Dover Behavioral Health System

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 51019 Based on a review of hospital policies and documents, medical records (MR), and staff (EMP) interviews, the facility failed to obtain the patient’s consent prior to treatment for 3 of 9 (PT2, PT7, and PT9) patients sampled. Findings include: I. Consent to Treat Hospital policy “Informed Consent” dated 4/2007, revealed “...It is the policy of Dover Behavioral Health System to consider and respect patient rights and need for relevant information through informed consent. Informed consent shall include the following...The risks, side effects, benefits and likelihood of success of all medication and treatment procedures...The patient or his/her representative, as followed by State law, has the right to make informed decisions regarding his/her care...The possible results of non-treatment...Informed written consents are required for the following, in addition to the authorizing for treatment signed on admission to the Hospital...Medications...” A) Review of MR3 revealed: The patient was an involuntary admission on 2/10/26 at 6:15 PM. The “Admission Agreement” documents that the patient was an “Adult 24-Hr Hold” and was signed by a staff member on 2/10/26 at 5:20 PM. The patient was an active patient at the time of this survey on 2/18/26. There was no evidence in MR3 that the patient consented to receive treatment after the 24-hour hold ended on 2/11/26. EMP10 confirmed this finding during an interview on February 19, 2026, at 2:55 PM. B) Review of MR7 revealed: A physician’s order dated 1/1/26 at 5:00 AM for PT7 to be admitted to the hospital voluntarily. The Admission Agreement, signed by staff on 1/1/26 at 12:25 AM, states that the patient refused to sign for consent. PT7 was discharged on 1/7/25 at 11:28 AM. There was no evidence in MR7 that the patient had consented to treatment since admission. During an interview on February 20, 2026, at 12:41 PM, EMP16 stated that if the patient refuses, the physician is to attempt gaining consent on the next day. II. Consent for Medication Hospital policy “Medication Informed Consent” dated 3/2020 revealed “...The Treating Practitioner has the legal responsibility for obtaining the Patient’s (or the Legal Representative’s) informed consent and approval to proceed with the proposed medication involving significant risk prior to administration, except for emergencies...For a listing of medications requiring informed consent, please see Appendix A - Dover Behavioral Health Systems...” Hospital document “Dover Behavioral Health System Commonly Prescribed Psychotropic Medications Require Informed Consent Appendix A”, not dated, revealed “...Antidepressants...Mirtazapine Remeron...Hypnotics...Diphenhydramine Benadryl...Antipsychotics...Chlorpromazine Thorazine...Olanzapine Zyprexa...Anti-anxiety agents...Hydroxyzine Atarax, Vistaril...Lorazepam Ativan...” During an interview on 2/19/2026 at 1:05 PM, EMP10 stated the process for psychotropic medication consents is the responsibility of the physician, who would not enter the order until the patient’s consent is received. A) Review of MR2 revealed: Physician orders dated: - 1/9/26 at 3:00 PM for Thorazine (antipsychotic medication) 50 mg by mouth three times a day as needed. - Mirtazapine (antidepressant) 7.5 mg by mouth every night at bedtime. Medication Administration Record documented the following medications administered: - Thorazine 50 mg by mouth was given 15 times between 1/10/26 at 9:00 PM and 1/18/26 at 8:45 PM. - Mirtazapine 7.5 mg by mouth was given 3 times between 1/17/26 9:00 PM and 1/19/26 at 9:00 PM. There is no evidence in MR2 that the patient consented to receive Thorazine and Mirtazapine. EMP10 confirmed this finding during an interview on February 19, 2026, at 2:55 PM. B) Review of MR7 revealed: Physician orders dated: - 1/1/26 at 12:00 PM for Olanzapine (antipsychotic medication) 10 mg by mouth every 8 hours as needed. - 1/1/26 at 12:00 PM for Olanzapine 10 mg intramuscular every 8 hours as needed. - 1/5/26 at 2:00 PM for Chlorpromazine (antipsychotic medication) 50 mg by mouth three times a day. - 1/5/26 at 2:00 PM for Chlorpromazine 25 mg injectable three times a day as needed. - 1/5/26 at 2:00 PM for diphenhydramine (hypnotic medication) 50 mg by mouth every 8 hours as needed. - 1/5/26 at 2:00 PM for diphenhydramine 50 mg injectable every 8 hours as needed. Medication Administration Record documented the following medications administered: -Olanzapine by mouth on 1/3/26 at 5:51 AM, 1/3/26 at 6:02 PM, 1/4/26 at 6:35 AM, and 1/5/26 at 2:55 AM. -Olanzapine intramuscular on 1/2/26 at 4:14 PM and 1/5/26 at 11:15 AM. -Chlorpromazine by mouth on 1/6/26 at 8:23 PM. -Chlorpromazine injectable on 1/6/26 at 7:02 AM. -Diphenhydramine by mouth on 1/6/26 at 8:23 PM. -Diphenhydramine injectable on 1/6/26 at 7:04 AM. There is no evidence in MR7 that the patient consented to receive Olanzapine, Chlorpromazine, and Diphenhydramine. EMP16 confirmed this finding during an interview on February 20, 2026, at 12:41 PM. C) Review of MR9 revealed: Physician order dated 12/15/25 at 3:00 PM for Hydroxyzine (anti-anxiety medication) 50 mg by mouth every 4 hours as needed. Medication Administration Record has Hydroxyzine 50 mg by mouth documented as given 15 times between 12/15/25 at 8:32 PM and 12/24/25 at 7:53 AM. There is no evidence in MR9 that the patient consented to receive Hydroxyzine. EMP10 confirmed this finding during an interview on February 20, 2026, at 11:41 AM.”

“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: 44819 Based on a review of hospital policy, observations, staff (EMP) interviews, and medication records (MR), the hospital failed to ensure a safe environment for patients, as demonstrated by an incident in which a patient (PT3) successfully wrapped bed linen around their throat. Findings include: A review of Hospital policy “Level of Observation/Rounds” dated 1/2027 and last revised 12/2025, revealed, “...Charge Nurse’s clinical assessment indicates the patient requires a higher level of observation, the RN [registered nurse] may implement, and then call the primary physician to obtain an order to place the patient on a 1:1...” During an interview on 2/18/26, from 11:36 to 11:44 AM, EMP18, RN, stated that if they felt a patient needed 1:1 observation, they would initiate it and then obtain an order from the provider. During an interview on 2/18/26, from 12:48 PM to 1:04 PM, EMP4, LPN, revealed that on the morning of 2/16/2026, PT3 told them that they were homicidal and suicidal and that they wanted to go to a different local psychiatric hospital. PT3 also stated he had attempted suicide in the past. EMP4 stated they relayed the patient’s conversation to EMP8, Charge Nurse, who texted the patient’s physician. The patient was offered Zyprexa (antipsychotic), but they refused, and EMP4 communicated this to EMP8. EMP4 stated she received a call from PT3’s insurance care coordinator that PT3 communicated a suicide plan “to tie a sheet around [their] neck.” EMP4 stated they communicated this to EMP8 and that 1:1 observations were not started for PT3 at that time. EMP4 stated that if a report of a suicide plan is received, they would notify the charge nurse, who would inform the physician, and the physician would determine the plan. During an interview on 2/18/2026, from 1:10 to 1:22 PM, EMP5, Social Worker, revealed they were aware that PT3’s insurance care coordinator reported, in the morning of 2/16/2026, that PT3 wanted to kill themselves. EMP5 stated they went to PT3’s unit, spoke with the patient, and then spoke with EMP8. During an interview on 2/19/26 at 1:05 PM, EMP17, RN, stated that if a patient’s condition warranted it, she would place a patient on 1:1 observations and then call the physician to obtain an order. During an interview on 2/18/26, from 1:23 to 1:37 PM, EMP8, Charge Nurse, revealed that in the morning of 2/16/26, both EMP6 and EMP4 communicated to them that PT3 was reported to be suicidal and wanted to hurt someone. EMP8 stated she texted the patient’s physician, who texted back at 11:05 AM with an order for Zyprexa, which the patient refused. The patient was pacing up and down the unit hallway at this time. At 11:14 AM, EMP8 texted the physician that the patient was refusing to take Zyprexa and that the patient had a history of “trying to hurt [themselves]” at another local psychiatric hospital. EMP8 stated that EMP4 reported PT3 had “hung” themselves twice at the other local psychiatric hospital. EMP8 reported that she texted the patient’s physician again at 11:52 AM, requesting that the patient be seen by the physician. The physician replied that EMP7, Psychiatric Nurse Practitioner (PsychNP), would see the patient soon. EMP7 arrived shortly after the text, and they went to the patient’s room. During the conversation with PT3 in their bedroom, PT3 was lying in bed, stating they wanted to go to another local psychiatric hospital and that they felt the medications were not working. EMP7 and the patient agreed to medication changes, and after further conversation, EMP7 and EMP8 left the room. EMP8 went to the Nurses Station to enter the medication changes in the patient’s record and heard EMP6 run by calling “code blue.” When asked by the surveyor when a patient’s observation level can be increased to 1:1, EMP8 stated that a physician’s order is required. When asked by the surveyor what precautions they took following reports that the patient threatened to harm themselves, EMP8 stated they asked the patient to lie down, kept the patient’s door open, and asked EMP6 to keep an eye on the patient. EMP8 stated that PT3 remained at an every-15-minute observation level. A review of MR3: “Code Blue RN Documentation” revealed on 2/16/2026 at 12:40 PM, the patient was found in bed with a pillowcase tied around their neck. Shears were used to cut the pillowcase. The patient was gasping for air when the staff arrived in the bedroom. CPR was not needed, and the patient was given oxygen. The patient remained alert during the code and was transported to the hospital at 1:00 PM. EMP8 failed to maintain a safe environment by not following the hospital’s policy to place a patient verbalizing an active suicide plan on a 1:1 observation level.”

