Ridgeview Institute Monroe

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 47718 Based on staff interviews, record review, and a review of policies and procedures, it was determined that the facility failed to ensure that one of four patients (P) (P2) reviewed received meals that were free of foods which the patient was allergic, when P2 was allowed to have a snack of yogurt that contained an allergen. This resulted in P2 having a reaction requiring a medication. Findings included: A review of the facility’s policy titled, “Patient Rights and Notice of Privacy Rights,” policy #PI714, last revised January 2026, revealed that the facility will strive to abide by and respect all patient rights without regard to race, religion, creed, ethnicity, gender, age, sexual orientation, or handicap, should support and protect the fundamental human, civil, constitutional, and statutory rights of the individual patient, and always recognize and respect the personal dignity of the patient. A review of the facility’s policy titled, “Food Allergies,” policy #DT1180, last revised January 2026, revealed that the patient with a food allergy will not receive that food while at the facility. The purpose of the policy is to ensure that any patient with food allergies is not served that specific food while the patient is in the hospital. A review of the facility’s policy titled, “Food Allergies and Alternative Entrees,” policy #DT1125, last revised January 2026, revealed that patients with food allergies will be identified by a red paper wristband. Patients with a red paper wristband will be asked for two patient identifiers before being provided with a meal or a snack. A review of the facility’s policy titled, “Documentation in the Medical Record,” policy #DT1120, last revised January 2026, revealed that the policy is to ensure good written communication between the dietitian, physician/ licensed practitioner/ provider, and auxiliary professional staff. To ensure a consistent method of communication in the patient’s record. To ensure that all information related to nutrition consultations and recommendations is documented clearly and accurately in the electronic medical record. A review of the initial nursing assessment on 02/07/2026, at 07:20 PM, revealed that P2 had a food allergy to pineapple and strawberries with a reaction of itching. A review of the medication administration record (MAR) revealed that Benadryl (medication used to treat allergy symptoms) was administered on 02/08/2026, at 10:51 PM, with an indication of allergic reaction. A review of the daily nursing progress notes on 02/08/2026, at 10:56 PM, revealed that P2 ate a small portion of a yogurt that contained strawberry, which she was allergic to. The provider was notified, and Benadryl 25 mg (milligrams) was ordered and administered. Documentation also revealed that P2’s vital signs were within the normal range after the incident A telephone interview was conducted in the facility’s boardroom on 07/28/2026, at 11:30 AM with Registered Nurse (RN) DD, who stated that a staff member had informed her that P2 had eaten a snack containing a product to which the patient was allergic. RN DD stated that unfortunately, there was no confirmation of how the patient got access to the snack. However, the provider was notified, anti-allergy medication was ordered and administered, and the patient was stabilized. An interview was conducted in the facility’s boardroom on 07/28/2026, at 12:00 PM with Regional Quality Director (RQD) GG, who stated that the Dietary Director ran a list every morning specifically documenting all patients’ allergies and sent it to the team, including the kitchen staff. RQD GG continued to state that if a patient had an allergy, the food would be labelled, and the patient would have a special plate to avoid any mix-up. RQD GG also stated that it was possible that the staff could have accidentally handed over the wrong snack to P2, or the patient could have grabbed the snack from another tray, probably when the staff was attending to another patient. RQD GG stated that there was no concrete evidence on how P2 had access to the snack she was allergic to; however, the staff had undergone re-training to ensure patient safety.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 42060 Based on review of medical records, Governing Body Bylaws, medical records, policy and procedures, and police investigative reports, and staff interviews, it was determined that the Governing Body failed to ensure patients’ safety while receiving care at the facility when 3 (P) (P1, P10, P11) of 17 sampled patients were not monitored as ordered. This failure to provide oversight resulted in 2 (P1, P11) patients being sexually assaulted while under the care of the facility and 1 (P10) patient eloping from the facility. Findings included: Review of the facility Governing Board Bylaws, reviewed 01/2026, Article III, Section 3.1 “General Powers” reveals the affairs of the hospital are managed by the Governing Board. The Bylaws delineate the fact that the Board is ultimately accountable for the quality of patient care, treatment and services. The bylaws state that the Governing Board ensures the safety of patients, staff and others. Cross refer to A044 as it relates to the facility’s failure to ensure a safe environment for P1 and P11. Cross refer to A0385 as it relates to nursing staff’s failure to ensure that patients were monitored as ordered.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42060 Based on review of medical records, policy and procedures, police investigative reports and staff interviews, it was determined that the facility failed to ensure that two patients (P) (P1, P11) of 17 sampled patient’s rights were not promoted and protected while hospitalized, specifically: 1. On 5/27/2025, P1 reported being sexually assaulted by a peer (P8). 2. P11 reported being sexually assaulted on 2/22/2025 by a peer (P14) Findings included: Refer to A0144 as it relates to the facility’s failure to ensure a safe environment for P1 and P11.”

“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: 42060 Based on reviews of medical records, policy and procedures, Police investigative report, and staff interviews, it was determined that nursing staff failed to ensure that patient observation/monitoring was implemented as ordered for 3 (P1, P11) of 17 sampled patients. This failure of nursing staff to provide supervision and oversight resulted in 2 patients (P1, P11) being sexually assaulted by 2 peers (P8, P14) while under the care of the facility; and resulted in P10 eloping from the facility. Findings included: Cross refer to A0398 as it pertains to nursing staff’s failure to conduct observation/monitoring as ordered for P1, P10, and P11.”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 42060 Based on review of medical records, Governing Body Bylaws, medical records, policy and procedures, police investigative reports, and staff interviews, it was determined that the facility failed to ensure that physician orders for observation/monitoring and proper oversight for provided for 3 (P1, P10, P11) of 17 sampled patients when: On 5/27/2025, P1 reported being sexually assaulted on “could not recall the exact date”. Facility staff notified local law enforcement on 5/27/2025 at 7:33PM and P1 was transferred for a sexual assault nursing exam (SANE). A review of the observation/monitoring for P1 from 5/21/2025 through 5/23/2025 revealed five instances in observation monitoring were P1’s observation checks were 30 minutes or more past every 15 minutes as ordered. On 11/21/2024 at 9:32AM, local law enforcement was notified that P10 had eloped from the facility. A review of P10’s record revealed that observation/monitoring was ordered for every ten minutes. A review of the medical record failed to reveal documentation monitoring on 11/21/2024 from 6:54AM and 8:30AM. Law enforcement located P10 and returned him to the facility. On 2/23/2025, P11 reported that she had been sexually assaulted on 2/22/2025 between 7:45PM and 8:45PM. The record indicated that a staff member notified local law enforcement; however the law enforcement report indicated that a family member notified law enforcement on 2/23/2025. On 2/23/2025, law enforcement responded and transported P11 to a local acute care emergency room for an assessment. A review of P11’s observation/monitoring revealed that P11’s location was not noted on 2/22/2025 between the hours of 8:06PM and 8:55PM. Observation/monitoring was ordered every 10 minutes. Findings included: Refer to A0115 as it relates to the facility’s failure to ensure care in a safe setting. Refer to A0385 as it relates to the facility’s failure to ensure that patients were monitored as ordered.”

