Centerstone of Florida

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 36678 Based on facility documents, record reviews, interviews, and policy review, the hospital failed to ensure patients were provided a written notice of their rights for 2 patients (#1 and #10) of 20 sampled. Findings included: Review of “Inpatient Combined Consent” packet includes consent for treatment, patient rights notice, and notice of Habeas Corpus. Review of Patient #1 medical record revealed on 10/30/2025 Patient #1 was admitted for Major Depressive Disorder, recurrent severe with psychotic symptoms. On admission, the “Inpatient Combined Consent” packet was provided to the patient. During thre record review for Patient #10, there was no evidence the patient was provided with Patient Rights. There was no signature indicating Patient #10 was provided Patient Rights, or documentation of refusal. At 2:50 PM on 11/17/25 during an interview with Staff B, Case Manager (CM) she said it might have been misfiled. She confirmed it was not found in Patient #10’s medical record. During an interview on 11/17/2025 at 2:50 PM, Staff C, CM stated I don’t see it. They are provided to every patient on admission though. During an interview on 11/19/2025 approximately 12:00 PM, the Inpatient Clinical Director stated I do not see inpatient combined consent packet for Patient #1. The packet includes consent for treatment, patient rights, and notice of Habeas Corpus. Looking at the record, it was never provided to the patient. Review of the policy, Client Rights and Responsibilities, effective 1/25, reflected Procedure: Upon initiation of services with Centerstone, all clients will be offered a copy of the Inpatient Hospital, Addiction Center Handbook containing Centerstone’s Statement of Client’s Rights, Client’s Responsibilities, and Client’s Grievance Procedures. Receipt of the Client’s Rights and Responsibilities and Client’s Grievance Procedures is evident by the client’s signature will be noted in the clinical record. In the event the client refuses to sign the requested receipt, the clinical r3ecord will document the refusal.”

“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: 48190 Based on facility documents, medical record reviews and interviews, the facility failed to obtain consent for treatment for 2 (Patient #1, and #10) of 20 patients sampled. Findings included: Review of “Inpatient Combined Consent” packet includes consent for treatment, patient rights notice, and notice of Habeas Corpus. Review of Patient #1 medical record revealed on 10/30/2025 Patient #1 was admitted for Major Depressive Disorder, recurrent severe with psychotic symptoms. On admission, the “Inpatient Combined Consent” packet was not addressed or signed by the patient. Review of patient #10 medical record revealed on 01/02/2025 Patient #10 was admitted for Bipolar Disorder, severe with psychotic symptoms. On admission, the “Inpatient Combined Consent” packet was not addressed or signed by the patient. During an interview on 11/17/2025 at 2:50 PM the case Manager stated “I don’t see it. They are supposed to be provided to every patient on admission.” During an interview on 11/19/2025 approximately 12:00 PM, the Inpatient Clinical Director stated I do not see inpatient combined consent packet for Patient #1. The packet includes consent for treatment, patient rights, and notice of Habeas Corpus. Looking at the record, it was never provided or signed by the patient.”

