assaultive behavior and use of Seclusion or Quiet Time..., demonstrates utilization of measures prior to Seclusion and Restrataint and 1:1 and diversional group activities and medication to decrease stimulation...., demonstrates competence in verbal de-escalation skills..., demonstrates competence in CPI personal defense releases and blocks and restraint techniques and escort techniques, demonstrates use of application of restraints and monitors patients in restraints and assesses and assists with discontinuation criteria. During a review of the Mental Health Technician (MHT), job code 466, Position Description at 11/12/24, the Position Summary defines the position as: The Mental Health Technician functions as an active part of the treatment team, providing continuous patient care, supervision, interaction and role modeling to patients ranging in age from adolescent through geriatrics. Mental Health Technicians work under the direction of a Registered Nurse. Essential Job Functions: Demonstrates responsibility for observation and application of sound judgement in patients’ physical and mental condition needs, provide continuous patient care and maintain safety of all assigned patients demonstrated by verifying patient safety every 15 minutes on appropriate forms, observe and document changes in patients appearance and behavior and ability to work towards treatment plan goals, and to communicate changes in patient’s condition to Charge Nurse or Nurse Manager. Interventions: ensure timely documentation of interventions and ensure interventions are based on the patients’ plan of care, apply appropriate crisis intervention techniques as required, assist patients in achieving their optimum level of independent functioning, document services rendered in accordance with established criteria. Performance Accountability: Demonstrates excellent guest relations in communication and cooperation assisting patients and licensed practitioners and co-workers and visitors in a prompt and courteous manner, acts as a patient advocate and assures patient rights are upheld, and demonstrates appropriate therapeutic boundaries. Treatment Planning: Provides pertinent feedback to the interdisciplinary treatment team regarding patient response to treatment interventions and therapeutic objectives as appropriate and necessary. During record review of daily Patient Care Assignment Sheets, the following is the three month look-back averages of census and licensed staff for Units 1, 2, 3 and 4: AUGUST 2024 Unit 1 AUGUST 2024 Unit 1 AM PM Census 24 Census 24.13 Licensed Staff 2.52 Licensed Staff 2.06 Only 19 staffing sheets received Only 15 staffing sheets received AUGUST 2024 Unit 2 AUGUST 2024 Unit 2 AM PM Census 15.5 Census 7 Licensed Staff 1.5 Licensed Staff 1 Only 4 staffing sheets received Only 3 staffing sheets received AUGUST 2024 Unit 3 AUGUST 2024 Unit 3 AM PM Census 25.26 Census 25 Licensed Staff 2.6 Licensed Staff 2 Only 15 staffing sheets received Only 16 staffing sheets received AUGUST 2024 Unit 4 AUGUST 2024 Unit 4 AM PM Census 16 Census 16 Licensed Staff 2 Licensed Staff 2 Only 21 staffing sheets received Only 19 staffing sheets received SEPTEMBER 2024 Unit 1 SEPTEMBER 2024 Unit 1 AM PM Census 28 Census 24.53 Licensed Staff 1.8 Licensed Staff 2.26 28 staffing sheets received 26 staffing sheets received SEPTEMBER 2024 Unit 2 SEPTEMBER 2024 Unit 2 AM PM Census 7.6 Census 7.51 Licensed Staff 1.43 Licensed Staff 1.11 30 staffing sheets received 27 staffing sheets received SEPTEMBER 2024 Unit 3 SEPTEMBER 2024 Unit 3 AM PM Census 23.96 Census 24.26 Licensed Staff 2.4 Licensed Staff 2.38 27 staffing sheets received 26 staffing sheets received SEPTEMBER 2024 Unit 4 SEPTEMBER 2024 Unit 4 AM PM Census 13.73 Census 13.60 Licensed Staff 2 Licensed Staff 2.13 Only 15 staffing sheets received Only 15 staffing sheets received OCTOBER 2024 Unit 1 OCTOBER 2024 Unit 1 AM PM Census 22 Census 21.71 Licensed Staff 2.06 Licensed Staff 2.1 30 staffing sheets received 28 staffing sheets received OCTOBER 2024 Unit 2 OCTOBER 2024 Unit 2 AM PM Census 6.6 Census 6.7 Licensed Staff 1.3 Licensed Staff 1.11 30 staffing sheets received 27 staffing sheets received OCTOBER 2024 Unit 3 OCTOBER 2024 Unit 3 AM PM Census 21.93 Census 21.23 Licensed Staff 2.03 Licensed Staff 2.26 30 staffing sheets received 26 staffing sheets received OCTOBER 2024 Unit 4 OCTOBER 2024 Unit 4 AM PM Census 16.03 Census 14.62 Licensed Staff 1.86 Licensed Staff 1.81 29 staffing sheets received 27 staffing sheets received 2. During a concurrent observation and staff interview on 11/5/24 at 11:00 a.m., during the initial tour and throughout the day 11/15/2024, patients on Unit 1 were frequently observed sitting or standing in large conference rooms engaged in what staff identified as “group activity and therapy” (a form of psychotherapy done in a group setting). RN1 and RN2 stated that recreation therapists (RT) and sometimes a social service staff (SS) staff member will conduct group sessions with patients. RN1 and RN2 stated RNs are supposed to participate and conduct group therapy sessions, but due to limited licensed SS, RT and RN staffing on the units, the Mental Health Technicians (MHTs) frequently conduct group therapy sessions with patients. During a concurrent interview and document review on 11/14/2024 at 9:00 a.m. with the Nurse Educator (NE), MHT training records were reviewed for MHT1, MHT2, MHT3, MHT4, MHT6 and MHT7. It was identified that none of the MHT files reviewed had documentation to support that the MHTs had received training