Valle Vista Health System

“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: 48061 Based on document review and interview, facility nursing services nursing failed to notify a provider of a patient medication concern in a timely manner and failed to document home medications received and returned to a patient for 1 of 10 medical records revived. (P1) The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing services nursing failed to notify a provider of a patient daily medication concern in a timely manner and failed to document home medications received and returned to a patient for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Medication Reconciliation”, PolicyStat ID 17964504, last revised 04/2025, indicated under PROCEDURE: 1. When a patient is admitted to the hospital, a registered nurse (RN), pharmacist, or pharmacy technician completes the admission section of the Physician/s Admission Orders - Medication Reconciliation in the electronic medical record. This includes a list of the most current medications the patient is taking prior to admission. 2. The Physician will authenticate the admission reconciliation orders either directly to an RN, via telephone order that has been read back and verified, or via HCS. 2. Facility policy titled, “Patient’s Own Medications (POM)”, Policy Stat ID 17879439, last revised 04/2025, indicated under A. PATIENT HOME MEDICATION (PHM) SUPPLY AND STORAGE: 2. Intake /admission places all medication in a sealed security bag labeled, Patients Medication Inventory. a. Intake/admission requirements for home medications noted. b. Patient name is to be written on bag or patient label applied. c. Bag is to be marked with date and name of medication. d. Bag is sealed using security seal. 6. Once orders are entered into HCS for the admitted patient, pharmacy staff will determine the need, if any, for the patient home medication. a. Medications brought to the facility after intake/admission process if completed. i. The front desk staff will identify patient has a ROI. ii. House supervisor is notified the patient has received home medications and follow the Patient Home Medications supply and storage requirements. 3. Review of P1’s MR (Medical Record) from H2 (Psychiatric Hospital) indicated: a. Intake assessment documentation dated 4/28/25 at 2:20 pm indicated P1 had a history of congestive heart failure, atrial fibrillation, and hypertension. P1 was a direct admission from H1 (Acute Care Hospital). P1 was noted to have heart surgery for congestive heart failure in 2018. Admission documentation indicated P1 was admitted to H2 on 4/28/25 at approximately 2:30 pm. b. Nursing note entered by N3 (Registered Nurse) dated 4/28/25 at 9:00 pm indicated P1 had no scheduled medications. Nursing note documentation lacked physician notification related to scheduled home medications. c. Admission home medication orders dated 4/29/25 at 10:25 am indicated MD1 (Medical Doctor) ordered the continuation of P1’s home medications that included jardiance, Amiodarone, and Torsemide. d. P1’s MR lacked documentation of provider notification by nursing staff of patient’s required daily cardiac medications at the time of admission or after on dates 4/28/25 and 4/29/25. e. P1 was emergently transferred to H3 (Acute Care Hospital) on 4/29/25 at approximately 3:30 pm with a heart rate of 145 beats per minute and complaints of atrial fibrillation reported by P1. f. Medication Order documentation dated 4/30/2025 at 9:00 a.m. indicated P1’s home medications: Amiodarone 200 mg tablet to be given orally daily, Torsemide 60 mg given orally twice daily, and Jardiance 10 mg tablet given orally daily were to be started on 4/30/2025. The patient was no longer at H2 when these orders were written. g. MR lacked documentation of receiving and/or returning home medications. 4. Review of P1’s MR from H3 indicated the following: a. EKG (Electrocardiogram) documentation dated 4/29/25 at 4:21 pm indicated P1 had a heart rate of 116 beats per minute. P1’s cardiac rhythm was atrial fibrillation with rapid ventricular response. b. Provider note documentation dated 4/29/25 at 6:51 pm indicated P1 underwent unsynchronized cardioversion with sedation. 5. Incident report documentation dated 4/29/25 at 3:25 pm indicated P1 was emergently sent to H3 with cardiac related concerns for atrial fibrillation, an increased heart rate of 145 beats per minute, and a blood pressure of 147/110 mmHg. 6. Complaint documentation for P1 dated 5/2/25 indicated P1 had concerns that H2 did not return all of the home medications brought to the facility on 4/29/25 by his/her parent. Complaint investigation indicated P1’s misplaced home medication was returned to the patient 5/1/2025 by H2 staff. 