“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: 42060 Based on review of medical records, policy and procedures, police investigative report, and staff interviews, it was determined that the facility failed to ensure that patients’ rights to receive care in a safe environment were promoted and protected when two of 17 sampled patients (P) (P1, P11) were not properly monitored. This failure resulted in the two female patients (P1, P11) being sexually assaulted by two male patients (P8, P14) while under the care of the facility. Findings included: 1. A review of P1’s medical record revealed that she was a 12-year-old female when she was admitted to the facility on 05/19/2025, with a diagnosis of Suicidal Ideation (SI) (thoughts of harming one’s self). A further review of the provider’s orders revealed that P1’s level of observation was every 15 minutes (Q15). A review of the psychiatric evaluation documented by the provider on 05/20/2025, at 10:13 AM, revealed that P1 was placed on the following precautions while at the facility: unit restriction, suicide, self-harm, and sexually acting out. Review of P1’s observation time intervals from 05/21/2025 00:00 (12:00 AM) to 05/23/2025 23:59 (23:59 PM), revealed five gaps in observation where P1’s safety check was over 30 minutes or more past the ordered Q15. A review of the nursing narrative on 05/27/2025, at 19:33 (7:33 PM), revealed that the registered nurse (RN) called law enforcement to report an alleged sexual intercourse involving P1. A review of the Memorandum to Transfer on 05/28/2025, revealed that P1 was transferred to a facility on 05/27/2025, at 00:00, to have a sexual assault nursing exam (SANE) for having vaginal intercourse with a peer. P1 denied anal intercourse and could not recall the exact date but believed it happened two, three or four days ago, at night. P1’s journal was found, with P1 reporting being sexually assaulted by a peer. A review documented by the Nurse Practitioner (NP) KK, revealed that P1 was transferred out to medical care for a SANE on 05/28/2025, at 14:37 (2:37 PM). A review of the daily nursing note documented by the psychiatry nurse on 05/28/2025, at 4:20 PM, noted that it was reported to the doctor that P1 allegedly had inappropriate sexual contact with a male peer. Law enforcement was notified, and a case number was filed. P1 was taken to a facility to be evaluated for sexual assault. P1 was tested for sexually transmitted disease and a sexual assault rape kit performed. A review of medical service notes on 05/29/2025, at 11:20 AM, revealed that P1 was sent for a SANE procedure and was treated prophylactically for sexually transmitted diseases. A review of medical service progress notes on 06/02/2025, at 10:39 AM, by the NP, revealed that P1 was to follow up with her primary medical doctor within two weeks. P1 was instructed to call 911 for any emergencies. A review of the discharge summary signed on 06/19/2025, at 15:27 (3:27 PM), revealed that P1 was discharged home with her department of family and children’s services (DFCS) case worker on 06/03/2025. Copies of the SANE report were requested and denied by local law enforcement and the SANE provider. 2. A review of P8’s medical record revealed that P8 was a 16-year-old male when he was admitted to the facility on 05/16/2025, with a diagnosis of SI. A continued review revealed that P8 had the appropriate intake assessment, and psychiatric evaluation. A review of the progress notes on 05/21/2025, at 6:56 AM, revealed that P8 was agitated and jumped over the counter in the nursing station because he wanted to be with P1. P8 kissed P1 in the nursing station. A review of the providers’ orders revealed that P8 was ordered to be observed Q15. A continued review of P8’s safety checks revealed that there were five gaps where P8 was observed 30 or more minutes past the ordered Q15, between 05/21/2025 00:00 to 05/23/2025 11:59. A review of the discharge notes on 05/26/2025, at 12:01 PM, revealed that P8 would be discharged home on 05/26/2025 with his family member. 3. Review of medical record revealed P11 was a 19-year-old female. She was admitted at the facility on 02/22/2025, at 01:02 AM for suicide attempt by overdose. P 11 reported she consumed eight Benadryl pills the night before and went to sleep. P11 was referred to Psychiatrist to evaluate for hospitalization. The facility Psychiatrist recommended that P11 be placed on 1013 (involuntary psychiatric evaluation and emergency mental health treatment of individuals who pose a danger to themselves or others) and admitted as an inpatient with a diagnosis of: Severe Major Depression. Further review of P11’s medical record indicated that she was on Q10 minutes surveillance. P11 was classified as “High Risk”, Suicide. Review of Incident Report revealed that on 02/22/2025, P11 reported that between the hours of 7:45 PM, and 8:45 PM, male patient (P14) came to her room after she came out of the shower and sexually assaulted her by kissing her mouth and her breast and ejaculating in a washcloth before exiting her room. P11 reported the incident to staff the next day, and P11 was sent to the emergency department (ED) for evaluation. Director of Quality (DQ) PP documented in the incident report that the local police were notified for further investigation. Review of County Police Report stated that the police received a call from P11’s family on 02/23/2025, to report the sexual assault. P11’s family explained to police that P11 was afraid to report the incident to facility staff for fear of retaliation. A Detective went to the facility the same day and interviewed P11, who confirmed the incident took place on 02/22/2026, at approximately 8:15 PM, and 8:30 PM, in her room after showering. County Detective transported P11 to a local ED for forensic swabs. On 03/04/2025, P14 was arrested and brought to the police station for interview. P14 confessed he sexually assaulted P11 while both were patients at the facility. A DNA sample was taken from P14, and P14 was transported to county jail. Review of “Safety Check” dated 02/22/2025, showed that Mental Health Technicians (MHT) were checking the patient’s location every 10 minutes between 7:01 PM to 8:05 PM. The record documented that P11 was in the activity room; and from 8:06 PM to 8:55 PM, for a total of 51 minutes, there was no documentation of P11’s location. Observation resumed from 9:04 PM to 9:36 PM, and MHT documentation stated that P11 was in her room in bed. 4. Review of the medical record revealed P14 was 46-year-old male who was admitted on 02/13/2025, at 9:43 PM, with a chief complaint of SI with plan to jump of a bridge. P1 had a