“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: 51019 Based on a review of hospital policies and documents, medical records (MR), and staff (EMP) interviews, the facility failed to supervise and evaluate nursing care 1 of 9 (PT9) patients sampled. Findings include: Hospital policy “Level of Observation/Rounds” dated 01/2017, last revised 12/2025, revealed “...The physician shall order one of two levels of observation at time of admission for all patients, and may change the level of observation if the patient’s condition warrants a change...Q15 [every 15] minute...One-to-One...Charge Nurse’s clinical assessment indicates the patient requires a higher level of observation, the RN [registered nurse] may implement, and then call the primary physician to obtain an order to place the patient on a 1:1 [one-to-one]...” Hospital job description for Registered Nurse (Level I) dated 11/24/24, revealed “... Plan, provide, and evaluate patient care through quality Nursing Assessments Documents observations, treatments, interventions, patient teaching, and responses according to the facility and department’s policy and procedures...” Review of MR9 revealed: PT9 was admitted to the hospital on 12/12/25 at 1:11 AM. Nursing documentation revealed PT9 was on one-to-one observation from 12/12/25 at 7:45 PM to 12/16/25 at 12:20 PM. No physician order was found to initiate one-to-one observation. EMP10 confirmed this finding during an interview on February 19, 2026, at 2:52 PM.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 51019 Based on a review of hospital policies and documents, medical records (MR), and staff (EMP) interviews, the facility failed to revise the interdisciplinary care plan to reflect the patient’s goals and current patient needs for 2 of 9 (PT1 and PT8) patients sampled. Findings include: Hospital policy “Interdisciplinary Patient-Centered Care Planning” dated 09/2020, last revised 07/2024, revealed, “...It is the policy...to provide therapeutic services based upon a patient-centered, individualized treatment plan...Each patient’s written Treatment Plan must include...Short-term and long-term goals for each active problem, developed with patient input...The specific treatment modalities with individualized patient focus...a review of the treatment plan as clinically indicated, or at a minimum every (7) seven days. Identified problems will be summarized, progress towards goals will be reviewed, new goals and interventions identified...The patient/family and/or representative is to sign the review form...” Review of MR1 revealed: PT1 was admitted to the hospital on 11/18/25 at 2:33 PM and discharged on 2/18/26 at 9:45 AM. - The “Initial Nursing Treatment Plan” was completed on 11/18/25 at 1:10 PM. - The initial “Interdisciplinary Master Treatment Plan” was completed on 11/21/25 with no evidence of long-term goals identified, and the identified short-term goals were given a target date of 11/28/25. - There was no evidence of updated long-term goals, short-term goals, documentation of progress towards goals, or needed treatment modalities on 13 of 14 Interdisciplinary Master Treatment Plans completed between 12/8/2025 and 2/13/26. EMP10 confirmed this finding during an interview on February 20, 2026, at 11:24 AM. Review of MR8 revealed: PT8 was admitted to the hospital on 10/17/25 at 2:46 PM and discharged on 1/29/26 at 10:30 AM. - The “Initial Nursing Treatment Plan” was completed but not signed or dated by nursing. The target date for the identified short-term and long-term goals was 10/27/25. - There was no evidence of updated long-term goals, short-term goals, documentation of progress towards goals, and needed treatment modalities for 12 out of 13 Interdisciplinary Master Treatment Plans completed between 10/27/25 and 1/27/26. EMP10 confirmed this finding during an interview on February 20, 2026, at 11:44 AM.”

“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: 51019 Based on review of hospital policies, medical records (MR), and staff (EMP) interviews, the hospital failed to ensure nursing completed the “Nursing Admission Assessment” according to policy for 1 of 9 (PT7) patients sampled. Findings include: A review of the facility policy “Timeline of Initial Assessments”, effective and last approved 4/2025, revealed, “...Each staff...will follow the time frames listed below in regard to their job duties...Nursing Assessment required within 8 hours...” Review of policy “Plan for the Provision of Patient Care” effective 12/2006 and last revised 2/2026, revealed, “...The nursing assessment is completed within the first 8 hours...” Review of MR7 revealed: - PT7 was admitted on 1/1/26 and discharged 1/7/26. - There was no evidence that the “Nursing Admission Assessment” was completed during this admission. EMP16 confirmed this finding during interview on February 20, 2026, at 12:42 PM.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47821 Based on review of facility policies, review of facility documents, review of medical records (MR), and interviews with staff (EMP), it was determined that the hospital failed to ensure that patients received care in a safe setting. This deficiency had the potential to impact all 83 patients at the facility. On October 7, 2024 at 11:28 AM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included staff re-education, review and assessment of all current patients precautions and observation levels, along with implementing appropriate precautions and monitoring when needed, reviewing staffing schedules and obtaining additional staff whenever a provider identifies the need. The IJ was removed on October 8, 2024 at 2:02 PM after the State Survey Agency completed onsite verification that the facility implemented the corrective actions addressing the IJ. Cross Reference: 482.13(c)(2) Patient Rights: Receive care in a safe setting”

“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: 47821 Based on medical record review (MR), review of facility policies, review of facility documents, review of facility video surveillance, and interviews with staff (EMP), it was determined that the hospital failed to maintain an organized nursing service as evidenced by: failure to ensure patient observations were completed as ordered (A395); failure to supervise and evaluate nursing care (A395); failure to ensure patient progress notes contained the date, time, and signature of the responsible discipline (A398); failure to ensure that nursing staff carried out a physician’s order (A398); and failure to ensure that medications were administered in accordance with acceptable standards of practice (A405). These deficiencies had the potential to impact all 83 patients at the facility. On October 8, 2024, at 12:30 PM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included re-education of medication administration with step-by-step instructions and return demonstration competencies, and daily monitoring. The IJ was removed on October 9, 2024, at 9:14 AM after the State Survey Agency completed onsite verification that the facility implemented the corrective actions addressing the IJ. Cross Reference: 482.23(b)(3) RN Supervision of Nursing Care 482.23(b)(6) Supervision of Contract Staff 482.23(c) Preparation and Administration of Drug”