on how to conduct group therapy sessions at the hospital. The NE acknowledged that the files all lacked documentation to support that training on how to conduct group therapy sessions had been provided to the MHTs. The NE stated that training was not being currently provided to MHTs and the training had not been added to their curriculum. During a review of the facility’s “Mental Health Technician job description” revised 8/13/2023, the MHT job functions include to “1. Provide continuous patient care and maintain safety of all assigned patients demonstrated by verifying patient safety every 15 minutes on appropriate forms, 2. Observe and document changes in patient’s appearance, behavior, and ability to work toward treatment plan goals, 3. Communicate changes in patient’s condition to Charge Nurse or Nurse Manager.” During a review of the Mental Health Technician (MHT), job code 466, Position Description at the Position Summary defines the position as: The Mental Health Technician functions as an active part of the treatment team, providing continuous patient care, supervision, interaction and role modeling to patients ranging in age from adolescent through geriatrics. Mental Health Technicians work under the direction of a Registered Nurse. Essential Job Functions: Demonstrates responsibility for observation and application of sound judgement in patients’ physical and mental condition needs, provide continuous patient care and maintain safety of all assigned patients demonstrated by verifying patient safety every 15 minutes on appropriate forms, observe and document changes in patients appearance and behavior and ability to work towards treatment plan goals, and to communicate changes in patient’s condition to Charge Nurse or Nurse Manager. Interventions: ensure timely documentation of interventions and ensure interventions are based on the patients’ plan of care, apply appropriate crisis intervention techniques as required, assist patients in achieving their optimum level of independent functioning, document services rendered in accordance with established criteria. Performance Accountability: Demonstrates excellent guest relations in communication and cooperation assisting patients and licensed practitioners and co-workers and visitors in a prompt and courteous manner, acts as a patient advocate and assures patient rights are upheld, and demonstrates appropriate therapeutic boundaries. Treatment Planning: Provides pertinent feedback to the interdisciplinary treatment team regarding patient response to treatment interventions and therapeutic objectives as appropriate and necessary. 34448”

“RN/LPN STAFFING CFR(s): 482.23(b)(1) The hospital must provide 24-hour nursing services furnished or supervised by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all times, except for rural hospitals that have in effect a 24-hour nursing waiver granted under o488.54(c) of this chapter. This Standard is not met as evidenced by: 11090 Based on observation, interview and record review, the facility failed to ensure that a Registered Nurse was on duty and on the unit to provide 24-hour nursing services on Unit 3 for 10/4/24, 10/8/24 and 10/27/24. This failure to ensure that a Registered Nurse was on duty to provide 24-hour nursing services and failure to provide sufficient licensed staff needed to direct and supervise patient care placed patients at risk for not receiving individualized supervsion and care. Findings: During the initial observation and facility tour of Unit 1 on 11/5/24 at 10:00 a.m., Registered Nurses (RN1) and RN2 stated the current census on their unit was 26 with staffing of two RNs and three unlicensed mental health technicians (MHT). RN1 and RN2 stated the number of licensed nurses scheduled is the same whether they have 25 or more patients but it was the same on any unit you were assigned regardless of acuity. RN1 acknowledged that Unit 1 had a higher acuity of psychiatric patients needing 1:1 (individual) supervision to redirect, when showering and putting on clean clothes, but limited staffing prohibits providing that care. RN1 and RN2 stated the “RN Job Description” indicates the RN is also to assist in conducting Groups (directed therapy in groups of patients) but limited RN staffing prohibits their participation in conducting groups. RN1 and RN2 also stated the past staffing sheets are inaccurate because facility staff write in names of licensed not staff not working that day, or they write the name of an MHT on the line designated for licensed nurses. PT-3 was observed consistently pacing the hallway, not communicating with other residents or staff, and not attending group activities. PT-3 was malodorous, hair uncombed and he was wearing soiled clothing (facility supplied hospital scrubs). RN1 and RN2 acknowledged that PT-3 needed more 1:1 assistance but due to the lack of of licensed staff , they are not able to direct and supervise the MHTs on providing basic care such as bathing and dressing for patients needing individualized assistance and direction. During an interview with the CNO on 11/5/24 at 11:00 a.m., the CNO stated the hospital follows required staffing regulations and guidance he receives from “corporate” and does not utilize registry or traveling nurse agencies to fill open and critical staffing positions. The CNO stated they use a staffing matrix, not acuity for determining staffing assignments. The CNO was not available to discuss staffing levels on numerous occasions throughout the survey. During a review of the daily staff