history of homelessness, and schizoaffective disorder (a chronic mental health condition defined by a combination of psychotic symptoms, like hallucinations or delusions, and mood disorder symptoms such as depression or mania. P14 reported auditory and visual hallucinations. P14’s drug screen was positive for amphetamines (a strong central nervous system stimulant drug that speeds up brain activity and increases alertness). P14 was admitted into acute inpatient psychiatric and substance use treatment. P14 was placed on a 1013 status, and Q10 minutes level of surveillance. P14 was classified as “High Risk, Suicide”. Review of “Safety Check” record dated 02/22/2025, showed that MHTs were checking the patient’s location Q10 between 7:00 PM and 10:00 PM. The record documented P14 was in the Day Room between 6:56 PM to 9:51 PM. Review of policy number PI:714, titled, “Patient Rights and Notice of Privacy, last revised 01/2026, indicated that it is the policy of the hospital to ensure that all patients receive a copy of the Patient’s Bill of Rights & Responsibilities form, as well as an oral explanation of those rights, both in their primary language and in simple non-technical terms. The hospital will strive to abide by and respect all patient rights without regard to race, religion, creed, ethnicity, gender, age, sexual orientation, or handicap and shall support and protect the fundamental human, civil, constitutional and statutory rights of the individual patient and always recognize and respect personal dignity of the patient. The policy listed a list of rights that are guaranteed to all patients admitted at the facility. The policy delineates these patients’ rights among others; rights: · to be free of abuse and neglect. · to receive care in a safe setting. · to be treated with respect, dignity and comfort in an emotionally safe environment. · Review of policy, NR# 13080, titled, “Observation Levels Including one to one Procedure,” effective date, 08/2025 indicated it is the policy of the hospital to provide a safe and secure environment for patients during their hospitalization. The policy indicates that the purpose of levels of patient observations is a recognized method for providing a safe and secure environment for the patient who presents requiring a system of progressive intensity of patient observation and oversight. Under Scope: The policy states that it applies to all staff members who perform care, treatment, and services for individuals that monitor patients to maintain the safety of each patient and provided by a system of progressive intensity of patient observation and oversight. Review of policy RN#: 13107, titled, “Precaution: Sexual Acting Out, SAO,” last reviewed 01/2026, revealed it is the policy of the facility to provide an increased level of observation/safety for patients with a clinically relevant history of sexually acting out behavior. The policy states that a patient with history of sexual acting out will remain on SAO precautions throughout his/her hospitalization. Patient on Sexual Acting Out precautions shall be observed every 15 minutes. Review of document titled, “Monroe Police Department Criminal Investigation Division” Investigative Report, Case Number: 25M011269,” revealed that city police detective received a call that P1 was sexually assaulted. On 05/28/2025, a SANE test was conducted in a specialized clinic. The result indicated that P1 was anally penetrated. An interview between P1, City Police Detective, and DFCS representative took place on 10/09/2025, at “approximately” 1:00 PM. P1 stated that she was threatened by P8 and that P8 made her do it. P1 gave a physical description of the male (P8) that committed the act. P1 said she did not tell anyone about the incident. P1 stated that the staff went through her journal and discovered the note that she had written about this incident. During the interview, P1 stated that he (P8) did it back there, indicating in her anus, according to the investigative report. regulatory concern was detected at the time. An interview with NP KK took place on 07/02/2026 at 2:01 PM in the conference room. NP KK discharged P11. NP KK said she did not recall any sexual allegations that took place over a year ago. She said she did not remember P11 at all. NP KK said she reported by policy all sexual allegations to the attending physician in charge of the patient, and Risk Management as well. NP KK stated that the protocol for patients reporting victim sexual aggression was to send the patient to the hospital for testing. An interview with RN NN took place on 07/02/2026, at 3:00 PM, in the conference room. RN NN stated that the nurse reported all sexual allegations to nursing Supervisor, including any form of physical and verbal violence. RN NN said the nurse interviewed any patient that made allegations of sexual and physical violence. RN NN said she was also to notify the parents (if the patient was a minor), and the CNO (Chief Nursing Officer) if necessary. RN NN said if the patient said she/he was a victim of rape; they sent the patient to the hospital for medical evaluation and testing. A phone interview with former facility Assistant Chief Nursing Officer (ACNO) QQ on 07/03/2026, at 12:38 PM, ACNO QQ said she did not remember P11 nor the associated sexual allegation because it was a long time ago. ACNO QQ added that they investigated all sexual allegations and alerted the local police if there was any credible evidence that sexual aggression took place. A phone interview with Mental Health Technician (MHT) EEE took place on 07/06/2026, at 2:10 PM. MHT EE did not recall the sexual allegation brought by P11. MHT EEE said that was the first time she heard of the allegation. She said she just did not remember something that took place a year ago, and even P11’s name did not mean anything to her. MHT EEE revealed staff watched patients closely and reported any form of abuse to the nurse. A phone interview with MHT FFF took place on 07/07/2026, at 11:00 AM. MHT FFF revealed she just did not recall P11 and the allegation. MHT FFF said something that took place more than a year ago did not ring a bell. MHT FFF only added that all forms of assaults, staff reported to the nurse, and the nurse may decide to separate the patients, if the allegation was serious enough. A phone interview with MHT FF took place on 07/07/2026, at 11:08 AM. MHT FFF indicated she just did not recall P11 and the allegation. MHT FF said sexual and physical aggression was more common in the adolescent units than in the adults and mostly worked in the adolescent unit. MHT FF said she did not know anything about the situation involving P11.”