“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: 47821 Based on observations, review of medical records (MR), review of facility policies and documents, and interviews with staff (EMP), it was determined that the facility failed to provide care in a safe setting as evidenced by failing to ensure that appropriate interventions were implemented for patients who demonstrated physical aggression towards a peer; failing to ensure safety observations were conducted as ordered; and failing to ensure that a unit locker containing PPE (personal protective equipment), a potential ligature risk, was secure. These deficiencies had the potential to impact all 83 patients within the facility. Findings include: Review of facility policy “Homicidal Patient Risk Reduction Guidelines” issued September 2023, last revised September 2023, revealed, “...Mental Health Professionals have a duty to protect individuals who are being threatened... verbally...with bodily harm by a patient. Patients...that...are a danger to others should be managed in such a way as to minimize the threat of injury or harm...1:1 Observation may be implemented if a patient is exhibiting extremely aggressive behaviors...which include...A history of attempting to harm others, which produced or could have produced serious physical harm while in an intensive treatment setting...” Review of facility policy “Level of Observation/Rounds”, issued January 2017, last revised January 2019, revealed, “...The physician shall order one of two levels of observation at time of admission...and may change the level...if the patient’s condition warrants a change...If...the patient’s condition changes and the Charge Nurse’s clinical assessment indicated the patient requires a higher level of observation, the RN [registered nurse] may implement, and then call the primary physician to obtain an order to place the patient on a 1:1...Any patient placed on 1:1 shall be assigned an identified staff member... MHTs [mental health technicians] ...identify and report any findings while conducting observation rounds ... Ensure doors that are to be locked are, on [sic] fact, locked...” Review of facility document “Dover Behavioral Health System Medical Staff Bylaws”, no date, revealed, “...each applicant to the Allied Health Professional (AHP) Staff...obligates himself to provide his patients...with continuous and timely care...The Prerogatives of an AHP shall be to...write orders within scope of their license...and in accordance with...the Facility’s Policies and Procedures...” I. Failure to Implement Appropriate Interventions Review of MR6 “Psychiatric Assessment” signed by EMP16 on 5/22/2024 at 3:41 PM revealed, “...Patient is acutely psychotic...intermittently becoming aggressive and loud but is easily redirectable...is verbally aggressive, but not violent at this time...Patient will be admitted...Q 15-minute safety check will suffice...” Review of MR6 “Final Ancillary Orders (non-med)” revealed that Patient #6 was ordered every 15-minute observations with precautions for self-harm and aggression/homicide on 5/22/2024 at 1 PM. Review of facility incident report revealed that on 5/28/2024 at 4:20 AM, Patient #5 was ambulating down the hall when Patient #6 pushed her/him to the floor. Patient #5’s head began to bleed, a laceration was assessed, the area was cleansed with normal saline solution and Patient #5 was sent to the acute care hospital for evaluation and treatment. Review of MR6 “Daily Physician Progress Notes” dated 5/27/2024 through 5/30/2024 revealed that patient was paranoid, manic, psychotic, loud, aggressive, agitated and refusing medication. Review of MR6 “Daily Nursing Progress Notes” dated 5/23/2024 through 5/29/2024 revealed that patient was irritable, delusional, paranoid, agitated, verbally aggressive towards peers and staff, and refusing medications. Review of MR6 revealed a copy of a notarized letter, dated 5/30/2024, addressed to “Your Honor, State of Delaware” and signed by EMP16. The letter revealed, “...Pt has refused to consent voluntary to take medication...Pt is imminently danger [sic] to...self and others...has physically assaulted... peer and...is currently on 1:1 for safety. Patient has been verbally aggressive towards peers and staff...” Review of MR6 “Physician’s Orders” revealed, “...5/30/24...1030 [10:30 AM] ...Will have 1:1 while awake, pt aggressive, physical towards peer, refusing meds...” Interview was conducted on 10/4/2024 from 10:59 AM to 11:16 AM with EMP16, staff psychiatrist. EMP16 was questioned about the rationale for not ordering a “1:1 while awake” level of observation for Patient #6 on 5/28/2024, the day Patient #6 assaulted Patient #5. EMP16 replied, “There were some staff shortages on the unit, we try to talk to the patient and calm them down. I would have liked to put the patient on 1:1.” EMP16 could not remember who in nursing administration told him/her about the West Unit being short staffed on the 7a-3p shift on 5/28/2024, the day of the incident. EMP16 admitted that he/she did not write the 1:1 order that day for Patient #6 because of the short staffing on the unit. EMP16 confirmed that the 1:1 should have been ordered for Patient #6 on 5/28/2024 after the incident with Patient #5, per hospital policy. Review of facility document titled, “Dover Behavioral Health System-Staffing Model 2024”, no date, revealed a staffing grid for the East, North, South and West Units. The document also revealed, “...The combination of Nurses and MHT’s [Mental Health Technicians] may also be adjusted based on the needs of the unit...West...4:1 Ratio on Days/Evenings...” On 10/4/2024, in reviewing West Unit staffing for the 5/28/2024 7a-3p shift, EMP4 stated that the unit had a census of 33 patients with no 1:1 cases. Staffing was 1 RN, 1 LPN, and 5 MHT’s, which was one MHT short for the 7a-3p shift. This finding was confirmed with EMP4 at 1:45PM. Review of MR12 “Patient Demographic Profile” revealed that Patient #12 was admitted on 6/2/2024 at 6:20 AM and discharged on 7/3/2024 at 6:20 PM. Review of MR10 “Patient Demographic Profile” revealed that Patient #10 was admitted on 5/22/2024 at 8:26 PM and discharged on 6/10/2024 at 5:30 PM. Review of MR10 “Psychiatric Assessment” revealed, “...Patient is acutely psychotic, paranoid...patient has been noncompliant to...medication and decompensated...Patient will be admitted...Q [every] 15-minute safety check will suffice; however, patient is currently in the [sic] seclusion because of agitation and aggression...” Review of facility incident reports revealed that on 6/4/2024 at 8:45 AM, Patient #12 was sitting in his/her wheelchair at the nurses’ station when Patient #10 pushed and slammed the wheelchair into the double doors which caused Patient #12 to hit his/her head and fall out of the wheelchair. Patient #12 sustained a bruise and raised area to the forehead and complained of pain. Patient #12 was sent to the acute care hospital to be evaluated for a possible head injury. The reports described Patient #10 as being angry and agitated at the time of the incident. Review of MR10 “Daily Physician Progress Notes” dated 5/29/2024 through 6/5/2024 revealed that the patient was delusional, irritated, angry, agitated and aggressive. Review of MR10 “Daily Physician Progress Note” dated 6/4/24 at 8:30 AM revealed, “...Pt aggressive, agitated yesterday, push [sic] the wheelchair & other peer got injured...Recommend 1:1...” Review of MR10 “Daily Nursing Progress Notes” dated 5/26/2024 through 6/5/2024 revealed that patient was irritable, unpredictable, intrusive, paranoid, delusional, manic, argumentative, and violent. In an interview conducted on 10/7/2024 from 11:07 AM to 11:17 AM with EMP16, staff psychiatrist, EMP16 was questioned about the rationale for not ordering a 1:1 level of observation for Patient #10 after the incident of physical aggression with Patient #12 on 6/4/2024. EMP16 replied, “[Patient #10] did not want to be a 1:1. After the incident, the patient did not remember it. Patient stated...cannot do 1:1 because it is a trauma for [him/her] ...I think I should have done that, put [him/her] on a 1:1 based on the patient and...behavior.” Nursing staff also failed to initiate a 1:1 level of observation for Patient #6 and Patient #10, based on each patient’s documented behaviors and hospital policy. These findings were confirmed with EMP1 and EMP4 during an interview on 10/8/2024 from 9:32 AM to 10:29 AM. II. Failure to Conduct Safety Observations as Ordered Review of MR5 “Final Ancillary Orders (non-med)” revealed, “...Observations-15-minute checks... Start Time: 5/17/24 12:00 [12 PM] ...” Review of MR5 medical record (MR) revealed no evidence of a “Patient Observation Record” for 5/29/2024. This finding was confirmed with EMP2 on 10/8/2024 at 1:58 PM. Review of MR10 “Final Ancillary Orders (non-med)” revealed, “...Observations-15-minute checks...Start Time: 5/22/24 22:00 [10:00 PM] ...” Review of MR10 medical record (MR) revealed no evidence of a “Patient Observation Record” for 6/6/2024. This finding was confirmed with EMP2 on 10/8/2024 at 1:58 PM. Review of MR12 “Final Ancillary Orders (non-med)” revealed, “... Observations-15-minute checks...Start Time: 6/2/2024 10:00 [10:00 AM] ...” Review of MR12 medical record (MR) revealed no evidence of a “Patient Observation Record” for 6/6/2024. This finding was confirmed with EMP2 on 10/8/2024 at 1:58 PM. III. Failure to Securely Store Items that Posed Potential Ligature Risks During a flash tour of the East Unit on 10/2/2024 from 10:06 AM to 10:55 AM, Locker 1426 B was found unsecured. The locker contained personal protective equipment including disposable gowns and disposable face shields, which could be considered potential ligature risks. During an interview on 10/3/2024 at 4:35 PM, EMP6, Corporate Director, confirmed, that per the “Level of Observation/Rounds” policy, “Patient observation policy can apply to all doors.” This finding was confirmed with EMP7 on 10/2/2024 at 10:18 AM.”