assignment sheets on 11/7/2024 at 11 a.m., for the month of October 2024, the daily staffing assignments sheets indicated that there was no Registered Nurse on duty and only one Licensed Vocational Nurse (LVN) on duty 10/4/24 on Unit 3 between the hours of 2 p.m. to 7 p.m. for 20 patients. On 10/8/24 on Unit 3 there was only one LVN on duty between the hours of 7 p.m. to 7 a.m. for 17 patients. On 10/27/24 on Unit 3 only one LVN and one RN orientee (newly hired RN orienting to new job) were on duty between the hours of 7 p.m. to 7 a.m. for 24 patients. During an interview on 11/12/24 at 9:15 a.m. with the Staffing Coordinator (SC), the SC stated he completes all schedules according to the facility Core Staffing Guidelines for the three adult and one adolescent patient units. The SC indicated he submits the staffing schedules to Administration by 3 p.m. The SC stated Administration makes the staffing assignment changes and cuts after the SC has left the facility for the day because he challenges any cuts in staffing that are proposed. The staffing assignments are made according to the facility Core Staffing Guidelines sheet. The staffing assignment sheets for October 2024 were reviewed with the SC. The SC acknowledged the lack of RN coverage on Unit 3 for 10/4/24, 10/8/24 and 10/27/24. On 10/27/24, the staffing sheet included an RN orientee (newly hired RN undergoing orientation). The SC clarified that the House Supervisor or an RN orientee cannot be counted in meeting the RN staffing requirement. During a review on 11/13/24 at 10:00 a.m. of the facility’s Policy and Procedure (P&P) titled, “Plan for the Provision of Inpatient Care policy #14339983,” dated 9/2023, the P&P documented,”General Staffing: Staffing patterns are determined by a combinaiton of employees per occupied bed ratio, and overall acuity on the units/program, which conideration given to each patients needs in each program. A core staffing level is determined for each inpatient unit consisting of registered nurses, mental health technicians, social service therapists and activities therapists....Unit staffing includes at least one RN at all times.” During a review of professional reference article from the National Library of Medicine, titled, “Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance” dated February 2020, the article indicated,”...Nursing staff are the core of the caring profession and central to their role is the development of effective relationships with the individuals they support...the interpersonal relationship is seen as foundational to a person-centred, recovery-oriented approach within mental health nursing...Therapeutic alliance has the greatest impact on treatment outcomes for those with mental health difficulties, over and above the specific mode or model of intervention that is provided...The therapeutic role of nursing staff in mental health care is especially pertinent in settings such as inpatient wards, where patients interact with nurses for the largest proportion of time and the relationship with them is cited as key to therapeutic progression with a perceived interplay between therapeutic relationships and the quality of care...” During a review of the Staff Nurse (registered nurse) (RN), job code 650, Position Description the RN Position Summary defines the position as: The Staff Nurse (R.N.) is a registered professional nurse who prescribes, coordinates, and evaluates patient care through collaborative efforts with health team members in accordance with the nursing process and the standards of care and practices. Essential Job Function categories listed as: Assessment, Intervention, Treatment Planning, Milieu, Teaching and Performance. Assessment: Document patient information and nursing care, document and reassess any significant changes in the patient’s condition in compliance with facility policy, report any signs of symptoms of infection to the Infection Control Nurse (ICN), and to verify the accuracy of patient records. Intervention: Employ principles of communication, interviewing techniques, problem solving and crisis intervention when performing psychotherapeutic interventions, accurately administer medications to patients, transcribe and carry out physicians treatment orders, utilize appropriate interventions in psychiatric medical emergencies. Treatment Planning: Prioritize and formulate a plan of care based on patient assessment, participate in development of an interdisciplinary treatment plan with measurable goals and objectives and interventions, update and revise the plan as goals and objectives are met or when patient condition changes, document both the nursing interventions on the treatment plan and the patient’s response to the intervention. Milieu: Assure patients are adequately oriented to the program, monitor program activity and encourage patient participation, prescribe and coordinate nursing care to patients, provide structured, monitor program activity and encourage patient participation, consistently utilize universal precautions and environmental safety guidelines, conduct structured didactic groups with patients and families, and utilize “self” as a role model to promote health communication. Teaching: Provide education to patients and families based on their identified needs and limitations, provide and document discharge instructions including food and drug interactions, diets and activities as appropriate, evaluate and document the effectiveness of all patient teaching, provide opportunities for patients and families to question, discuss