“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: 42060 Based on reviews of medical records, policy and procedures, Police investigative report, and staff interviews, it was determined that nursing staff failed to ensure that observation of patients was implemented as ordered for 3 (P1, P11) of 17 sampled patients. This failure of nursing staff to provide supervision and oversight resulted in the two female patients (P1, P11) being sexually assaulted by two male patients (P8, P14) while under the care of the facility; and resulted in P10 eloping from the facility. Findings Included: A review of Patient (P)1’s medical record revealed that she was a 12-year-old female when she admitted to the facility on 05/19/2025 with a diagnosis of Suicidal Ideation (SI). A further review of the provider’s orders revealed that P1’s level of observation was every 15 minutes (Q15). A review of the psychiatric evaluation documented by the provider on 05/20/2025 at 10:13 AM revealed that P1 was placed on the following precautions while at the facility; unit restriction, suicide, self-harm, and sexually acting out. Review of P1’s observation time intervals from 05/21/2025 00:00 to 05/23/2025 23:59 revealed five gaps in observation where P1’s safety check was over 30 minutes or more past the ordered Q15. A review of the nursing narrative on 05/27/2025 at 19:33 revealed that the registered nurse called law enforcement to report an alleged sexual intercourse involving P1. A review of the Memorandum to Transfer on 05/28/2025 revealed that P1 was transferred to a facility on 05/27/2025 at 00:00 to have a sexual assault nursing exam (SANE) for having vaginal intercourse with a peer. P1 denied anal intercourse and could not recall the exact date but believed it happened two, three or four days ago at night. P1’s journal was found with P1 reporting being sexually assaulted by a peer. A review documented by the nurse practitioner (NP KK) revealed that P1 was transferred out to medical care for SANE on 05/28/2025 at 14:37. A review of the daily nursing note documented by the psychiatry nurse on 05/28/2025 at 4:20 PM noted that it was reported to the doctor that P1 allegedly had inappropriate sexual contact with a male peer. Law enforcement was notified, and a case number was filed. P1 was taken to a facility to be evaluated for sexual assault. P1 was tested for sexually transmitted disease and a sexual assault rape kit performed. A review of medical service notes on 05/29/2025 at 11:20 revealed that P1 was sent for a SANE procedure (a forensic test conducted in a specialized clinic in cases of sexual assault) and was treated prophylactically for sexually transmitted diseases. A review of medical service progress notes on 06/02/2025 at 10:39 AM by the Nurse Practitioner revealed that P1 was to follow up with her primary medical doctor within two weeks. P1 was instructed to call 911 for any emergencies. A review of the discharge summary signed on 06/19/2025 at 15:27, revealed that P1 was discharged home with her department of family and children’s services (DFCS) case worker on 06/03/2025. Review of medical record revealed P11 was a 19-year-old female. She was admitted at the facility on 02/22/2025 at 01:02 AM. for Suicide attempt by overdose. Further review of P11’s medical record indicates that she was on Q10 minutes surveillance. P11 was classified as “High Risk”, Suicide. Review of Incident Report revealed that on 02/22/2025 P11 reported that between the hours of 7:45 P.M. and 8:45 P.M., male patient (P14) came to her room after she came out of the shower and sexually assaulted her by kissing her mouth and her breast and ejaculating in a washcloth before exiting her room. P11 reported the incident to staff the next day, and P11 was sent to the emergency department for evaluation. Director of Quality (DQ PP) documented in the incident report that the local police was notified for further investigation. Review of County Police Report stated that the police received a call from P11’s family on 02/23/2025 to report the sexual assault. P11’s family explained to police that P11 was afraid to report the incident to staff facility for fear of retaliation. Detective went to the facility the same day and interviewed P11 who confirmed the incident took place on 02/22/2026 at approximately 8:15 P.M. and 8:30 P.M. in her room after shower. County Detective transported P11 to a local ED for forensic swabs. On 03/04/2025, P14 was arrested and brought to the police station for interview. P14 confessed he sexually assaulted P11 while both were patients at the facility. DNA sample was taken from P14, and P14 was transported to County jail. Review of P11’s “Safety Check” dated 02/22/2025 record showed that mental health tech (MHT) was checking the patient’s location every 10 minutes between 7:01 P.M. to 8:05 P.M. The record documented P11 was in the activity room; and from 8:06 P.M. to 8:55 P.M. for a total of 51 minutes, there was no documentation of P11’s location. Observation resumed from 9:04 P.M. to 9:36 P.M. and MHT documentation stated that P11 was in her room in bed. A review of medical record reveals that P10 was a 31-year-old male who came to the facility on 11/12/2024 for severe Psychosis, agitation, disorganized, poor impulse control. P10 was put on a 1013 status. Urine drug test was positive for Marijuana. P10 was admitted for psychosis. P10 was under Q10 minutes supervision. Review of safety Check dated 11/21/2024, revealed a 96-minute gap between 6:54 A.M. and 8:30 A.M. Progress notes indicated “ Unit disruption “ . On 11/21/2024 at 9:32 A.M. Police received a 911 call coming from the facility. P10 was reported walking out of the gate and did not return. Police searched the area, found the patient in the neighborhood, and returned him back to the facility. Review of policy, NR# 13080, title Observation Levels Including one to one Procedure, effective date: 08/2025 states it is the policy of the hospital to provide a safe and secure environment for patients during their hospitalization. The policy indicates that the purpose of levels of patient observations is a recognized method for providing a safe and secure environment for the patient who presents requiring a system of progressive intensity of patient observation and oversight. Under Scope: The policy states that it applies to all staff members who perform care, treatment, and services for individuals that monitor patients to maintain the safety of each patient and provided by a system of progressive intensity of patient observation and oversight. The policy indicates the Registered Nurse will assign staff to perform the standard observation level on a designated set of patients. Patients placed on Line of Sight (LOS) or One to One will be assigned specific staff. The Nurse will arrange for staff to be relieved for breaks and meals. Review of policy RN#: 13107, title “Precaution: Sexual Acting Out, SAO”, last reviewed 01/2026 revealed it is the policy of the facility to provide an increased level of observation/safety for patients with a clinically relevant history of sexually acting out behavior. The policy states that a patient with history of sexual acting out will remain on SAO precautions throughout his/her hospitalization. Patient on Sexual Acting Out precautions shall be observed every 15 minutes. Review of document title “Monroe Police Department Criminal Investigation Division” Investigative Report, Case Number: 25M011269 stated that city police detective received a call that P1 was sexually assaulted. On 05/28/2025 a SANE (sexually assault nurse examiner; it is a forensic test conducted in cases of sexual assault) test was conducted in a specialized clinic. The result indicated that P1 was anally penetrated. An interview between P1, City police Detective, and DFCS representative took place on 10/09/2025 at “approximately” 1:00 P.M. P1 stated that she was threatened by P8 and that P8 made her do it. P1 gave a physical description of the male (P8) that committed the act. P1 said she did not tell anyone about the incident. P1 stated that the staff went through her journal and discovered the note that she had written about this incident. During the interview, P1 stated that he (P8) did it back there, indicating in her anus, according to the investigative report. regulatory concern was detected at the time. An interview with Nurse Practitioner (NP) KK took place on 07/02/2026 at 2:01 P.M. in the conference room. NP KK discharged P11.NP KK said she did not recall any sexual allegations that took place over a year ago. She said she did not remember P11 at all. NP KK said she reported by policy all sexual allegations to the attending physician in charge of the patient, and Risk Management as well. NP KK stated that the protocol for patients reporting victim sexual aggression was to send the patient to the hospital for testing. An interview with RN NN took place on 07/02/2026 at 3:00 P.M. in the conference room. RN NN stated that the nurse reported all sexual allegations to nursing Supervisor, including any form of physical and verbal violence. RN NN said the nurse interviewed any patient that made allegations of sexual and physical violence. RN NN said she was also to notify the parents (if the patient was a minor), and the CNO if necessary. RN NN said if the patient said she/he was a victim of rape; they sent the patient to the hospital for medical evaluation and testing. A phone interview with former facility Assistant Chief Nursing Officer (ACNO) QQ on 07/03/2026 at 12:38 P.M. ACNO QQ said she did not remember P11 nor the associated sexual allegation because it was a long time ago. ACNO QQ added that they investigated all sexual allegations and alerted the local police if there was any credible evidence that sexual aggression took place. A phone interview with Mental Health Technician (MHT) EEE took place on 07/06/2026 at 2:10 P.M. MHT EE did not recall the sexual allegation brought by P11. MHT EEE said that was the first time she heard of such allegation. She said she just did not remember something that took place a year ago, and even P11’s name did not mean anything to her. MHT EEE said staff watched patients closely and reported any form of abuse to the nurse. A phone interview with MHT FFF took place on 07/07/2026 at 11:00 A.M. MHT FFF said she just did not recall P11 and the allegation. MHT FFF said something that took place more than a year ago did not ring her bell. MHT FFF only added that all forms of assaults, staff reported to the nurse, and the nurse may decide to separate the patients, if the allegation was serious enough. A phone interview with MHT FF took place on 07/07/2026 at 11:08 A.M. MHT FFF said she just did not recall P11 and the allegation. MHT FF said sexual and physical aggression was more common in the adolescent units than in the adults and mostly worked in the adolescent unit. MHT FF said she did not know anything about the situation involving P11.”