“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: 47821 Based on observations, review of medical records (MR), review of facility policies, review of facility documents, and interviews with staff (EMP), it was determined that the facility failed to complete ordered patient observations and failed to supervise and evaluate the nursing care for 17 out of 21 patients sampled (MR1, MR2, MR3, MR4, MR5, MR7, MR8, MR10, MR12, MR14, MR15, MR16, MR17, MR18, MR19, MR20, and MR 21). Findings include: Review of facility job description, “Charge Nurse (RN [registered nurse] III)”, updated July 27, 2018, revealed, “ ...Timely review of the Patient Observation Round sheets for each patient to ensure all levels of observation and precautions are accounted for and sign and date round sheets twice per shift ...” Review of facility policy “Level of Observation/Rounds” issued January 2017, last revised January 2019, revealed, “...The Charge Nurse reviews and signs the Patient Observation Rounds sheet a minimum of 2x per shift...MHTs [mental health technicians] ...Observe each patient, a minimum of every 15 minutes...and document observation on the patient form...” I. 15-Minute Observations Patient #2 ordered Q (every) 15-minute checks on 9/9/2024 at 1 AM. Review of MR2 “Patient Observation Record”, dated 9/11/2024, revealed no documentation of a 15-minute patient observation at 11:15 AM, as ordered. This finding was confirmed with EMP4 on 10/8/2024 at 9:53 AM. II. Nursing Supervision of Patient Safety Observations The Patient Observation Rounds sheet contains a section for registered nurses to sign for supervising the observations in 4-hour time slots (12:00 AM - 4:00 AM; 4:00 AM - 8:00 AM, etc.). Review of MR1 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the observation rounds on the following dates and times: 9/23/2024: 8 AM to 4 PM (4 hours) 9/25/2024: 12 AM to 4 PM (16 hours) 9/26/2024: 8 AM to 4 PM (8 hours) These findings were confirmed during an interview conducted on 10/8/2024 between 9:35 AM-9:42 AM with EMP4. Review of MR2 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the observation rounds on the following dates and times: 9/8/2024: 8 PM-12 AM (4 hours) 9/10/2024: 12 AM-8 AM (8hours) and 8 PM-12 AM (4 hours) 9/12/2024: 8AM-4PM (8 hours) 9/13/2024: 8AM-12 PM (4 hours) 9/14/2024: 12 AM-12AM (24 hours) 9/15/2024: 4 PM-12 AM (8 hours) 9/16/2024: 12 PM-4 PM (4 hours) 9/19/2024: 4 PM-12 AM (8 hours) 9/20/2024: 8AM-4 PM (8 hours) 9/23/2024: 8 AM-4 PM (8 hours) 9/25/2024: 12 AM-4 PM (16 hours) 9/26/2024: 8 AM-4 PM (8 hours) and 8 PM-12 AM (4 hours) These findings were confirmed during an interview conducted on 10/8/2024 from 9:51 AM-9:57 AM. Review of MR3 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times: 9/10/24: 8 PM-12 AM (4 hours) 9/14/24: 12 PM-4PM (4 hours) 9/18/24: 8 AM-4 PM (8 hours) 9/19/24: 4 PM-12 AM (8 hours) 9/20/24: 8 AM-4 PM (8 hours) 9/23/24: 8 AM-4 PM (8 hours) 9/24/24: 8 AM-4 PM (8 hours) 9/25/24: 12 PM-4 PM (4 hours) 9/26/24: 8 AM-4 PM (8 hours) 9/27/24: 8 AM-4 PM (8 hours) 9/29/24: 8 AM-4 PM (8 hours) These findings were confirmed by EMP4 on 10/8/24 at 9:30AM. Review of MR4 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times: 9/10/24: 8 AM-12 AM (16 hours) 9/12/24: 8 AM-4 PM (8 hours) 9/14/24: 12 PM-4 PM (4 hours) 9/18/24: 8 AM-4 PM (8 hours) 9/19/24: 4 PM-12 AM (8 hours) 9/20/24: 8 AM-4 PM (8 hours) 9/23/24: 8 AM-12 AM (16 hours) 9/24/24: 8 AM-4 PM (8 hours) 9/25/24: 12 AM-8 AM (8 hours) 9/27/24: 8 AM-4 PM (8 hours) 9/29/24: 8 AM-4 PM (8 hours) These findings were confirmed with EMP4 on 10/8/24 at 9:30AM. Review of MR5 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times: 5/19/2024: 8 AM-12 PM (4 hours) This finding was confirmed with EMP4 on 10/8/2024 at 10:07 AM. Review of MR7 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times: 9/19/2024: 4:00 PM-12:00 AM (8 hours) 9/20/2024: 8:00 AM-4:00 PM (8 hours) 9/25/2024: 12:00 AM-4:00 PM (16 hours) 9/26/2024: 8:00 AM-4:00 PM (8 hours) 9/29/2024: 8:00 AM-4:00 PM (8 hours) 10/1/2024: 12:00 AM-8:00 PM (20 hours) These findings were confirmed during an interview conducted on 10/8/2024 between 9:35 AM-9:42 AM with EMP4. Review of MR8 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times: 9/21/24: 12 PM-4 PM (4 hours) 9/25/24: 12 AM-8 AM (8 hours) 9/26/24: 8 AM-4 PM (8 hours) 9/28/24: 12 PM-12 AM (12 hours) These findings were confirmed with EMP4 on 10/8/24 at 930AM. Review of MR10 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times: 5/28/2024: 4 PM-12 AM (8 hours) 5/29/2024: 4 PM-12 AM (8 hours) These findings were confirmed with EMP4 on 10/8/2024 at 10:19 AM. Review of MR12 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times: 6/5/2024: 8 PM- 12 AM (4 hours) 6/16/2024: 4 PM-12 AM (8 hours) These findings were confirmed with EMP4 on 10/8/2024 at 10:28 AM. Flash tour of the East Unit conducted on 10/2/2024 from 10:06 AM-10:55 AM. Review of MR14, MR15, MR16, MR17, MR18, MR19, MR20 and MR21 “Patient Observation Record” revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times: 10/2/2024: 12 AM-8 AM (8 hours) These findings were confirmed by EMP4 on 10/2/24 at 10:42AM.”