“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: 36678 Based on documentation review, interviews, policy review, and Quality Management Plan review, the hospital failed to ensure appropriate data collection for Utilization Review was collected, aggregated, and reviewed for outliers and trends, and appropriate summaries of the data collection for review by the QAPI (Quality Assessment and Performance Improvement) program, for one of one QAPI programs. Findings included: During an interview with Staff A, UR (Utilization Review) supervisor on 11/18/2025 at 1140 AM she said she reports to QI (quality improvement) monthly meeting using excel spread sheets for denials and a utilization review report. A review of data collected by the Utilization Review Supervisor reflected documentation of review of potential outliers. However, upon request during the survey timeframe of 11/17/25 to 11/19/25, no data or reports were provided summarizing findings for presentation to QAPI or other designated committees. A review of the policy, Resource Utilization Plan, dated 11/25, revealed the following: Purpose of Utilization Review To monitor and evaluate the quality of patient care through the analysis, review and evaluation of clinical practices To establish and maintain length of stay (LOS) norms/levels throughout levels of care To document current patterns of utilization To identify patterns of over utilization To promote efficient, cost-effective use of organizational resources, facilities and services. To recommend corrective action plans To monitor and measure the impact of corrective actions taken Organizational Structure and Resources Responsibility of the Governing Board and Professional Ethics Privileging, and Education Committee. The corporate quality council has oversight responsibility Inpatient level of CARE is the responsibility of the Utilization Review Staff Utilization management staff meet regularly in the form of the resource utilization Committee Issues identified, such a staffing, productivity, finance, infomatics, facilities, and equipment will be brought to the Corporate Quality Committee for follow-up. Functions/Committees Establish and implement a system of concurrent review of admission, continued stay, discharge planning, and to ensure continuity of care. The source of payment shall not be the sole determinant of identifying patients for review. Coordinates between utilization review activities and financial resources utilization Identifies utilization related problems, i.e., admission screening criteria , clinical, appropriateness, necessity for continued treatment, standards for care ... Coordination with the QI program The QI program monitors outliers, trends, and overall quality and an annual inter-rater reliability study Summary data will be reported to the Resource Utilization Committee Policy review, Quality Management Plan FY (fiscal year) 2025, last revision 10/25, revealed Quality Management Plan Purpose To communicate the QM activities and findings to key stakeholders To identify opportunities to improve care through intentional and proactive collection and analysis and interpretation of data To evaluate performance trends Goals: Standardize Chart audit processes to ensure quality documentation and quality of care ...the following activities will be monitored and/or reported during FY2025 activities: Quality measure reporting and monitoring Implementation of a standardized chart audit process to ensured quality documentation and quality of care Quality Management Process (QMP) and Model The work of the quality management system is organized into three basic activities: quality assessment, quality improvement, and activity tracking. These activities are overseen by and reported on by the QS (Quality and Safety) committee. The QMP processes are informed by the use of data to measure quality of care, efficiency of practice and sound business functions, and are designed to obtain input from various stakeholders. They derive from a number of sources of information about quality of care and services issues which include: Data is one of the only objective methods of measuring quality improvement, the QS committee works closely with relevant members to develop a data feedback structure on a timely basis Predetermined performance thresholds will be established. Data is collected, displayed, and reported routinely, using data visualization when helpful. Data is analyzed to identify trends, patterns, and performance levels that suggest opportunities for improvement. Committees Quality and safety committee function The committee report on and evaluates the quality of care and outcomes. In an effort to achieve the best management of limited resources, this model mandates the prioritization of data collection.”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 36678 Based on interviews and policy review, the hospital failed to ensure appropriate data collection for discharge planning for review of the facility QAPI (Quality Assurance Performance Improvement) program to identify potential outliers and quality of care concerns for discharge planning, for one of one QAPI programs. Findings included: At 3:18 PM on 11/19/25 during an interview with the Regional Director of Quality and Patient Safety, she said the only thing that goes to QAPI for discharge planning is client surveys. At 3:25 PM on 11/19/25 during an interview with the Director of Case Management she said the case managers do weekly meetings. They talk about things like referrals that need to be made, readmission rates, length of stay. “We were talking about adding it to the quality meetings.” There have been no fall outs that she knows of. There isn’t a system for data entry for tracking and trending. At 3:55 PM on 11/19/25 during a follow up interview with the Regional Director of Quality and Patient Safety she stated that they are in the middle of an EHR (electronic health record) change and they have not been collecting any data for case management or discharge planning. They have weekly meetings. They don’t write anything down. Policy review, Quality Management Plan FY (fiscal year) 2025, last revision 10/25, revealed Quality Management Plan Purpose To communicate the QM activities and findings to key stakeholders To identify opportunities to improve care through intentional and proactive collection and analysis and interpretation of data To evaluate performance trends Goals: Standardize Chart audit processes to ensure quality documentation and quality of care ...the following activities will be monitored and/or reported during FY2025 activities: Quality measure reporting and monitoring Implementation of a standardized chart audit process to ensured quality documentation and quality of care Quality Management Process (QMP) and Model The work of the quality management system is organized into three basic activities: quality assessment, quality improvement, and activity tracking. These activities are overseen by and reported on by the QS (Quality and Safety) committee. The QMP processes are informed by the use of data to measure quality of care, efficiency of practice and sound business functions, and are designed to obtain input from various stakeholders. They derive from a number of sources of information about quality of care and services issues which include: Data is one of the only objective methods of measuring quality improvement, the QS committee works closely with relevant members to develop a data feedback structure on a timely basis Predetermined performance thresholds will be established. Data is collected, displayed, and reported routinely, using data visualization when helpful. Data is analyzed to identify trends, patterns, and performance levels that suggest opportunities for improvement. Committees Quality and safety committee function The committee report on and evaluates the quality of care and outcomes. In an effort to achieve the best management of limited resources, this model mandates the prioritization of data collection.”