“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: 50617 Based on review of policy titled “Medication Administration/Downtime Process,” record review, and staff interviews, it was determined that the facility failed to ensure medications were administered as ordered; provider was notified of missed medication; and missed medications were documented in the medical record for one (P2) of two sampled patients. Findings Included: Review of the facility policy titled “Medication Administration/Downtime Process,” policy NR#13070, last revised 01/2026, revealed medications eligible for scheduled dosing included anticonvulsants. The policy further stated all missed medications, and late administrations must be reported to the physician/licensed practitioner/provider, pharmacist, and included in reports submitted to the PI Director by the CNO. The policy also required documentation of the reason for missed doses and actions taken. A review of P2’s Medication Administration Record (MAR) revealed Clobazam (Onfi), an anticonvulsant medication, was ordered 15 milligrams (mg) by mouth twice daily (BID). Review of the MAR revealed the following missed medication doses: On 05/04/2026 at 2100, RN MM documented that Clobazam (Onfi) was not administered because it was unavailable. Medical Nurse Practitioner (MNP) SS was notified and ordered Ativan (used to treat anxiety disorders, insomnia, alcohol withdrawal, and active seizures) PRN (as needed). Continued review of the MAR failed to reveal that Ativan was administered on 05/04/2026. Review of the medical record failed to reveal documentation that P2’s family was notified of the missing medicine. On 05/05/2026 at 2100, Registered Nurse (RN) NN documented that Clobazam (Onfi) was unavailable in the Omnicell medication dispensing system. Review of the medical record failed to reveal documentation that the provider and P2’s family were notified of the missed medicine. During an interview conducted on 05/12/2026 at 3:06 PM Assistant Chief Nursing Officer (ACNO) BB stated she was unaware P2 had missed seizure medication for two consecutive days. ACNO BB stated nursing staff were primarily psychiatry-focused and acknowledged re-education was needed. ACNO BB further acknowledged there was a lack of documentation in P2’s medical record During a phone interview conducted on 05/13/2026 at 1:40 PM RN MM stated P2’s seizure medication had initially been supplied from the patient’s own prescription bottle because the medication needed to be ordered. RN MM stated she later discovered the bottle was empty and Onfi was not available in the Omnicell. RN MM stated she searched other Omnicell systems and requested assistance from another nurse; however, the medication could not be located. RN MM stated she notified MNP SS, who provided a telephone order for Ativan PRN and stated she would evaluate P2 the next day. RN MM further stated she attempted to contact P2’s mother without success but was unsure whether an incident report had been completed. During a phone interview conducted on 05/13/2026 at 1:57 PM, RN NN stated she was unable to locate Onfi in the Omnicell on 05/05/2026 and informed the Nurse Practitioner but did not document the notification in the medical record and could not recall the Nurse Practitioner’s name. RN NN stated she had spoken with P2’s mother earlier that day and believed the medication was available; therefore, she did not contact the mother again when the medication could not be administered. RN NN acknowledged she did not complete an incident report regarding the missed anticonvulsant medication dose.”

“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: 47718 Based on review of medical records, observations, policy and procedures, and staff interviews, it was determined that the facility failed to provide quality care in a safe environment. Specifically, the facility’s staff failed to detect contraband (vape) on one patient (P) (P#5) of five patients (P#1, P#2, P#3, P#4, P#5) reviewed. Failing to detect contraband has the potential to jeopardize the safety of the patients on the unit. Findings include: A review of P#5 ’ s medical record revealed that P#5 was admitted to the facility voluntarily on 1/27/26 at 2:35 p.m. A review of the plan of care on 1/30/26 at 8:53 a.m. revealed that continued inpatient psychiatric treatment, close safety monitoring, and supportive interventions addressing psychosocial stressors were indicated to promote stabilization and ensure safety. A continued review of P#5 ’ s medical record revealed that a nursing assessment: Body Check/Safety Check was done by Mental Health Technician (MHT) II and Registered Nurse (RN) GG on 1/27/26 at 5:15 p.m. Documentation failed to reveal contraband was noted during the body check on admission. A review of the nursing progress notes on 1/28/26 at 5:07 a.m. revealed that a mental health technician (MHT) found a THC vape (a device that heats cannabis oil or extract, containing tetrahydrocannabinol) in P#5’ s bra. The nurse practitioner and P#5’s family member were notified P#5 required frequent redirection. A review of the facility’s policy titled “ Admission of Patient to the Unit, “ policy #NR13006, last revised 1/2026, revealed that the facility’s unit staff would complete clothed or unclothed body inspection as ordered by physician/ licensed practitioner/ provider, using caution to prevent accidental blood-borne exposure through contact with sharps, if present. Would send any restricted or dangerous items home whenever possible. Utilized caution in examining contents of purse, pockets, etc. by having Patient empty contents of purse, pocket, etc. onto a countertop to avoid accidental bloodborne exposure through contact with sharps. Would collect any electrical items that will be needed during their stay. An interview was conducted in the facility’s conference room on 2/10/26 at 10:00 a.m. with Nurse Practitioner (NP) CC, who stated that the staff was able to collect the vape from P#5 when her peers reported that she had one, and the vape was confiscated. An interview was conducted in the facility’s conference room on 2/10/26 at 10:30 a.m. with Director of Clinical Services (DCS) HH, who stated that she had spoken to P#5 after a couple of incidents and an allegation from another patient that P#5 had asked the other patient to touch her private area, but P#5 denied all allegations. An interview was conducted in the facility’s conference room on 2/10/26 at 11:00 a.m. with Registered Nurse (Intake), RN EE, who stated that the facility’s staff wanded patients at intake to detect metals, collected belongings and kept them in a safe place. RN EE continued to state that patients were not completely stripped, especially adolescents, to preserve their dignity. However, another check was done when the patient got to the unit. An interview was conducted in the facility’s conference room on 2/10/26 at 11:30 a.m. with Registered Nurse (RN) GG, who stated that a body check was done when patients got to the unit; however, patients were not completely stripped, and were only asked to flip their underwear, and bend and cough just in case they were hiding anything in the private area. An interview was conducted in the facility’s office on 2/10/26 at 1:15 p.m. with Director of Risk (DR) JJ, who stated that the body check for adolescents were less intrusive, and the facility’s staff instructed adolescents to pop their bra up and did not completely strip them to preserve the adolescent’s dignity. A telephone interview was conducted on 2/10/26 at 2:00 p.m. with Mental Health Technician (MHT) KK, who stated that a THC vape was found on P#5. The nurse practitioner was notified, and the incident was documented on the log.”