“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: 47821 Based on medical record review (MR), review of facility policies, review of facility documents, and interviews with staff (EMP), it was determined that, for 4 out of 21 patients sampled (MR2, MR5, MR6, and MR12), the facility failed to ensure patient progress notes contained the date, time, and signature of the responsible discipline, and failed to ensure that nursing staff carried out a physician’s order. Findings include: Review of facility policy “Chart Documentation Requirements” issued April 2007, last reviewed April 2024, revealed, “...Each entry is to be dated and timed, with the discipline writing the note identified...NSG =Nursing...MHT=Mental Health Technician...” Review of facility document “Registered Nurse (Level I), last reviewed July 27, 2018, revealed, “Essential Job Duties: ...Transcribe and carry out physician orders...” I. Progress Notes Missing Date, Time, and Signature of Responsible Discipline Review of MR2’s “Progress Record” revealed two (2) notes written on 9/15/24 at the following two (2) times: 8:00 AM and 11:00 AM. These notes revealed no evidence of the writer’s signature and discipline. Review of MR2’s “Progress Record” for the admission dates of 9/8/2024 through 9/26/2024 revealed five (5) notes with no evidence of a date, or the writer’s signature and discipline. These findings were confirmed with EMP4 on 10/8/2024 between 9:45 AM-9:55 AM. Review of MR5’s “Progress Record” revealed a note dated 5/28/24 at 4:53 AM. The note revealed no evidence of the writer’s signature and discipline. This finding was confirmed with EMP4 on 10/8/2024 at 10:06 AM. Review of MR6’s “Progress Record” revealed four (4) notes written on 5/31/24 by a MHT [mental health technician] at the following four (4) times: 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM. These four notes revealed no evidence of the writer’s signature. These findings were confirmed with EMP4 on 10/8/2024 at 10:05 AM. II. Failure of Nursing Staff to Carry Out Physician’s Order Review of facility incident reports revealed that on 6/4/2024 at 8:45 AM, Patient #12 was sitting in a wheelchair at the nurses’ station when Patient #10 pushed and slammed the wheelchair into the double doors which caused Patient #12 to hit his/her head and fall out of the wheelchair. Patient #12 sustained a bruise and raised area to the forehead and complained of pain. Patient #12 was sent out to the acute care hospital to be evaluated for a possible head injury. Review of MR12’s “Physician Orders” revealed, “...6/4/24 1500 [3:00 PM] ...Orders to transfer to East Unit...” Hospital census reports reviewed for 6/3/2024 through 6/5/2024 revealed that Patient #10 and Patient #12 were on the West Unit. Review of MR12’s “Patient Observation Records” dated 6/5/2024, 6/7/2024, 6/8/2024, 6/9/2024 and 6/10/2024, revealed that Patient #12 was in Room 1150A on the West Unit. Review of MR10’s “Patient Demographic Profile” revealed that Patient #10 was discharged on 6/10/2024 at 5:30 PM. Review of MR12’s “Patient Demographic Profile” revealed Patient #12 was discharged on 7/3/2024 at 6:20 PM. Patient #12 was never transferred to the East Unit as ordered on 6/4/2024, after the incident with Patient #10. Patient #12 and Patient #10 both remained on the West Unit through 6/10/2024, when Patient #10 was discharged. This finding was confirmed with EMP4 on 10/8/2024 at 10:24 AM.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47821 Based on review of facility policies, review of medical records (MR), and interviews with staff (EMP), it was determined that the hospital failed to ensure that medications were administered in accordance with hospital policy. This deficiency had the potential to impact all 83 patients within the facility. Findings include: Review of facility policy “Medication Management”, issued August 2007, last revised May 6, 2022, stated, “ ...Procedure ...The nurse will identify the patient using the two (2) of the following approved patient identifiers ...Asking the patient to state their name ...Using the patient picture located in the MAR ...date of birth ...The nurse will inspect the patient’s mouth to ensure ingestion of the medication ...” I. Patient identifiers Interview on October 2, 2024 between 10:20 AM and 10:35 AM with EMP5, indicated that his/her standard of practice is to administer medications without the use of two (2) patient identifiers. EMP5 indicated that they know all the kids, so they do not need to ask their name when they come up to get their medications. EMP5 stated that he/she works primarily on the adolescent unit, and this is his/her standard practice when administering medications. During an interview on October 2, 2024 at 10:50 AM with EMP6, this finding was confirmed. EMP6 stated that he/she provided immediate remedial education to EMP5 after witnessing the above statements. II. Mouth checks Review of MR1, Progress Record”, dated September 26, 2024, stated, “Pt [patient] was walking the hallway ...Pt fell to floor c/o [complained of] chest pain. Rapid response called. Pt was pale, clammy, diaphoretic ...Pt stated...took an orange and white capsule that was in [his/her] room....While waiting on transport pt stated...had also cheeked [his/her] meds from the day before which...was trazadone, ASA, and Melatonin ...Pharmacy had identified there is one pt in adolescent unit taking orange and white capsule and identified that capsule to be Vyvanse ...” Review of MR1, “Physician Medication Orders”, revealed an order for lisdexamfetamine (Vyvanse) oral 30 mg capsule daily to start on 9/26/2024. Review of MR1, “Medication Administration Record”, revealed that the patient received scheduled dose of Vyvanse on 9/26/24 at 12:41 PM. Review of facility video surveillance for 9/25/24 between 8:21 PM and 10:00 PM, revealed, at 8:21 PM, Patient #1 received his/her scheduled melatonin at the medication window. After taking the medications he/she appeared to have a small unidentifiable object between his fingers. No mouth check was completed by the nurse administering the medication. At 9:59 PM, Patient #1 walks to the nursing station door to receive his/her scheduled medication. No mouth check was completed by the nurse administering the medication. As Patient #1 walks away from the nursing station holding cups of water, he/she opens their mouth and spits the medication into the cup of water. Review of facility video surveillance for 9/26/24 between 12:39 PM and 12:45 PM, revealed, at 12:39 PM, Patient #1 arrives to the nursing station and the nurse hands him/her a medication cup and a cup of water. As soon as he/she takes the medication, he/she spits the medication into his water cup. He/she then appears to drink the water from the cup. Patient #1 hands the medication cup and the water cup back to the nurse, who appears to glance in the cup, and then dispose of it. No mouth check was completed. Interview on October 3, 2024 between 10:26 AM and 11:00 AM, with EMP4, revealed the hospital recognized the need for staff re-education relating to medication administration, specifically, the need to ensure that patients are not holding medications in their mouths. EMP4 stated that all staff received education regarding appropriate medication administration and signed an attestation. EMP4 provided evidence that all active nursing staff received the education. Review of facility video surveillance from October 8, 2024 between 8:50 AM and 9:30 AM on the South Unit, revealed no mouth checks were completed for patients that received medications during that timeframe. Review of facility video surveillance from October 8, 2024 between 8:10 AM and 8:30 AM on the North Unit, revealed no mouth checks were completed for patients that received medications during that timeframe. During an interview on October 8, 2024 at 11:47 AM with EMP3, the above findings were confirmed. During an interview on October 8, 2024, between 10:40 AM and 10:44 AM with EMP4, it was stated that all nurses were expected to complete mouth checks with every med pass. It was also stated that no monitoring was currently being done by the facility to ensure that the recent education provided to staff on completing mouth checks had improved compliance.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48349 Based on review of facility policies, review of facility documents, review of medical records (MR), review of facility video surveillance, and interviews with staff, it was determined that the hospital failed to ensure that patients received care in a safe setting, with the potential to negatively impact all 84 patients at the facility. Cross Reference: 482.13(c)(2) Patient Rights: Receive care in a safe setting On August 16, 2024 at 10:30 AM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included staff re-education, review and assesment of all current patients needs, and increased monitoring. The IJ was removed on August 19, 2024 at 2:00 PM after the State Survey Agency completed onsite verification that the facility implemented the corrective actions addressing the IJ.”