and explore their feelings about prescribed therapies/interventions/diagnosis. During a review of the LVN/LPT (licensed vocational nurse, licensed psychiatric technician), job code 435, Position Description the Job Description defines the position: The LVN/LPN/LPT administers nursing care to designated patients under the direction and supervision of a Registered Nurse and performs a variety of direct and indirect patient care duties. Primary Criteria/Responsibilities: Assists in the delivery of patient care in an acute psychiatric setting for patients experiencing a wide rate of psychiatric conditions, provides nursing care within the scope of practice to meet the unique needs of each patient, assists Charge/Staff Nurse by collecting data related to the patient’s condition, reports data findings related to patient’s condition to the Charge Nurse, assists the RN in assessing for pain using pain scale and documents accordingly, assists the Charge/Staff Nurse to organize and deliver patient care and to supervise staff, documents patient activity and behavior in an accurate, timely and legible manner, recognizes when patient is in need of 1:1 intervention and interacts therapeutically and informs Charge/Staff Nurse of significant developments and documents in progress note, provides 1:1 intervention as directed, assists the Charge/Staff Nurse in assessing patient’s response to interventions and communicates these findings to other team members....., transcribes and administers medications and treatments accurately and documents on medication record..., keeps Charge/Staff Nurse informed of events that may change staffing needs such as admissions, discharges, transfers and patients in crisis, provides education to patients on medications and disease management and coping mechanisms,,,, notifies Charge/Staff Nurse of patients with potential risk for injury due to falls or self-destructive or assaultive behavior and implements fall precautions..., demonstrates effective management of assaultive behavior and use of Seclusion or Quiet Time..., demonstrates utilization of measures prior to Seclusion and Restrataint and 1:1 and diversional group activities and medication to decrease stimulation...., demonstrates competence in verbal de-escalation skills..., demonstrates competence in CPI personal defense releases and blocks and restraint techniques and escort techniques, demonstrates use of application of restraints and monitors patients in restraints and assesses and assists with discontinuation criteria. During a review of the Mental Health Technician (MHT), job code 466, Position Description at 11/12/24 at 3:00 p.m., the Position Summary defines the position as: The Mental Health Technician functions as an active part of the treatment team, providing continuous patient care, supervision, interaction and role modeling to patients ranging in age from adolescent through geriatrics. Mental Health Technicians work under the direction of a Registered Nurse. Essential Job Functions: Demonstrates responsibility for observation and application of sound judgement in patients’ physical and mental condition needs, provide continuous patient care and maintain safety of all assigned patients demonstrated by verifying patient safety every 15 minutes on appropriate forms, observe and document changes in patients appearance and behavior and ability to work towards treatment plan goals, and to communicate changes in patient’s condition to Charge Nurse or Nurse Manager. Interventions: ensure timely documentation of interventions and ensure interventions are based on the patients’ plan of care, apply appropriate crisis intervention techniques as required, assist patients in achieving their optimum level of independent functioning, document services rendered in accordance with established criteria. Performance Accountability: Demonstrates excellent guest relations in communication and cooperation assisting patients and licensed practitioners and co-workers and visitors in a prompt and courteous manner, acts as a patient advocate and assures patient rights are upheld, and demonstrates appropriate therapeutic boundaries. Treatment Planning: Provides pertinent feedback to the interdisciplinary treatment team regarding patient response to treatment interventions and therapeutic objectives as appropriate and necessary. During record review of daily Patient Care Assignment Sheets, the following is the three month look-back averages of census and licensed staff for Units 1, 2, 3 and 4: AUGUST 2024 Unit 1 AUGUST 2024 Unit 1 AM PM Census 24 Census 24.13 Licensed Staff 2.52 Licensed Staff 2.06 19 staffing sheets received 15 staffing sheets received AUGUST 2024 Unit 2 AUGUST 2024 Unit 2 AM PM Census 15.5 Census 7 Licensed Staff 1.5 Licensed Staff 1 4 staffing sheets received 3 staffing sheets received AUGUST 2024 Unit 3 AUGUST 2024 Unit 3 AM PM Census 25.26 Census 25 Licensed Staff 2.6 Licensed Staff 2 15 staffing sheets received 16 staffing sheets received AUGUST 2024 Unit 4 AUGUST 2024 Unit 4 AM PM Census 16 Census 16 Licensed Staff 2 Licensed Staff 2 21 staffing sheets received 19 staffing sheets received SEPTEMBER 2024 Unit 1 SEPTEMBER 2024 Unit 1 AM PM Census 28 Census 24.53 Licensed Staff 1.8 Licensed Staff 2.26 28 staffing sheets received 26 staffing sheets received SEPTEMBER 2024 Unit 2 SEPTEMBER 2024 Unit 2 AM PM Census 7.6 Census 7.51 Licensed Staff 1.43 Licensed Staff 1.11 30 staffing sheets received 27 staffing sheets received SEPTEMBER 2024 Unit 3 SEPTEMBER 2024 Unit 3 AM PM Census 23.96 Census 