“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: 52783 Based on interview, record review, and facility policy review, the facility failed to obtain consent from the Power of Attorney (POA) for 1 (Patient #1) of 10 sampled patients reviewed for informed consent. Findings included: A facility policy titled, “Informed Consent for Care, Treatment & Services,” reviewed/revised 01/2025, revealed, “3. Procedure - a. Informed consent must be given by the legally authorized representative of a patient admitted under the voluntary or involuntary statues, or by the patient himself if he meets the following criteria: b. Legal Capacity - The patient is an adult and has not been adjudicated incompetent to manage his personal affairs by an appropriate court of law; c. Receipt of Information - The person giving the consent has been informed of the nature, purpose, risks, and benefits of specific care, treatment, & services. d. Voluntariness - The consent has been given voluntarily Information required to be given: Before providing specific care, treatment, & services to any patient the treating physician/licensed practitioner/provider shall explain to the patient and/or the patient’s legally authorized representative, the following in a simple, non-technical language. e. The nature of the patient’s mental illness and condition. f. The beneficial effects of the patient’s mental illness and/or condition expected as a result of treatment. g. The probable consequences to the patient of not receiving treatment, as appropriate, unnecessarily prolonged hospital stays, repeated hospital admission, deterioration in the patient’s ability to care for self. h. family, social or work adjustment, and the occurrence or reoccurrence of frightening, painful, or i. incapacitating signs and symptoms of mental illness. j. A description of the proposed course of care, treatment & service. k. An offer to answer any questions concerning care, treatment & service. l. The patient’s right to refuse care, treatment & service at any time. m. Those patients are not here voluntary that are here on an Emergency Detention Order/Involuntary or a court order will follow the court order or law concerning care, treatment, and services.” “Physician Medication Orders,” indicated Patient #1 was admitted to the hospital on 06/21/2025 at 5:19 PM. A nurse’s “Admission” note, dated 06/21/2025 at 5:41 PM, indicated Patient #1 was involuntarily admitted to the hospital with diagnoses of dementia and aggressive behavior and was oriented only to person. “Initial Nursing Assessment: Summary Notes,” dated 06/21/2025 at 5:43 PM, revealed Patient #1 had learning barriers with cognitive capacity, emotional barriers, and impaired thought processes. The Initial Nursing Assessment: Summary Notes revealed, “Pt [patient] presents to [hospital name] d/t [due to] aggression towards caretakers r/t [related to] [the patient’s] memory issues. Pt only responds with single word, nonsensical responses to assessment questions. Per records pt has h/o [history of] Alzheimer’s [a disease that effects memory and the ability to care for one’s self], HTN [high blood pressure], HLD [hyperlipidemia, high fat levels in the blood], Thyroid problems.” An “Intake Assessment: Conservator,” dated 06/22/2025 at 1:04 PM, revealed, “Legal Guardian and Power of Attorney Notes” and included [family member’s name and phone number].” A provider “Medical History and Physical Examination (H&P),” dated 06/22/2025 at 3:48 PM, revealed, “Impression 1. Dementia.” A provider “Psychiatric Progress Note,” dated 06/24/2025 at 4:14 PM, revealed, “Patient is confused, illogical disorganized, patient will continue with 1:1 [one-to-one, continuous observation of one observer to one resident] observation. Patient is unable to care for self, patient is isolating, withdrawn, patient is guarded, requires frequent redirections. Patient’s appetite is poor, patient is irritable, and agitated.” A “Patient Rights and Responsibilities,” form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:13 PM. An “Advance Consent and Assignment for Insurance Benefits,” form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM. An “Agreements and Conditions of Voluntary Admissions,” form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM. A “Professional Services Insurance Authorization and Guarantee,” form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM. An “Advance Directive Acknowledgment for Behavioral Health and Medical Care,” form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM. The form revealed Patient #1 indicated “No” in the boxes “I have executed an Advance Directive for Medical Care” and “I have executed an Advance Directive for Behavioral Health Care.” A “Personal Property Disclaimer,” form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM. A “Consent to Routine Procedures and Treatment,” form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:11 PM. During an interview on 07/23/2025 at 8:20 AM, the Regional Director of Quality stated the POA paperwork for Patient #1 was not received until after the patient was admitted and gave verbal consent. The Regional Director of Quality stated the POA was with the patient in the emergency room and was aware the patient was admitted to the hospital. A review of Patient #1’s medical record failed to reveal documentation that the hospital contacted the POA for consents once the POA paperwork was received.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 52070 Based on observation, staff interviews, and facility policy review, the facility failed to ensure a patient’s right to personal privacy for one patient (P) (P#4) of four patients reviewed for patient rights. The failure resulted in a patient’s medical information being revealed to other patients and staff. Findings included: A facility policy titled “Patient Rights,” reviewed 01/2025, indicated “6. Patient Rights include the following rights” and “d. to care and treatment that is respectful, recognizes a person’s dignity, cultural value and religious beliefs, and provides for personal privacy to the extent possible during course of treatment.” On 01/13/2025 at 10:29 a.m., Registered Nurse (RN) #3 was observed administering medication to P#4. The observation revealed that, when RN #3 could not find P#4’s blood sugar result, RN #3 spoke loudly from a medication room to RN #4 at the nurses’ station and asked for P#4’s blood sugar result. The observation revealed patients were in the hall and standing next to P#4. The observation revealed RN #4 responded with P#4’s blood sugar result. It was observed that RN #3 then gathered supplies and administered insulin to P#4. On 01/13/2025 at 10:35 a.m., RN #3 stated they did not normally ask for patient information when others were around, noting they did not know why they did that. On 01/15/2025 at 8:50 a.m., the Assistant Chief Nursing Officer stated patient privacy was important, noting they expected staff to keep patient information confidential.”