“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: 48349 Based on review of facility policies, review of facility documents, review of medical records (MR), review of facility video surveillance, and interviews with staff, it was determinted that the facility failed to implement an increased level of observation for a patient that sexually assaulted another patient, per hospital policy. This deficient practice resulted in the hospital’s inability to protect patient rights and provide services in a safe setting. This deficiency had the potential to impact all 84 patients within the facility. Findings include: Review of facility policy “Patient’s Rights Bill of Rights” effective April 2007, reviewed October 2023, revealed, “ ...The patient has the right to receive care in a safe setting ...” Review of facility policy “Sexual Precautions (perpetration/victimization)” effective December 2006, reviewed April 2024, stated, “ ...When a patient is regarded as a risk for sexual misconduct, or at risk of being a victim of sexual misconduct the physician’s orders will specify “Sexual Precautions” ...In the event of serious intent and overt attempt/act, the patient will be placed on 1:1 [level of observation] ... Constant, continuous, and effective observation and supervision is an effective method of prevention ...” Review of MR #1 “Psychiatric Assessment” dated July 21, 2024 revealed “ ...Patient is acutely psychotic, aggressive, agitated and belligerent ...patient is currently admitted under involuntary status for psychosis and aggression. [He/She] has made multiple suicidal and homicidal threats in general ...Q [every] 15-minute safety checks will suffice ...however, we will continue to monitor patient closely; if needed, [he/she] can be on one-to-one for safety ...” Review of MR #1 “Final Ancillary Orders” revealed physician orders were placed on July 21, 2024, at 2:16 AM (time of admission) for “Sexual Aggression Risk” precautions. Review of facility document “Incident Investigation Summary”, no date, revealed that Patient # 2 reported a sexual assault by Patient #1 on the evening of 7/21/2024 that occured in Patient # 2’s room, witnessed by Patient # 2’s roommate. Review of MR # 2 “Discharge Summary”, dated July 23, 2024 revealed that Patient # 2 was admitted to the hospital on July 20, 2024, and discharged July 22, 2024 with a diagnosis of unspecified mood disorder and intellectual disability. “...Significant Finding...According to staff, patient was sexually molested by another patient on the unit...” Review of MR # 3 “Physician Discharge Orders/Plan” dated July 31, 2024 revealed, discharge diagonses of unspecified psychotic disorder and intellectual disability. Review of facilty document “Daily Census” dated July 21, 2024 revealed that Patient # 1 and Patient # 3 were roommates on July 21, 2024. Review of facility document “Daily Census” dated July 22, 2024 revealed that Patient # 1 and Patient # 3 remained roommates on July 22, 2024. Interview on August 16, 2024 at 10:20 AM with Employee # 2 revealed that Patient # 1 was moved to a private room on July 22, 2024 at 1:47 PM. It was confirmed that an open patient room was available on July 21, 2024, however, Patient # 1 was not moved until the next afternoon. Patient # 2 and Patient # 3 were both close in age and both had intellectual disabilities. No evidence was found that the facility took action to address this situation appropriately. Review of MR #1 “Daily Physician Progress Note” dated July 22, 2024 revealed that the patient was hypersexual and sexually inappropriate with another patient. Review of MR #1 “Daily Physician Progress Note” dated July 29, 2024, revealed “ ...tried to sexually assault another patient today but staff intervened ...” Reveiw of MR #1 “Patient Observation Record” from July 21, 2024 and July 31, 2024, revealed that the patient was on a Q15 minute safety check level of observation. Interview with Employee # 3 and Employee # 4 on August 16, 2024 between 5:45 PM and 6:15 PM revealed that Patient # 1 moved to a private room on July 22, 2024 as an intervention after the report of sexual assault. It was confirmed that Patient # 1 had ongoing inappropriate sexual behaviors throughout thier hosptial stay, Employee #3 and Employee #4 were unable to indicate whether a discussion occurred to evaluate the need for increased supervision for Patient # 1 after the incident, and no documentation relating to an evaluation of the need for increased supervision was found.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48349 Based on review of facility policies, review of facility documents, review of medical records (MR), and interviews with staff, it was determined that the hospital failed to revise the interdisciplinary care plan to reflect current patient needs for 1 out of 4 patients (Patient # 1) reviewed in the sample. Findings include: Review of facility policy “Interdisciplinary Patient-Centered Care Planning” effective July 2024, revealed, “ ...It is the policy ...to provide therapeutic services based upon a patient- centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment team and develop appropriate goals and interventions ...must include ...Identification of problems to be treated and the specific behavioral manifestations of those problems in the patient ...The treatment team ...will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) days. Identified problems will be summarized, progress towards goals will be reviewed, new goals and interventions identified, as well as discharge considerations will be updated. A treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient’s needs. Reviews of the treatment plan are documented on the appropriate treatment plan forms in the medical record. The following would be cause for conducting a review of the plan and developing a revision ...A new impairment/problem or significant information about an existing impairment is identified ...” Review of facility document “Incident Investigation Summary”, no date, revealed that Patient # 2 reported a sexual assault by Patient #1 on the evening of 7/21/2024. Review of MR # 1 “Individual Treatment Plan” dated July 21, 2024 did not contain any short term or long-term goals related to sexual acting out behaviors. Review of MR # 1 “Interdisciplinary Master Treatment Plan” dated July 21, 2024 did not contain any information relating to sexual acting out behaviors. Review of MR #1 “Final Ancillary Orders” revealed physician orders were placed on July 21, 2024, at 2:16 AM (time of admission) for “Sexual Aggression Risk” precautions. Review of MR #1 “Daily Physician Progress Note” dated July 22, 2024 revealed that the patient was hypersexual and sexually inappropriate with another patient. Review of MR #1 “Daily Physician Progress Note” dated July 23, 2024 revealed that the patient was very hypersexual. Review of MR #1 “Daily Physician Progress Note” dated July 29, 2024 revealed “ ...tried to sexually assault another patient today but staff intervened ...” Interview with Employee # 3 and Employee # 4 on August 16, 2024 between 5:45 PM and 6:15 PM revealed that Patient # 1 had ongoing inappropriate sexual behaviors throughout their hospital stay, including successful and attempted sexual assaults. It was confirmed that patient’s care plan was not updated to reflect current patient needs.”

“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: 48349 Based on review of facility policies, review of medical records (MR), and interview with staff, it was determined that the facility failed to adhere to the policies and procedures of the hospital for 1 out of 4 patients (Patient # 2) reviewed in the sample. Findings include: Review of facility policy “Timeliness of Initial Assessments” effective December 2002, revised January 2021, revealed that a nursing assessment is required to be completed within 8 hours of admission. A preliminary treatment plan is required withing 24 hours of admission. Review of facility policy “Plan for the Provision of Patient Care” effective December 2006, revised May 2022, revealed, “ ...Assessment of Patients ...On arrival, patients receive a nursing assessment to include physical status and functioning. The nursing assessment is completed within the first 8 hours ...” Review of facility policy “Interdisciplinary Patient-Centered Care Planning” effective July 2024, revealed, “ ...It is the policy ...to provide therapeutic services based upon a patient-centered, individualized treatment plan ... The nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission ...” Review of MR # 2 revealed no evidence of a completed nursing assessment within eight (8) hours of admission. Review of MR # 2 revealed no evidence of an initial treatment plan within 24 hours of admission. During an interview on August 14, 2024 between 11:52 AM and 12:00 PM with Employee # 3, these findings were confirmed.”