7. In interview on 6/9/25 at approximately 12:30 pm with A3 (Director of Nursing) confirmed nursing staff did not follow the home medications policy when receiving or returning P1’s home medications and did not escalate medication reconciliation concerns r/t (related/to) P1’s cardiac medications to a provider at the time of admission or during hospitalization but should have. A3 also confirmed nursing staff did not follow the home medications policy when receiving or returning P1’s home medications, but should have.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, the facility failed to follow their staffing policy and/or grid for 14 of 21 days reviewed on the youth unit. Findings include: 1. Facility policy titled, Staffing and Scheduling, PolicyStat ID 15820124, last revised 05/2024, indicated under PROCEDURE: 1. Planning. a. A plan for meeting staffing needs are developed by the CNO, based on the following: i. patient needs/acuity/census. b. Staffing guidelines are developed by nursing leadership with input from executive leadership. Guidelines serve as a reference point for planning. Staffing is adjusted each shift or more frequently based upon patient acuity, activity level, employee qualifications and census changes. 5. Staffing. A. Staffing numbers and mix for each unit will be reviewed daily and adjusted each shift according to the staffing grid. g. Additional staff coverage is considered when there is a patient on a 1:1 status or is in seclusion/restraint. 2. Facility staffing grid indicated the youth unit should be staffed with 1 nurse from the hours of 7:00 am - 7:30 pm/7:00 pm-7:30 am with a patient census of 1-15, 2 nurses from 7:00 am-7:30 pm/7:00 pm - 7:30 am with a patient census of 16-26. 1 MHT (Mental Health Tech) from 7:00 am-3:30 pm/3:00 pm -11:30 pm/11:00 pm- 7:30 am with a patient census of 1-8. 2 MHTs from 7:00 am-3:30 pm/3:00 pm -11:30 pm/11:00 pm- 7:30 am with a patient census of 9-16. 3 MHTs from 7:00 am-3:30 pm/3:00 pm -11:30 pm with a patient census of 17-26. 2 MHTs 11:00 pm- 7:30 am with a patient census of 17-26. Additional MHT(s) would be needed depending on the number of 1:1 observation patient assignments. 3. Staffing pattern worksheet for H1 was reviewed for dates 9/15/24-10/10/24 indicated the youth unit was not adequately staffed per facility staffing policy and/or grid r/t acuity and census. Dates, number of clinical staff member(s) lacked and patient census are indicated as follows: a. 9/15/24 short 1 MHT (Mental Health Tech) from 7:00 pm - 11:00 pm with a patient census (PC) of 18. 4 MHTs were needed but only 3 MHTs were present. PC included a 1:1 observation. b. 9/16/24 short .5 of an RN (Registered Nurse) from 11:00 pm - 3:00 am with a PC of 17. 2 RNs were needed but only 1.5 RNs were present. PC included a 1:1 observation. c. 9/17/24 short 1 RN from 7:00 pm - 7:00 am with a PC of 17-18. 2 RNs were needed but only 1 RN was present. PC included a 1:1 observation. d. 9/18/24 short 1 RN from 7:00 am - 7:00 pm and 7:00 pm-7:00 am with a PC of 18-19. 2 RNs were needed but only 1 RN was present. PC included a 1:1 observation. e. 9/21/24 short 1 RN from 7:00 am - 7:00 pm and short 1 MHT from 7:00 pm-7:00 am with a PC of 19-20. 2 RNs were needed but only 1 RN was present. PC included a 1:1 observation. f. 9/22/24 short 1 MHT (Mental Health Tech) from 7:00 pm - 3:00 pm, 3:00 pm -11:00 pm, and short 2 MHTs from 11:00 pm - 3:00 am with a PC of 20. 4 MHTs were needed but only 3 were present between 7:00 pm - 3:00 pm, 3:00 pm -11:00 pm. 4 MHTs were needed between 11:00 pm - 3:00 am. PC included a 1:1 observation. g. 9/23/24 short 1 MHT from 7:00 am - 11:00 am, 7:00 pm -11:00 pm, and 11:00 pm - 3:00 am with a PC of 20. 4 MHTs were needed but only 3 were present. PC included a 1:1 observation. h. 9/24/24 short 1 RN and 1 MHT from 7:00 am - 11:00 am with a PC of 20. 2 RNs were needed but only 1 RN was present. 4 MHTs were needed but only 3 were present. PC included a 1:1 observation. g. 9/26/24 short .75 of an RN 7:00 am - 11:00 am, .75 of an RN from 3:00 pm-7:00 pm, 1 RN from 7:00 pm-7:00 am with a PC of 18-20. 2 RNs were needed but only 1 RN was present. h. 9/27/24 short 1 RN 7:00 am - 7:00 pm and 7:00 pm- 7:00 am with a PC of 18-29. 2 RNs were needed but only 1 RN was present. i. 9/28/24 short 1 RN 7:00 am - 7:00 pm and .5 of an MHT from 11:00 am-3:00 pm with a PC of 19. 