“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: 48190 Based on facility record review and interviews conducted, the facility failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program for 1 of 1 QAPI program. Refer to A0286.”

“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: 48190 Based on review of medical records, review of facility policy and procedures, and staff interviews, the facility failed to ensure a safe setting for 3 (#1, #2, #3) of 4 patients. Findings included: Review of the facility policy “Protection from Abuse, Neglect and Exploitation” last reviewed 09/19/2022. Policy states no individual served by Centerstone will be subjected to physical or verbal abuse by any employee or patient/client. Review of Patient #1’s medical record revealed the patient was admitted on 06/29/2023 for schizoaffective disorder, bipolar type. Review of Physician documentation on 06/30/2023 showed Patient #1 was noted pacing and demanding to be let out early in the morning. He began banging on the double doors. The staff brought an ETO (Emergency Treatment Order- medications used in hospitals to calm patients who are endangering themselves or staff) and a restraint chair. The patient lunged at the staff resulting in the staff to perform a take- down (when a patient is forced down and immobilized for application of a restraint). Review of the nurse’s notes revealed Patient #1 resisted verbal de-escalation and physically fought staff members. Patient #1 was taken to the floor where an ETO medication was administered. It was at that point the nurse noticed deformity to right forearm and an abrasion to the right side of the forehead from the carpet. The patient was then sent to an acute care hospital for evaluation. Review of the video footage with no audio from 06/30/2023 with Staff A, Vice President of Quality (VPQ), Patient #1 was pacing the halls, Staff E, Behavioral Health Technician (BHT), noted to bring in a restraint chair. After bringing in restraint chair, Patient #1 walked past the chair and down the hall. Upon returning, Staff E, BHT wrapped his arms around Patient #1 and body slammed Patient #1 to the ground. Then Staff G, BHT laid on top of both Patient #1 and Staff E, BHT. Staff F, Registered Nurse (RN) was seen stepping on Patient #1’s right arm as she leaned over him. On 01/31/2024 at 10:35 AM, an interview was conducted with Staff D, Case Manager/BHT. During the interview, she stated Staff E told the patient to get into the restraint chair himself or the staff will put him in the chair. Soon after that was said, the take- down occurred. On 01/31/2024 at 12:00 PM, an interview was conducted with Staff A, VPQ. During the interview, she stated the take down was unnecessary and Staff E BHT, Staff F RN and Staff G BHT were sent home and taken off the schedule during the timeframe of the investigation. After investigating and reviewing the video footage, Staff E, BHT, Staff F, RN and Staff G, BHT were terminated. Review of Patient #2 medical record revealed the patient was admitted on 09/13/2023 for alcohol abuse and generalized anxiety. Review of nurse’s notes on 09/13/2023 revealed patient #2 was admitted on a voluntary basis seeking help with alcohol detoxification. Patient #2 uses a cane for assistance with ambulation. Review of nurse’s notes on 09/14/2023 revealed Patient #2 was observed on video falling to the ground because another patient had pushed him, and subsequently complained of neck pain. Patient #2 was taken to an acute care hospital for evaluation. Review of Physician notes on 09/18/2023 revealed Patient #2 had to be reminded he experienced a fall and that he was sent out to an acute care hospital for evaluation and was sent back to facility with no concerns. Patient #2 verbalized concerns that he may have early signs of dementia stating that he will not drive himself as he is afraid he will get lost. Patient #2 reports his sister has dementia. On 01/31/2024, review of video footage with no audio from 09/14/2023 with Staff A VPQ was conducted. Video shows Patient #2 walking down the facility hallway with his cane for assistance. At the end of the hallway, Patient #2 is seen walking into another patient’s room. He is then seen falling back to the ground and the other patient is standing over him with Patient #2’s cane. Then staff is seen running down the hallway toward the patient. On 01/31/2024 at 11:00 AM, an interview was conducted with Staff A, VPQ. During the interview, Staff A, VPQ stated when we investigated