“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: 45764 Based on medical record review, policy review, document review, observation, video surveillance review, and staff interview, it was determined that the facility failed to provide care in a safe setting for 1 of 4 patients (Patient #1) in the sample by not performing safety observations per hospital policy. These findings have the potential to negatively impact all 96 patients at the facility. Findings include: Hospital policy “Level of Observation/Rounds” stated, “...Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient form...Observe patients on bed rest or when sleeping by...Looking for the rise and fall of the chest...Counting at least three respirations...Making sure that the patient has moved from his/her previous sleeping position...Observations may not be completed standing in the doorway, or at a distance...It is expected that staff conducting 15 minute observations will enter the room, approach the patient...3 sets of respirations, and to ensure that they are not in any distress...Visually observe patient when behind closed doors by...Announce that they are stepping into the room for rounds...Open door and visually observe the safety of the patient...” Hospital document “Patient Rights and Responsibilities” stated, “...Personal Safety - The patient can expect a reasonable safety [sic] in so far as hospital practices and environment are concerned to include protective precautions when indicated...” Patient #1 was admitted to Dover Behavioral Health System (DBHS) on 3/8/24 at 2:44 PM with a diagnosis of opioid dependence, uncomplicated. Physician orders, initiated on 3/8/24 at 10:00 PM, included routine every 15-minute (Q15) safety rounding. Patient #1’s “Observation Record” for 3/9/24 lists that the patient was awake, agitated, and bizarre from 4:45 to 7:00 AM. At 8:15, 8:30, 8:45, 9:00, 9:15, and 9:30 AM, the patient was documented as in the patient room and with eyes closed. Video surveillance review from 3/9/24 revealed: - 8:15:06 Employee #11, Mental Health Technician (MHT), delivers food items to Patient #1 in room - 8:16:18 Employee #9, MHT, closes the patient’s door - 8:45 Employees #11 and 12, MHTs, at the doorway of Patient #1 - 8:59 Employee #11 performs every 15-minute safety check from the door - 9:24 Employee #12 walks past Patient #1’s door without stopping - 9:38 Employee #9 performs every 15-minute safety check - 9:56:04 Employee #9 enters the patient’s room for the safety check - 9:56:20 Employee #9 runs out of the room - 9:56:38 Employees #9, 11, and 13 (RN) enter the patient’s room - 9:58:46 The code cart and additional staff arrive at room - 10:06:49 Emergency Medical Services (EMS) arrives “Observation Record” listed the 8:15 AM and 8:30 AM observations were performed by Employee #9, however, based on video surveillance review, Employee #9 was at Patient #1’s door at 8:16:18. The next MHT was at the patient’s door at 8:45. Therefore, the 8:30 AM observation was not completed at documented. Also, at 9:15 AM, the patient was documented as being in the room with eyes closed. However, on video review, Employee #11 was visualized at the patient’s door, at 9:24 AM, Employee #12 walks past the patient door without stopping to visualize, and at 9:38 AM, Employee #9 was visualized at the patient’s door, therefore the 9:30 AM observation was not performed as documented. In an interview statement conducted on 3/9/24 by Employee #1, Director of Risk Management, Employee #11, MHT, was questioned regarding performing safety checks from the doorway. Employee #11 stated this was done for multiple safety checks as Patient #1 was undressed during multiple safety checks. On one safety check, the patient was visualized standing up. Yet, on the Observation Record, the patient was charted as lying down with eyes closed. The patient was provided a pair of scrubs, however, the patient only donned the top and not the bottoms. In an interview statement conducted on 3/9/24 by Employee #1, Director of Risk Management, Employee #9 stated that on the 9:45 AM safety check, the patient was visualized lying down, with eyes open. At the 10:00 AM rounds, Patient #1 was visualized with eyes open, and mouth open, but Employee #9 stated something “didn’t look right”. Employee #9 stated an attempt was made to arouse the patient, but was unsuccessful. Employee #9 then ran down the hallway to retrieve the nurse. Employee #1, Director of Risk, stated in an interview on 3/13/23 from 9:25 to 9:37 AM, that, after video surveillance review, the administration identified observations were not being conducted for Patient #1 per policy, and did not align to what was documented on the Observation Record for Patient #1.”

“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: 45764 Based on medical record review, policy review and staff interview it was determined that the facility failed to supervise and evaluate the nursing care for 2 out of 4 (50%) patients (Patients #2 & #3) sampled. Findings include: The hospital job description title, “Charge Nurse (RNIII)” stated, “Timely review the Patient Observation Round sheets ...and sign and date round sheets twice per shift ...” The hospital policy titled, “Level of Observation/Rounds” revised 1/24 stated, “...The Charge Nurse reviews and signs the Patient Observation Rounds sheet a minimum of 2x per shift.” Review of the hospital policy titled, “Timeliness of Initial Assessments” dated 3/23 stated, “...Each staff member responsible for any document or entry in a patient’s medical record will follow the time frames listed...Progress Note Entries...Once per shift...” I. Nursing Assessments Medical record review for Patient #2 revealed: No evidence that a nursing assessment was completed and no evidence of a “Daily Nurse Progress Note” in the medical record for the following dates and shifts: 3/9/24: 3 PM-11 PM 3/10/24: 3 PM-11 PM 3/11/24: 3 PM-11 PM 8/23/23: 3 PM-11 PM These findings were confirmed by Employee # 1 on 3/13/24 at 2:30 PM. Medical record review for Patient #3 revealed: No evidence that a nursing assessment was completed and no evidence of a “Daily Nurse Progress Note” in the medical record for the following dates and shifts: 2/4/24: 3 PM-11 PM 2/6/24: 3 PM-11 PM These findings were confirmed by Employee #1 on 3/13/24 at 2:30 PM. II. Nursing Supervision of Patient Safety Observations The Patient Observation Rounds sheet contains a section for registered nurses to sign for their review of the observations in 4-hour slots (12:00 AM - 4:00 AM; 4:00 AM - 8:00 AM, etc.). Medical record review for Patient #2, admitted with Bipolar Disorder and history of suicide attempt at last hospitalization in January (1/30/24), revealed: Observation Record 24-Hour Inpatient Form showed there were no nursing signatures to indicate a nurse reviewed the observation rounds on the following dates and times: 3/8/24 (admission date): 9 PM-12 AM (3 hours) 3/10/24: 12 PM-4 PM (4 hours) 3/11/24: 8 AM-1:45 PM (5.75 hours - patient sent to local Emergency Department) 3/21/24: 4 PM-12 AM (8 hours) These findings were confirmed by Employee # 1 on 3/13/24 at 2:30 PM. Medical record review for Patient #3, admitted with Major Depressive Disorder and placed on suicide precautions revealed: Observation Record 24-Hour Inpatient Form showed there were no nursing signatures to indicate a nurse reviewed the observation rounds on the following dates and times: 2/1/24: 4 PM-12 AM (8 hours) 2/3/24: 12 AM-8 AM; 9 PM-12 AM (12 hours) 2/4/24: 4 PM-12 AM (8 hours) 2/6/24: 12 PM-12 AM (12 hours) These findings were confirmed by Employee #1 on 3/13/24 at 2:30 PM.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48349 Based on review of facility policies, review of medical records, video surveillance, and staff interviews it was determined that the facility failed to protect and promote each patient’s rights as evidenced by failure to ensure that patients receive necessary levels of supervision (A0145). Cross Reference: 482.13(c)(3) Patient Rights: Free from abuse/harassment On January 24, 2024 at 10:48 AM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included staff re-education, implementation of a zero tolerance policy, and an increase in leadership review and auditing. These interventions were implemented and verified by the State Agency, and the IJ was removed on January 25, 2024 at 12:41 PM.”