24.26 Licensed Staff 2.4 Licensed Staff 2.38 27 staffing sheets received 26 staffing sheets received SEPTEMBER 2024 Unit 4 SEPTEMBER 2024 Unit 4 AM PM Census 13.73 Census 13.60 Licensed Staff 2 Licensed Staff 2.13 15 staffing sheets received 15 staffing sheets received OCTOBER 2024 Unit 1 OCTOBER 2024 Unit 1 AM PM Census 22 Census 21.71 Licensed Staff 2.06 Licensed Staff 2.1 30 staffing sheets received 28 staffing sheets received OCTOBER 2024 Unit 2 OCTOBER 2024 Unit 2 AM PM Census 6.6 Census 6.7 Licensed Staff 1.3 Licensed Staff 1.11 30 staffing sheets received 27 staffing sheets received OCTOBER 2024 Unit 3 OCTOBER 2024 Unit 3 AM PM Census 21.93 Census 21.23 Licensed Staff 2.03 Licensed Staff 2.26 30 staffing sheets received 26 staffing sheets received OCTOBER 2024 Unit 4 OCTOBER 2024 Unit 4 AM PM Census 16.03 Census 14.62 Licensed Staff 1.86 Licensed Staff 1.81 29 staffing sheets received 27 staffing sheets received”

“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: 11090 Based on observation, interview and record review, the facility failed to ensure that a Registered Nurse was on duty and on the unit to supervise and evaluate care when: 1. There was no Registered Nurse on duty on Unit 3 for 10/4/24, 10/8/24 and 10/27/24. 2. Unlicensed Mental Health Technicians (MHTs) who routinely conduct group therapy sessions were not trained to do so in in three randomly sampled MHT personnel files and three selected MHT personnel files of MHT staff providing group therapy during the survey (MHT1, MHT2, MHT3, MHT4, MHT7, MHT8). (All of these findings probably should be in A392 and and the appropriate Btag) This failure resulted in placing patients at risk for not receiving individualized supervsion and care and possibly negatively affecting patients’ mental health status. Findings: 1. During a concurrent interview and document review with the Staffing Coordinator (SC), on 11/12/2024 at 9:15 a.m., of the daily staff assignment sheets selected for the month October 2024 for Unit 3, the daily staffing assignments sheets indicated that there was no Registered Nurse on duty and only one Licensed Vocational Nurse (LVN) on duty 10/4/24 on Unit 3 between the hours of 2 p.m. to 7 p.m. for 20 patients. On 10/8/24 on Unit 3 there was only one LVN on duty between the hours of 7 p.m. to 7 a.m. for 17 patients. On 10/27/24 on Unit 3 only one LVN and one RN orientee (newly hired RN orienting to new job) were on duty between the hours of 7 p.m. to 7 a.m. for 24 patients. The SC acknowledged the lack of RN coverage on Unit 3 for 10/4/24, 10/8/24 and 10/27/24. On 10/27/24, the staffing sheet counted an RN orientee (newly hired RN undergoing orientation) as licensed staff. The SC clarified that an RN orientee cannot be counted in meeting the RN staffing requirement. (SC), the SC stated he completes all schedules according to the facility Core Staffing Guidelines for the three adult and one adolescent patient units. The SC indicated he submits the staffing schedules to Administration by 3 p.m. The SC stated Administration makes the staffing assignment changes, cuts and adjustments after the SC leaves the facility for the day. The SC stated the staffing assignments are made according to the facility Core Staffing Guidelines sheet. During a concurrent observation and interview on 11/5/2024 at 10:00 a.m., with RN1 and RN2, during the initial facility tour of Unit 1, Patient (PT-3) was observed pacing the hallway, not communicating with other residents or staff and not attending group activities. PT-3 was malodorous, face and arms soiled, hair uncombed and wearing soiled clothing (facility supplied hospital scrubs). PT-3 had been admitted to the facility on 9/18/24. The physician’s (MD1) history and physical dated 9/18/24 identified PT-3 with diagnoses of “schizophrenia bipolar type, unspecified psychotic disorder and rule out catatonic.”. RN1 and RN2 acknowledged that Unit 1 had patients needing more 1:1 (individual) supervision to redirect. PT-3 needed 1:1 assistance and direction showering and putting on clean clothes, but limited staffing prohibited staff from providing that care. RN1 and RN2 stated the current census on their unit was 26 and was staffed with two Registered Nurses (RN1, RN2) and three unlicensed mental health technicians (MHT). RN1 stated the number of licensed nurses scheduled is the same whether they have 25 or 30 patients. During a concurrent interview and document review on 11/12/24 at 9:15 a.m., of the” General Adult Core Staffing Guidelines”, the SC stated the document was used to determine the number of RNs to be assigned to each unit. The document listed the following: Census 17-23, two RNs per shift, census 24-28, three RNs per shift, census 29-35 three RNs per shift. Licensed Practical Nurses (LVNs) were not included in the staffing plan. As the census increased, mental health technicians (MHT)s were added. The SC clarified that MHTs are not licensed nursing staff. During a review of the facility’s policy titled, “Plan for the Provision of Inpatient Care policy #14339983” on 11/12/24 at 10:00 a.m., policy effective 9/2023, page 17 under Nursing Staffing, indicated, “Nursing care is planned, delegated, and coordinated by registered nurses. Members of nursing staff include registered nurses, licensed practical nurses, and mental health technicians. Unit staffing includes at lest one RN at all times. Assignments for nursing care are made according to programmatic and patient care needs as defined in the Plan for Nursing Care. Adjustments to the core staffing levels