the incident, the staff said Patient #2 was known to pace the hallways and sometimes even wander into other patients’ rooms. The staff also said they knew the other patient at the end of the hallway was in his room and was agitated. When Patient #2 walked down the hallway, he wandered into the agitated patient’s room and that patient got up and pushed Patient #2 down for coming into his room. The staff was not watching Patient #2 carefully when he walked down towards the agitated patient’s room. Review of patient #3 medical record revealed patient was a 15-year-old patient admitted on 11/10/2023 for Bipolar Disorder, severe depression and suicidal ideation. Patient #3 ordered visual observation, 1:1 (For patients identified as high risk for suicide who have access to ligature or other safety risks, constant 1 to 1 visual observation must be implemented.) at all times. Review of physician’s notes from 11/11/2023 showed Patient #3 stated “I wanted to kill myself”. Patient #3 admits to swallowing a loose piece of metal that was lying around her bathroom and experienced abdominal pain. Patient #3 then states prior to swallowing the metal, she also swallowed glass. Patient #3 was transferred to this facility after being medically cleared at an acute care hospital. Review of nurse’s notes revealed on 11/17/2023 Patient #3 came to staff at the medication window and stated, “I’ve done something bad, but not to anyone else, just myself.” When asked what Patient #3 did, she stuck her tongue out and revealed 8-10 staples. Patient #3 was advised multiple times to spit the staples out, but she stated she did not want to and wanted to hurt herself. Patient #3 then walked away from the medication window and went to sit near a window. When approached by another staff member to spit the staples out, Patient #3 stated “I will not. I want to kill myself, and by any means necessary, I will, and you cannot stop me.” Patient #3 then swallowed the staples. The Physician was notified, and Patient #3 was transferred to an acute care hospital for evaluation. Review of physician notes on 11/18/2023 reveals, Patient #3 was sent out last night after showing numerous staples in her mouth to staff and then proceeded to swallow them before staff could intervene. Patient #3 was transferred to an acute care facility for evaluation and was medically cleared. Upon return, Patient #3 states she found the staples in coloring books on the unit. On 01/31/2024, review of video footage with no audio from 11/17/2023 with Staff A, VPQ and Staff C, OM (Operations Manager) was performed. Based on video surveillance, Patient #3 is seen sitting at a table with 2 other patients placing multiple things in her mouth and not spitting them back out. Staff C, OM verifies a behavioral health technician is sitting in the corner of the room watching Patient #3 and not stopping her from eating items. On 01/31/2024 at 11:00 AM, an interview was conducted with Staff A, VPQ. Staff A stated when we investigated the incident, we discovered the therapy intern brought in magazines/pamphlets that were held together by the staples and left them in the day room. Her reasoning for bringing them in is for an art project. The therapy intern did not think about the staples being a safety issue for the patients. On 01/31/2024 at 01:45 PM, a follow up interview was conducted with Staff C, OM. Staff C, OM stated Staff A, VPQ asked me to review the video. The video shows Patient #3 sitting at a table with 2 other patients. They seem to be talking, laughing, coloring with markers and dancing in their seats; there is no audio unfortunately. Throughout the video, you can see Patient #3 putting things in her mouth and not spitting anything back out. The behavioral health technician is not in the view, but I was told she is sitting in the corner of the room watching them. She did not stop the patient from putting things in her mouth.