“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: 48349 Based on review of hospital policies, medical record review, video surveillance review, and interview with staff, it was determined that the facility failed to keep patients free from harm by failing to ensure that patient observations are conducted at indicated intervals consistent with facility policy, for 2 of 4 patients sampled (Patient #1 and Patient #2). “Hospital policy titled “Patient’s Rights” (last reviewed by facility 09/2023) stated, “...the patient has the right to be free from all forms of abuse, neglect, mistreatment, harm, or harassment...” Hospital policy titled “Level of Observation/Rounds” (last reviewed by facility 2/2023) stated, “It is the policy of Dover Behavioral Health System that all patients will be routinely observed in compliance with physician orders and prescribed protocols...observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient form...whenever possible, staff should make informal, verbal contact with assigned patients to ascertain safety and well being...the assigned RN [Registered Nurse] will accompany the MHT [Mental Health Technician] or other assigned staff making rounds on 11-7 every 2 hours to ensure the patient is not in any distress, all doors remain open on 11-7 and there is a ‘hall monitor’ in place...” Medical record review revealed: Patient #1 - “Psychiatric Assesment” dated 01/20/24 stated, “...patient had increasing symptoms in the community leading to suicidal ideation and increased psychosis...patient will be placed on q [every] 15 minute checks to guard against harm to self and others...” - No documented safety observation rounds after 5:15 AM on 1/21/24 Patient #2 - “Psychiatric Assessment” dated 01/18/24 stated, “...Q [every] 15- minute safety checks...” - No documented safety observation rounds after 5:15 AM on 1/21/24 Video surveillance on 1/21/24 indicated that at 6:11 AM Patient #1 and Patient #2 entered their room. At 6:12:43 the door to the patients’ room was closed from the inside. At 6:25:39 AM, Employee #7 opens the patients’ door. No interactions or patient observations by staff were visible between 5:59 AM and 6:25 AM (26 minutes without a safety observation). No hallway monitor was present during this time. Employee #7, in a written statement provided by hospital administration, indicated “...I walked into one patient room to do rounds and found one patient [Patient #1] over another patient [Patient #2] over the floor, face down. Roommate [Patient #1] was over him with a towel around the patient’s [Patient #2’s] neck. The patient [Patient #2] was not moving. I told [Patient #1] to get off [Patient #2] and the patient [Patient #1] let go... I went to get the cart and we started CPR...” During an interview with Employee #3, it was revealed that during the time of the missing safety observation, Patient #2 was assaulted by Patient #1 in their room utilizing a towel around Patient #2’s neck, which resulted in the loss of pulses and respirations, requiring immediate life-saving measures including cardiopulmonary resuscitation (CPR). These findings were confirmed during an interview on 01/23/24 at 09:24 AM with Employee #3.”

“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: 48349 Based on review of facility policies, review of medical records, and staff interviews, it was determined that the hospital nursing staff failed to properly supervise safety observations for 4 out of 4 patients (Patients #1, #2, #3, #4) sampled. The hospital policy titled, “Level of Observation/Rounds”, dated 02/23 stated, “...The Charge Nurse reviews and signs the Patient Observation Rounds Sheet a minimum of 2x per shift...” The Patient Observation Rounds sheet, in each patient’s medical record, contains a section for nursing to sign for their review and supervision of their observations in 4-hour slots (12:00 AM - 4:00 AM; 4:00 AM - 8:00 AM, etc.). Medical record review for Patient #1 revealed: Review of the Observation Record 24-Hour Inpatient Form showed there was no nursing signature to indicate a nurse reviewed and supervised the observation rounds on the following dates and times: 1/20/24: 12 AM-8 AM (8 hours) Medical record review for Patient #2 revealed: Review of the Observation Record 24-Hour Inpatient Form showed there was no nursing signature to indicate a nurse reviewed and supervised the observation rounds on the following dates and times: 1/18/24: 9 PM-12 AM (4 hours) 1/19/24: 8 AM-12 AM (20 hours) 1/20/24: 9 PM-12 AM (4 hours) 1/21/24: 12 AM-8 AM (8 hours) Medical record review for Patient #3 revealed: Review of the Observation Record 24-Hour Inpatient Form showed there was no nursing signature to indicate a nurse reviewed and supervised the observation rounds on the following dates and times: 1/13/24: 4 PM-4 PM (12 hours) 1/14/24: 4 AM-4 PM (12 hours) 1/15/24: 4 AM-12 AM (20 hours) 1/16/24: 12 AM-4 PM (16 hours) 1/18/24: 8 AM-12 AM (16 hours) 1/19/24: 4 AM-4 PM (12 hours) 1/20/24: 12 AM- 12 AM (24 hours) 1/21/24: 12 AM-8 AM; 4 PM-12 AM (16 hours) 1/22/24: 12 AM-8 AM; 4 PM-12 AM (16 hours) Medical record review for Patient #4 revealed: Review of the Observation Record 24-Hour Inpatient Form showed there was no nursing signature to indicate a nurse reviewed and supervised the observation rounds on the following dates and times: 1/5/24: 4 AM-8 AM; 4 PM-12 AM (12 hours) 1/6/24: 4 PM-12 AM (8 hours) 1/7/24: 12 AM-12 AM (24 hours) 1/8/24: 4 AM-8 AM; 4 PM-12 AM (12 hours) 1/9/24: 4 AM-8 AM; 4 PM-12 AM (12 hours) 1/10/24: 4 AM-8 AM; 12 PM-4 PM (8 hours) 1/11/24: 4 PM-12 AM (8 hours) 1/12/24: 12 AM-8 AM; 4 PM-12 AM (16 hours) 1/13/24: 4 AM-4 PM (12 hours) 1/14/24: 4 AM-4 PM (12 hours) 1/15/24: 4 AM-8 AM; 4 PM-12 AM (12 hours) These findings were confirmed by Employee #3 on 1/23/24 at 2:43 PM.”

“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: 48349 Based on hospital policy review, medical record review, and interviews with staff, it was determined that for 4 out of 4 patients (Patient #1, 2, 3, and 4) the hospital failed to adhere to the policies and procedures of the hospital. Findings include: 1. Failure to document a code blue event. Hospital policy titled “CPR” (last reviewed by facility 5/2022) stated, “...Documentation of Code Blue will include...time of cardiac, and/or respiratory arrest...how arrest was recognized...time CPR started...vital signs...procedures performed...time medical control relinquished to paramedic team...disposition of patient...” Review of Patient #2’s medical record revealed: - No documented evidence of a Code Blue event occurring, or any of the required Code Blue documentation requirements. It was confirmed during interviews on 1/23/24 between 2:10 PM and 2:40 PM with Employee #2 and Employee #3, Patient #2 received CPR on 1/21/24 from facility staff and that no documentation of the event took place. 2. Failure to document nursing assessments. The hospital job description titled, “Registered Nurse” stated, “...Essential Job Duties ...Plan, provide, and evaluate patient care through quality nursing assessments...” Review of the hospital policy titled, “Timeliness of Initial Assessments” (last reviewed by facility 3/2023) stated, “...Each staff member responsible for any document or entry in a patient medical record will follow the time frames listed ...Progress Note Entries ...Once per shift...” Hospital policy titled “Chart Documentation Requirements” (last reviewed by facility 1/2022) stated, “...required documentation consists of the following...progress notes documented for each shift...” Review of Patient #3’s Medical record revealed: No evidence that a nursing assessment was completed and no evidence of a “Daily Nurse Progress Note” in the medical record for the following dates and shifts: - 1/17/24 from 3 PM to 11 PM - 1/21/24 from 3 PM to 11 PM Review of Patient #4’s Medical record revealed: No evidence that a nursing assessment was completed and no evidence of a “Daily Nurse Progress Note” in the medical record for the following dates and shifts: - 1/7/24 from 7 AM to 3 PM - 1/12/24 from 3 PM to 11 PM - 1/16/24 from 3 PM to 11 PM These findings were confirmed by Employee #3 on 1/23/24 at 2:47 PM. 3. Failure to document a patient’s change in condition. Hospital policy titled “Reporting Changes in Patient’s Medical/Mental Condition” (last reviewed by facility 5/2022) stated, “...documentation in the record of change in condition will include any interventions...” Hospital policy titled “Chart Documentation Requirements” (last reviewed by facility 1/2022) stated, “Documentation in the progress notes (using the narrative format) is performed by physician and nursing staff...incorporating the following circumstances...medical emergency and/or problem...events, which significantly impact patient’s status whether positively or negatively...significant interactions with the patient...” Review of records revealed: Patient #1 - Patient with no documented history of violence or acting out per the medical record. - On 01/21/24, Patient #1 assaulted Patient #2, the roommate, using a towel around Patient #2’s neck, and causing severe harm as indicated in a written statement from Employee #7. - No documentation of this change in behavior or interventions implemented for the patient was able to be located within the medical record. This finding was confirmed during an interview on 1/22/24 at 3:27 PM with Employee # 2. Patient # 2 - On 01/21/24, Patient #2 was assaulted by Patient #1 in their room and sustained serious harm as indicated in a written statement from Employee #7. No documentation of this change in patient’s in medical condition was able to be located within the medical record. This finding was confirmed during an interview on 1/22/24 at 3:27 PM with Employee #2.”