are made on the basis of identified patient needs. Such adjustments for planned staffing are made daily by the CNO or designee based on the individualized needs of patients on the units.” During a review of professional reference article from the National Library of Medicine, titled, “Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance” dated February 2020, the article indicated,”...Nursing staff are the core of the caring profession and central to their role is the development of effective relationships with the individuals they support...the interpersonal relationship is seen as foundational to a person-centred, recovery-oriented approach within mental health nursing...Therapeutic alliance has the greatest impact on treatment outcomes for those with mental health difficulties, over and above the specific mode or model of intervention that is provided...The therapeutic role of nursing staff in mental health care is especially pertinent in settings such as inpatient wards, where patients interact with nurses for the largest proportion of time and the relationship with them is cited as key to therapeutic progression with a perceived interplay between therapeutic relationships and the quality of care...” During a review of the Staff Nurse (registered nurse) (RN), job code 650, Position Description the RN Position Summary defines the position as: The Staff Nurse (R.N.) is a registered professional nurse who prescribes, coordinates, and evaluates patient care through collaborative efforts with health team members in accordance with the nursing process and the standards of care and practices. Essential Job Function categories listed as: Assessment, Intervention, Treatment Planning, Milieu, Teaching and Performance. Assessment: Document patient information and nursing care, document and reassess any significant changes in the patient’s condition in compliance with facility policy, report any signs of symptoms of infection to the Infection Control Nurse (ICN), and to verify the accuracy of patient records. Intervention: Employ principles of communication, interviewing techniques, problem solving and crisis intervention when performing psychotherapeutic interventions, accurately administer medications to patients, transcribe and carry out physicians treatment orders, utilize appropriate interventions in psychiatric medical emergencies. Treatment Planning: Prioritize and formulate a plan of care based on patient assessment, participate in development of an interdisciplinary treatment plan with measurable goals and objectives and interventions, update and revise the plan as goals and objectives are met or when patient condition changes, document both the nursing interventions on the treatment plan and the patient’s response to the intervention. Milieu: Assure patients are adequately oriented to the program, monitor program activity and encourage patient participation, prescribe and coordinate nursing care to patients, provide structured, monitor program activity and encourage patient participation, consistently utilize universal precautions and environmental safety guidelines, conduct structured didactic groups with patients and families, and utilize “self” as a role model to promote health communication. Teaching: Provide education to patients and families based on their identified needs and limitations, provide and document discharge instructions including food and drug interactions, diets and activities as appropriate, evaluate and document the effectiveness of all patient teaching, provide opportunities for patients and families to question, discuss and explore their feelings about prescribed therapies/interventions/diagnosis. 2. During a concurrent observation and staff interview on 11/5/24 at 11:00 a.m., during the initial tour and throughout the day 11/15/2024, patients on Unit 1 were frequently observed sitting or standing in large conference rooms engaged in what staff identified as “group activity and therapy” (a form of psychotherapy done in a group setting). RN1 and RN2 stated that recreation therapists (RT) and sometimes a social service staff (SS) staff member will conduct group sessions with patients. RN1 and RN2 stated RNs are supposed to participate and conduct group therapy sessions, but due to limited licensed SS, RT and RN staffing on the units, the Mental Health Technicians (MHTs) frequently conduct group therapy sessions with patients. During a concurrent interview and document review on 11/14/2024 at 9:00 a.m. with the Nurse Educator (NE), MHT training records were reviewed for MHT1, MHT2, MHT3, MHT4, MHT6 and MHT7. It was identified that none of the MHT files reviewed had documentation to support that the MHTs had received training on how to conduct group therapy sessions at the hospital. The NE acknowledged that the files all lacked documentation to support that training on how to conduct group therapy sessions had been provided to the MHTs. The NE stated that training was not being currently provided to MHTs and the training had not been added to their curriculum. During a review of the facility’s “Mental Health Technician job description” revised 8/13/2023, the MHT job functions include to “1. Provide continuous patient care and maintain safety of all assigned patients demonstrated by verifying patient safety every 15 minutes on appropriate forms, 2. Observe and document changes in patient’s appearance, behavior, and ability to work toward treatment plan goals, 3. Communicate changes in patient’s condition to Charge Nurse or Nurse Manager.””