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: 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 ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48190 Based on video review, interview conducted, and record review, the facility failed to analyze events involving patient harm without prompt intervention in order to seek effective preventive measures to protect the patients in 1 of 1 QAPI program. The lack of sufficient safety measures places all patients at risk for harm. The findings included: Review of the Facility Quality Management Plan for Fiscal year 2023-2024 revealed Quality Management Plan (QPM) Purpose . . . to identify opportunities to improve care through intentional and proactive collection and analysis and interpretation of data, to evaluate performance trends . . . To monitor the implementation and evaluation of performance improvement activities. Review of Patient #1’s medical record revealed the patient was admitted on 06/29/2023 for schizoaffective disorder, bipolar type. Review of Physician documentation on 06/30/2023 showed Patient #1 was noted pacing and demanding to be let out early in the morning. He began banging on the double doors. The staff brought an ETO (Emergency Treatment Order- medications used in hospitals to calm patients who are endangering themselves or staff) and a restraint chair. The patient lunged at the staff resulting in the staff to perform a take-down (when a patient is forced down and immobilized for application of a restraint). Review of the nurse’s notes revealed Patient #1 resisted verbal de-escalation and physically fought staff members. Patient #1 was taken to the floor where an ETO medication was administered. It was at that point the nurse noticed deformity to right forearm and an abrasion to the right side of the forehead from the carpet. The patient was sent to an acute care hospital for evaluation. Review of the video footage with no audio from 06/30/2023 with Staff A, Vice President of Quality (VPQ), showed Patient #1 was pacing the halls. Staff E, Behavioral Health Technician (BHT), noted to bring in a restraint chair. After bringing in restraint chair, Patient #1 walked past the chair and down the hall. Upon returning, Staff E, BHT wrapped his arms around Patient #1 and body slammed Patient #1 to the ground. Then Staff G, BHT laid on top of both Patient #1 and Staff E, BHT. Staff F, Registered Nurse (RN) was seen stepping on Patient #1’s right arm as she leaned over him. On 01/31/2024 at 12:00 PM, an interview was conducted with Staff A, VPQ. During the interview, she stated the take down was unnecessary and Staff E BHT, Staff F RN and Staff G BHT were sent home and taken off the schedule during the timeframe of the investigation. After investigating and reviewing the video footage, Staff E, BHT, Staff F, RN and Staff G, BHT were terminated. Review of Patient #2 medical record revealed the patient was admitted on 09/13/2023 for alcohol abuse and generalized anxiety. Review of nurse’s notes on 09/13/2023 revealed Patient #2 was admitted on a voluntary basis seeking help with alcohol detoxification. Patient #2 uses a cane for assistance with ambulation. Review of nurse’s notes on 09/14/2023 revealed Patient #2 was observed on video falling to the ground because another patient had pushed him, and subsequently complained of neck pain. Patient #2 was taken to an acute care hospital for evaluation. Review of Physician notes on 09/18/2023 revealed Patient #2 had to be reminded he experienced a fall and that he was sent out to an acute care hospital for evaluation and was sent back to facility with no concerns. Patient #2 verbalized concerns that he may have early signs of dementia stating that he will not drive himself as he is afraid he will get lost. Patient #2 reports his sister has dementia. On 01/31/2024, review of video footage with no audio from 09/14/2023 with Staff A VPQ was conducted. Video shows Patient #2 walking down the facility hallway with his cane for assistance. At the end of the hallway, Patient #2 is seen walking into another patient’s room. He is then seen falling back to the ground and the other patient is standing over him with Patient #2’s cane. Then staff is seen running down the hallway toward the patient. On 01/31/2024 at 11:00 AM, an interview was conducted with Staff A, VPQ. During the interview, Staff A, VPQ stated when we investigated the incident, the staff said Patient #2 was known to pace the hallways and sometimes even wander into other patients’ rooms. The staff also said they knew the other patient at the end of the hallway was in his room and was agitated. When Patient #2 walked down the hallway, he wandered into the agitated patient’s room and that patient got up and pushed Patient #2 down for coming into his room. The staff was not watching Patient #2 carefully when he walked down towards the agitated patient’s room. Review of patient #3 medical record revealed patient was a 15-year-old patient admitted on 11/10/2023 for Bipolar Disorder, severe depression and suicidal ideation. Patient #3 ordered visual observation, 1:1 (For patients