“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: 52070 Based on staff interviews, record review, and facility policy review, the facility failed to ensure medications were administered per the providers orders for one patient (P) (P#1) of four patients reviewed for medication errors. The failure resulted in a patient receiving a medication earlier than ordered with the potential for a negative impact on the medication’s intended therapeutic use. Findings included: A facility policy titled, “The Role of Nursing in Medication Administration,” revised 07/2023, in the section, “b. Medications eligible for scheduled dosing times,” revealed, “(ii) There are two types of ‘eligible’ medications (time-critical and non-time-critical). - Time-Critical (eligible) medications are medications which the early or late administration greater than 30 minutes might cause harm or have a significant negative impact on intended therapeutic or pharmacological effect. Time-critical medications must be administered 30 minutes before or after their scheduled dosing time, for a total window that does not exceed 1 hour. Time critical medications will include Insulin, Levothyroxine, and Warfarin. -Non-time-critical (eligible) medications are those that a longer or shorter interval time since the prior dose does not significantly impact or change the therapeutic effect. -All medications in the non-time critical category shall be administered within 1 hour before or after the scheduled dosing time, for a window that does not exceed 2 hours.” P#1’s “Physician Medication Orders,” for the timeframe from 05/23/2024 through 05/28/2024, contained an order for Haldol (haloperidol, an antipsychotic) 5 mg (milligrams) intramuscularly (IM, injected in the muscle) every four hours (Q4H) as needed (pro re nata, PRN). P#1’s “Physician Medication Orders” contained an order, started 05/23/2024, for Ativan (lorazepam, a benzodiazepine) 2 mg IM Q4H PRN. P#1’s “Physician Medication Orders” contained an order, started 05/23/2024, for diphenhydramine (Benadryl, an antihistamine) 50 mg IM Q4H PRN for extrapyramidal symptoms (EPS, movement disorder) for side effects prevention. A “Medication Administration Record [MAR]” dated for the timeframe from 05/22/2024 through 06/12/2024 revealed P#1 could receive IM Haldol Q4H PRN. The MAR indicated Haldol was administered intramuscularly to P#1 on 05/24/2024 at 5:08 a.m. The MAR indicated another dose of Haldol was administered intramuscularly to P#1 on 05/24/2024 at 8:00 a.m., by Registered Nurse (RN) #2. The MAR documentation indicated that the two doses of Haldol were administered within two hours and 52 minutes (less than four hours apart). A MAR dated for the timeframe from 05/22/2024 through 06/12/2024 revealed P#1 could receive intramuscular Ativan every four hours as needed. The MAR indicated lorazepam was administered on 05/24/2024 at 5:07 a.m. The MAR indicated another dose of lorazepam was administered on 05/24/2024 at 8:00 a.m., by RN #2. The MAR indicated the doses of lorazepam were administered within two hours and 53 minutes (less than four hours apart). A MAR dated for the timeframe from 05/22/2024 through 06/12/2024 revealed P#1 could receive intramuscular Benadryl IM Q4H PRN for EPS prevention. The MAR indicated Benadryl was administered on 05/24/2024 at 5:09 a.m. The MAR indicated another dose of Benadryl was administered on 05/24/2024 at 8:00 a.m., by RN #2. The MAR indicated the doses of Benadryl were administered within two hours and 51 minutes (less than four hours apart). On 01/14/2025 at 11:15 a.m., Medical Doctor (MD) #1 stated that Haldol, Ativan, and Benadryl were time critical medications, and they expected nurses to administer medications per orders or communicate if medications needed to be given earlier than ordered. On 01/14/2025 at 11:52 a.m., Registered Nurse (RN) #2 stated they considered Haldol, Ativan, and Benadryl time sensitive medications, noting they generally administered these medications within an hour of the ordered time. RN #2 stated they tried to administer these medications within 30 minutes of the ordered time and, in the case of P#1, did not remember why the medications were given early. On 01/14/2025 at 4:03 p.m., the Assistant Chief Nursing Officer (ACNO) stated they expected their staff to administer medications in a timely manner, described as between 30 minutes to an hour before or after ordered. The ACNO stated the expectation was for staff to follow orders and to get clarification when needed. The ACNO stated if a medication was ordered for every four hours, but was given at two hours and 52 minutes, it would have to be investigated.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 42060 Based on review of medical records, interviews, and policy and procedures, it was determined that the facility failed to ensure a safe discharge for one (Patient #1) out of five sampled patients reviewed when the facility failed to secure timely and direct communication with the receiving facility that resulted in P#1 being discharged to the wrong location. A review of the medical record revealed Patient #1 (P #1) was transferred to the facility from a local hospital on 10/11/23 at 12:52 p.m. P #1 was on a 1013 (involuntary) status. A review of the Intake Assessment completed on 10/11/23 at 1:27 p.m. revealed that P #1 had a chief complaint of Auditory and Visual Hallucinations (hearing and seeing things that did not exist in reality) and psychosis (a severe mental condition that resulting in loss of contact with external reality). P #1’s appearance was described as disheveled and thought process as disorganized. Program Therapist BB completed the Psychosocial Assessment on 10/12/23 at 11:33 a.m. the current living situation indicated P #1 had lived in a group home for three months and financial hardship was an identified stressor. Community Support and resources were identified as P #1 indicated she was at risk for food insecurity. The assessment indicated P #1 was able to return to the group home after discharge. P #1 stated that her goal was to get back to work and be stable on her medication. Review of “Collateral Notes” from P #1’s medical record indicated the following communication: On 10/23/23 at 4:18 p.m. Therapist (BB) called and spoke with P #1’s group home 1’s coordinator. The group home stated P #1 was okay to return. The coordinator was available to receive P #1 between 12:00 p.m. and 1:00 p.m. On 10/23/23 at 4:25 p.m., Therapist BB called P #1’s parent (was also the guardian) to inform her of upcoming discharge to the group home where she had been living. Therapist BB notes indicated P #1’s guardian stated No; she did not want P #1 to go back to the group home. On 10/24/23 at 11:25 a.m., Therapist BB called and spoke with a community Group Home Placement Coordinator (telephone number on file) to inquire about group home placement for P #1. Placement Coordinator said they may have a placement available in the next few days. Therapist BB was to follow up with placement options. On 10/24/23 at 4:19 p.m., Therapist BB and Director of Clinical Services AA called and spoke with P #1’s parent to inform the parent that P #1 was medically cleared for discharge. P #1’s parent stated P #1 could not return to the previous group home. Staff AA and Therapist BB informed parent that P #1 was medically cleared for discharge and there was no placement available at this time. Staff AA and Therapist BB gave different placement options to P #1’s parent including picking her up while they continued to work on placement. P #1’s parent declined. On 10/24/23, the facility had communication for P #1 to be discharged to a group home with address and phone number. Nursing progress notes dated 10/26/23 at 1:32 a.m. indicated P #1 was stable and medication compliant. Progress notes stated P #1 was cooperative with staff. A Nursing Discharge Note dated 10/26/23 at 8:53 a.m. revealed that P #1 was alert, cooperative, denied suicide ideation, homicidal ideation, auditory and visual hallucinations. Nursing notes revealed that P #1 was discharged with instructions on medications, follow-up