“Personnel - Discharge Planning CFR(s): [The hospital must employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to:] Engage in discharge planning; This Standard is not met as evidenced by: 11090 Based on observation, interview and clinical record review, the facility failed to ensure that ongoing discharge planning was completed on 8 of 22 sampled and unsampled patients (PT-2, PT-3, PT-9, PT-10, PT-11, PT-13, PT-14, PT-22) when there were no assessments of patients needs or discharge planning. This failure resulted in PT-22 not receiving prescribed discharge treatments and had the potential to cause delay in discharge and for patients to not receive the ongoing resources needed after discharge. Findings: During a concurrent interview and clinical record review on 11/5/2024 at 10:00 a.m., during the initial tour of Unit 1, Registered Nurse (RN 2) stated that PT-3 had been admitted on 9/18/24 and had been on Unit 1 the longest of all patients on the unit. RN 2 stated she was not aware of any discharge plan for PT-3. During a concurrent interview and record review of PT-3’s clinical record on 11/9/24 at 9:30 a.m., with the House Supervisor (HS), the record indicated that PT-3 had been admitted on 9/18/24 with a diagnosis of “unspecified psychotic disorder” (loss of touch with reality).The HS acknowledged that the PT-3’s clinical record lacked documentation of any ongoing discharge plan. During a concurrent interview and record review of PT-2’s clinical record with the Nurse Educator (NE,) on 11/3/2024 at 10:00 a.m., the record indicated PT-2 was admitted on 10/2/2024 with diagnosis of “major depressive disorder” (mental health condition that causes a persistently low or depressed mood and loss of interest in activities that once brought joy),and was discharged on 10/7/2024. The NE acknowledged that the clinical record did not contain any ongoing discharge planning. During a concurrent interview and record review of PT-9’s clinical record with the NE, on 11/13/2024 at 10:00 a.m., the record indicated PT-9 was admitted on 11/4/2023 with diagnosis of “bipolar” (extreme mood swings) and was discharged on 11/13/2024. The NE acknowledged that the clinical record did not contain any ongoing discharge planning. During a concurrent interview and record review of PT-10’s clinical record with the NE, on 11/13/2024 at 10:15 a.m., the record indicated PT-10 was admitted on 10/24/2024 with diagnosis of “unspecified bipolar disorder” (extreme mood swings). The NE acknowledged that the clinical record did not contain any ongoing discharge planning. During a concurrent interview and record review of PT-11’s clinical record with the NE, on 11/13/2024 at 10:15 a.m., the record indicated PT-11 was admitted on 10/28/2024 with diagnosis of “major depressive disorder” and was discharged on 11/10/2024. The NE acknowledged that the clinical record did not contain any ongoing discharge planning. During a concurrent interview and record review of PT-14’s clinical record with the NE, on 11/13/2024 at 10:30 a.m., the record indicated, PT-14 was admitted on 11/9/2024 with diagnoses including a “major depressive disorder” and “post traumatic stress disorder” (an anxiety disorder that can develop after a person experiences or witnesses a traumatic event.). As of 11/13/2024, the clinical record contained no documentation that ongoing discharge planning had been initiated. The NE acknowledged that the clinical record did not contain any ongoing discharge planning. During a and record review on 11/15/2024 at 9 a.m., the record indicated PT-22 was an 18-year-old patient admitted on 10/27/2024 with diagnoses of bipolar (extreme mood swings) and depression. PT-22 was discharged on 11/5/2024. The Discharge Plan was not documented in the clinical record until the day of discharge and the plan did not include any input from the patient. Upon discharge, PT-22 was referred to an outpatient drug treatment clinic for follow up treatment. During a telephone conducted with PT-22 on 11/15/24 at 10 a.m., PT-22 stated she was unable to attend the outpatient treatment program because the facility had failed to check to see if outpatient program she had been referred to accepted her insurance, which they did not. PT-22 stated she has been unable to attend any outpatient psychiatric support services since discharge. During an interview on 11/8/2024 at 1:00 p.m., with the Director of Pharmacy (DP), the DP stated lack of facility staff to do discharge planning has hindered patients being sent home with prescribed medications. The DP stated it is important to have medications ready to give patients upon discharge to alleviate patients needing to go to a pharmacy to get their medications and the patient possibly not going. The DP stated to facilitate that process, the facility contracts with a pharmaceutical company that prepares outpatient medications to be given to the patient upon discharge. The DP stated to ensure that the discharge medications are ready at the time of discharge, the DP needs to be notified of the pending discharge and medications to be ordered two days prior to discharge. During an interview on 11/13/2024 at 11 a.m. with psychologist (PSY1) acting as temporary Chief of Medical Staff, PSY1 stated he comes to the facility to see his patients daily, Monday through Friday, and does tele-health video interviews with his patients on weekends. PSY1 stated he relies on the nursing staff for their patient observations, but as the staffing is now, “It is not enough”. PSY1 stated the facility needs more nursing staff and social workers and has discussed the issue at last Medical Executive Committee meetings. The lack of ongoing discharge planning affects the patient’s ability to obtain scheduled outpatient treatment upon discharge. PSY 1 stated, “If a psychiatric patient is told to call for an outpatient appointment after being discharged, PSY1 finds that generally it will not get done.” During a review of the hospital’s policy titled, “Discharge Planning Process ID 13985595”, effective 11/2023 on 11/14/2024 at 1 p.m., the policy indciated: “The development of a Discharge Plan begins upon admission and is a continuous process....The multi-disciplinary treatment team will develop after care plans on all patients ...The Social Services therapist is responsible for coordinating discharge plans and for communicating any plan to the patient, their family, natural supports and others involved in their continuing care.””