identified as high risk for suicide who have access to ligature or other safety risks, constant 1 to 1 visual observation must be implemented.) at all times. Review of physician’s notes from 11/11/2023 showed Patient #3 stated “I wanted to kill myself”. Patient #3 admits to swallowing a loose piece of metal that was lying around her bathroom and experienced abdominal pain. Patient #3 then states prior to swallowing the metal, she also swallowed glass. Patient #3 was transferred to this facility after being medically cleared at an acute care hospital. Review of nurse’s notes revealed on 11/17/2023 Patient #3 came to staff at the medication window and stated, “I’ve done something bad, but not to anyone else, just myself.” When asked what Patient #3 did, she stuck her tongue out and revealed 8-10 staples. Patient #3 was advised multiple times to spit the staples out, but she stated she did not want to and wanted to hurt herself. Patient #3 then walked away from the medication window and went to sit near a window. When approached by another staff member to spit the staples out, Patient #3 stated “I will not. I want to kill myself, and by any means necessary, I will, and you cannot stop me.” Patient #3 then swallowed the staples. The Physician was notified, and Patient #3 was transferred to an acute care hospital for evaluation. Review of physician notes on 11/18/2023 reveals, Patient #3 was sent out last night after showing numerous staples in her mouth to staff and then proceeded to swallow them before staff could intervene. Patient #3 was transferred to an acute care facility for evaluation and was medically cleared. Upon return, Patient #3 states she found the staples in coloring books on the unit. On 01/31/2024, review of video footage with no audio from 11/17/2023 with Staff A, VPQ and Staff C, OM (Operations Manager) was performed. Based on video surveillance, Patient #3 is seen sitting at a table with 2 other patients placing multiple things in her mouth and not spitting them back out. Staff C, OM verifies a behavioral health technician is sitting in the corner of the room watching Patient #3 and not stopping her. On 01/31/2024 at 11:00 AM, an interview was conducted with Staff A, VPQ. Staff A stated when we investigated the incident, we discovered the therapy intern brought in magazines/pamphlets that were held together by the staples and left them in the day room. Her reasoning for bringing them in is for an art project. The therapy intern did not think about the staples being a safety issue for the patients. On 01/31/2024 at 01:45 PM, a follow up interview was conducted with Staff C, OM. Staff C, OM stated Staff A, VPQ asked me to review the video. The video shows Patient #3 sitting at a table with 2 other patients. They seem to be talking, laughing, coloring with markers and dancing in their seats; there is no audio unfortunately. Throughout the video, you can see Patient #3 putting things in her mouth and not spitting anything back out. The behavioral health technician is not in the view, but I was told she is sitting in the corner of the room watching them. She did not stop the patient from putting things in her mouth. On 01/31/2024 at 02:00 PM, an interview was conducted with Staff A VPQ. Staff A stated after reviewing the incident plans for Patient #1, #2 and #3, I am now seeing there was no plan put into place to prevent any of the incidents from occurring in the future. During that time, there was no Risk Manager, so I was acting as the VP Quality and the Risk Manager. There were people helping me with the risk manager role, but I know was ultimately responsible as the risk manager. The people helping with the role were the ones that completed the incident plans, and I did approve them. I did the best I could covering both roles. On 02/01/2023 at 12:47 PM, an interview was conducted with Staff H Director of Nursing (DON). Staff H states based on the review of the incidents that occurred, I’ve been brainstorming and have come up with some ideas that we could utilize in the future Some of these ideas include better management of patients that are on 1 to 1 observation, immediate notification and discussion for events with safety concerns, reminders to staff to remove items brought in to the patient day room when they leave, and reviewing safety competencies quarterly instead of annually. Review of Inpatient Quality and Safety Agenda meetings from June 2023 to January 2024 revealed no mention of patient safety events or action plans.”