care appointment, and P #1 received all her belongings. On 10/26/23 at 8:55 a.m. RN HH completed the Columbia -Suicide Severity rating Scale (C-SSRS) and P #1 was not a suicide risk. On 10/26/23 at 9:44 a.m. Discharge Planner CC requested transportation for P #1 and trip report showed driver dropped P #1 off at address indicated for group home #2 at 11:08 a.m. Communication between group home #2 and the facility indicated P #1 never made it to group home #2 but ended up returning to the previous group home where she resided at the time of admission. During an interview with Program Therapist (BB) on 11/14/23 at 3:20 p.m. in the conference room, Therapist BB explained her role in discharge planning process. Therapist BB said she worked with all patients while they were admitted to inpatient; she established contact with family to get information pertaining to Psychosocial for continuation of care after discharge. Therapist BB said she and her team were mainly involved in post discharge placement. Therapist BB said she saw patients within 24 hours of admission to complete their Psychosocial Assessment and she gathered information that helped determine resources patients in general were going to need once they became stable to leave the facility. Therapist BB said she was the discharge facilitator for P #1. Therapist BB said P #1 came from a group home. Therapist BB said she was in contact with P #1’s father at the beginning of the process because it was difficult to get in touch with P #1’s mother. Therapist BB said that P #1’s mother did not want her to go back to the group home where she came from and once, she was aware of it, she started working on finding placement for P #1. Therapist BB said on 10/25/23 she was able to find a group home that accepted P #1. Therapist BB stated she gave the group home contact person to P #1’s mother for vetting. Therapist BB said she then finalized the transfer with the group home, and it was fine for P #1 to go to the new group home on 10/26/23 (the next day). Therapist BB explained unless P #1’s mother had made payment arrangements, the group home would not have allocated a bed to P #1; therefore P #1’s mother could not say she was not aware of transfer. Therapist BB said P #1 was discharged the next day via Uber Health services (taxi). Therapist BB said the transport service was safe, they had been using them to transport patients for over two years. Therapist BB said she called the group home sometime after P #1 left the facility as a follow-up; that was when the group home administrator told her P #1 had not made it to the group home. Therapist BB said she had ordered staff CC to call the county and file a missing person report. Therapist BB said before that was done, P #1’s mother called the facility to report they had found P #1 near the former group home. During an interview with Discharge Planner (DC) CC on 11/14/23 at 4:00 p.m. in the conference room, he explained that his role in discharge planning process was to start getting patients ready once they were admitted. DC CC explained that the therapists did the Psychosocial Assessment that focused on finding resources for patients such as housing placements. DC CC explained that if placement was difficult, the team started working on placement early in the admission. DC CC said the case of P #1 became complicated when the patient’s mother did not want P #1 to return to the most recent group home although the group home welcomed her to come back. DC CC recalled that the facility learned of this just as the physician wrote the discharge order. DC CC said Therapist BB was able to find a new group home that would take P #1. DC CC stated that Therapist BB informed P #1’s mother because she was the guardian and was responsible to make payment arrangement. DC CC recalled that he arranged for the ride once he received order from Therapist BB. DC CC said one of the techs took P #1 to the vehicle with her belongings. DC CC explained that the facility arranged transportation for patients with no family to pick them up. DC CC said the facility used Uber Health for safety and he had the capacity to monitor the vehicle from the time the driver left the facility until the patient arrived to the final destination. DC CC said he was able to track the vehicle for P #1 and he kept it on record. DC CC said the driver dropped P #1 off at the new group home and P #1 recognized the neighborhood and walked to the former group home located about a mile away. DC CC said when Therapist BB called the group home to check on P #1, they told her that P #1 never made it. DC CC said Therapist BB asked him to call the county police to report P #1 as missing, but P #1 was found minutes later near the former group home. During a second interview with DC CC on 11/16/23 at 11:35 a.m. in the conference room. DC CC confirmed that the morning that P #1 was discharged, Therapist BB asked him to call the group home where P #1 was going to make sure someone was waiting to receive P #1. DC CC said he called the group home after P #1 got in the Uber and nobody answered the phone. DC CC said he left a voice message for the group home administrator. DC CC confirmed that he never had direct communication with the group home administrator. DC CC confirmed the group home administrator never returned his call. During a second interview with Program Therapist BB on 11/16/23 at 11:50 a.m. in the conference room, Therapist BB confirmed she spoke with the group home administrator the morning P #1 was getting discharged, but she could not remember the time. Program Therapist BB said she communicated with the group home administrator that morning via text messages, but she had deleted the messages. Program therapist BB said she was not aware that DC CC did not communicate directly with the group home coordinator; she knew about the lack of direct communication after the facts. Program Therapist BB stated that DC CC did not tell her that he did not speak with the group home administrator although she had asked him to call the group home to let them know P #1 was on her way. Program Therapist BB said she learned about the breakdown in communication after she placed a call to the group home to check on P #1’s arrival status. A review of Policy Number: NR #46, title: “DISCHARGE PLANNING” effective 1/2017, last reviewed 1/2023 revealed the development of a Discharge Plan began on admission. The policy delineated that the Discharge Plan should: a. Prepare the patient and family for the transition to the next level of care. b. Address the patient’s and family’s need for instructions about continued treatment. c. Delineate how progress made in the current level of care was to continue after discharge. d. Identify problems to be addressed in the next level of care. e. Identify the responsibility for ensuring that the prescribed follow-up was accomplished. f. Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care. Review of Policy Number: SS #17, title: “DISCHARGE” effective 1/2017, last reviewed 1/2023 revealed Discharge Planning began the day of admission and continued through-out the treatment. II: PROCEDURE 1. During the initial assessment the client’s discharge plans were discussed. 2. In the development of the Initial Treatment Plan the therapist and client/guardian developed a specific discharge plan. 3. Discharge plans were updated as changes occurred. 4. The discharge plan included but was not limited to: a. Appropriate referrals. b. Activities needed to be conducted to facilitate accessibility to services. c. Assistance needed to resolve obstacles to effective transition back into the community; and d. Involvement with referral sources in discharge planning with consent from the client/ guardian. 5. The client’s family was involved in the discharge planning process, with the client’s consent. 6. The completed discharge plan was signed by the therapist, client/guardian. 7. Upon discharge a copy of the discharge plan was given to the client/guardian. 8. The signed discharge plan was placed in the client’s chart. 9. A discharge order from the physician was obtained.”