“Social Services Staff Responsibilities CFR(s): Social service staff responsibilities must include, but are not limited to, participating in discharge, planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital. This Standard is not met as evidenced by: 11090 Based on interview, and record review, the facility failed to ensure social service records were documented or documented timely (within 72 hours of admission), including patient interview reports, family member interviews, assessment of home plans, assessment of community resources and social history, for 8 of 22 sampled patients, patient (PT-1, PT-3, PT-6, PT-7, PT-8, PT-9, PT-12 and PT-13) when Psychosocial Assessments ( PSA-a tool used to evaluate a person’s mental health, social well-being, and ability to function in the community) were not completed according to facility’s policy and procedure. This failure had the potential to result in delay in treatment, interventions, care, and delayed discharge for all patients. Findings: During an interview on 11/7/2024 at 10:45 a.m., with the Social Services Director (SSD), the SSD stated she had only been employed by the facility less than a month and the facility had numerous unfilled Social Service staff positions open The SSD stated this was affecting social service staff’s ability to complete assessments and complete the required psychosocial assessments. During an interview on 11/13/24, at 10:35 a.m. with the Social Services Director (SSD), the SSD stated, the social worker is responsible to complete the PSA within 72 hours of admission. The SSD stated the PSA form is an important part of the medical record, it contains important patient information like family and community resources, patient mental health baseline status, patient stressors, and any barriers patients may have. The nurses, doctors, and other staff use this data to help understand the patients when providing care. The SSD stated, “It is not acceptable for late or missing PSAs”. During a record review on 11/7/2024 at 10:00 a.m., indicated PT-1was an 18-year-old male admitted on 9/16/24, at 8:20 p.m. on an involuntary basis, with a primary diagnosis of unspecific psychosis (diagnosis for people who have psychotic symptoms but do not meet specific criteria for a specific psychotic disorder). PT-1 was discharged on 9/26/24, at 3:20 p.m. PT-1’s clinical record indicated that the social assessment, and PSA was not completed until 9 days after admission on 9/25/24, at 4:20 p.m. During a concurrent interview and record review on 11/14/24 at 10:00 a.m., with the Nurse Educator (NE) the record indicated PT-3 was admitted on 9/18/24,with diagnoses of “schizophrenia (a serious mental condition involving a breakdown in the relation between thought,emotion,and behavior leading to faulty perception, inapproopriate actions and feelings,withdrawal from reality and personal relationships into fantasy and delusion) bipolar type(characterized by both manic and depressive episodes), unspecified psychotic disorder and rule out catatonic(Catanoia- a collection of signs and symptoms where the brain doesn’t manage muscle movement signals as it should). The NE acknowledged , PT-3’s PSA had not been completed until 9/28/24, 10 days after admission. The NE stated the PSA should have been completed per policy (within 72 hours of admission.). During a record review on 11/13/24 at 10:00 a.m., indicated PT-6 was a 41-year-old male admitted on 8/5/24, at 4:27 p.m. on an involuntary basis, with a primary diagnosis of major depressive disorder (a serious but treatable mood disorder that impacts how a person feels, thinks, and acts). PT-6 was discharged on 8/13/24, at 11:25 a.m. PT-6’s PSA, was not completed until 7 days after admission on 8/13/24, at 7:52 a.m.. During a record review on 11/13/24 at 11 a.m., indicated PT-7 was a 46-year-old female admitted on 8/19/24, at 11:05 a.m. on an involuntary basis, with a primary diagnosis of unspecifed psychosis. PT-7 was discharged on 9/3/24, at 2:04 p.m.. PT-7’s PSA was completed 9 days after admission on 8/29/24, at 10:25 a.m.. During a record review on 11/12/24 at 11 a.m., indicated PT-8 was a 20-year-old male admitted on 10/30/24, at 3:17 p.m. on an involuntary basis with a primary diagnosis of unspecified psychosis. PT-8 was discharged on 11/5/24, at 4:54 p.m.. PT-8’s medical record did not contain a PSA. During a concurrent interview and record review on 11/14/2024 at 11:15 a.m.,with the Nurse Educator (NE), the record indicated PT-9 was admitted on 11/4/2024 with diagnosis of bipolar (a mental health condition that causes extreme mood swings) and cannibis disorder (excessive use of marijuana). PT-9’s care plan documented, “Warning, aggressive homicidal”. The NE stated she was unable to locate a PSA in the clinical record. The NE stated a PSA had not been completed by social service staff within 72 hours as stated in hospital policy. During a concurrent interview and record review on 11/14/2024 at 9:00 a.m., with the Nurse Educator (NE), the record indicated PT-12 was a 40 year old male admitted on 11/8/2024 with diagnosis of bipolar. The NE was unable to locate a PSA in the clinical record. The NE stated a PSA had not been completed by social service staff within 72 hours as stated in hospital policy. During a concurrent interview and record review on 11/14/2024 at 9:00 a.m with the NE, the record indicated PT-13 was a 43-year-old male admitted on 11/4/2023 with diagnosis of suicidal ideation (thinking about or forming plans for suicide). The NE stated that the PSA had not been completed until 11/10/2024, six days after admission and had not been completed within 72 hours as stated in hospital policy. During a review of the facility’s policy and procedure (P&P) titled, “Psychosocial Assessment and Social Work Documentation” dated 2023, indicated, “Procedure, the following documentation will be maintained in the medical record by qualified social services staff: Psychosocial assessment, discharge planning log, discharge planning assessment, master treatment plan, group notes, family individual sessions, and collateral call and safety planning. The psychosocial assessment evaluates each person’s social situation to ascertain strengths and deficits including but not limited to the following areas persons current living situation, family relationships, and sources of support, environmental stressors, cultural needs, current stressors, access to lethal means, identified barriers to continuity of care and trauma history. The psychosocial assessment will include a chemical dependency screening and assessment. The psychosocial assessment will be completed by the social worker or therapist within 72 hours of the patient admitting to the hospital, and prior to the development of the master treatment plan. It will be completed with the patient, and if possible, with the involvement of significant other as applicable.””