2 RNs were needed but only 1 RN was present. 3 MHTs were needed but only 2.5 were present. j. 9/29/24 short 1 RN 7:00 am - 7:00 pm and 7:00 pm- 7:00 am with a PC of 19. 2 RNs were needed but only 1 RN was present. k. 9/30/24 short 1 RN 7:00 am - 3:00 pm with a PC of 19. 2 RNs were needed but only 1 RN was present. l. 10/5/24 short 1 RN 7:00 pm - 7:00 am, short 2 MHTs from 7:00 pm-11:00 pm with a PC of 17. 2 RNs were needed but only 1 RN was present and 4 MHTs were needed but only 3 were present. PC included a 1:1 observation. 4. In telephone interview on 10/16/24 at approximately 3:45 pm with A7 (Chief Executive Officer) confirmed the youth unit of H1 did not have, but should have had, adequate staffing based on the facility matrix and grid (lacking either RN’s and/or MHT’s) on variable shift blocks for dates 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/21/24, 9/22/24, 9/23/24, 9/24/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24, 9/30/24, and 10/5/24.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, nursing staff failed to complete emergency transfer notes for 1 of 10 medical records (MR) reviewed. (P10) Findings include: 1. The facility policy titled, Interfacility Patient Transfer, PolicyStat ID 15820403 last approved 05/2024, indicated under PROCEDURE: 2. If an emergency situation exists, the nursing staff calls 911. The RN completes the Emergency Transfer Note prior to the transfer. 2. MR review for P10 indicated emergency transport documentation for 9/25/24 d/t (due/to) seizure activity, 9/27/24 d/t seizure activity and 9/28/24 d/t seizure activity had no been completed by nursing staff per policy. On 9/25/24 the documentation lacked a psychiatric diagnosis, notification of family for the need of transport including the name and time of notification, name of facility contacted ,time contacted, name of contacted facility employee and title, time emergency services was called and arrival time, and RN (Registered Nurse) Signature along with date and time. On 9/27/24 the documentation lacked psychiatric diagnosis, name of ambulance service with time called and time arrived, and RN (Registered Nurse) Signature along with date and time. MR lacked an Emergency Transport Note for 9/28/24. 3. In the interview on 10/10/24 at approximately 4:35 pm with A1 (Director of Risk Management) confirmed emergency transfer note documentation was not completed by facility nursing staff members for P10 on 9/25/24, 9/27/24, and 9/28/24 and should have been.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48061 Based on document review, observation and interview, the facility failed to ensure a patient was free from abuse, failed to report an occurrence of patient abuse by a staff member to government agencies within 24 hours of the abuse, facility nursing staff implemented restraint or seclusion without a provider order for 1 of 10 medical records reviewed. (P4); and failed to ensure all direct patient care staff members held a current Handle with Care and/or restraint/seclusion certification for 8 of 15 personnel files reviewed. (N3 [Registered Nurse], N4 [Licensed Practical Nurse], MHT6 [Mental Health Tech], MHT7 [Mental Health Tech], MHT8 [Mental Health Tech], MHT9 [Mental Health Tech], MHT10 [Mental Health Tech], MHT11 [Mental Health Tech]) The cumulative effect of this systemic problem resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“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: 48061 Based on document review, observation and interview, facility nursing staff failed to complete direct visual contact with assigned patients during patient observation rounding visual for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled, Level of Observation, PolicyStat ID 15820401, last revised 11/2018, indicated under PROCEDURE: 5. Every 15 Minute Observations. Staff will observe patient and document on the Patient Observation record q 15 minutes. Staff will make direct visual contact with their assigned patients and confirm they are in no danger or distress. 2. Review of P1’s MR indicated the patient was 41 y/o (year/old) admitted to facility from 8/22/24-8/23/24, with diagnoses including but not limited to delusions, schizophrenia, and methamphetamine use disorder. Patient Observation documentation dated 8/23/24 indicated MHT5 (Mental Health Technician) charted P1 being in the courtyard from 5:30 pm -7:00 pm then as in his/her room at 7:15 pm, MHT4 (Mental Health Technician) documented P1 as being in the courtyard at 7:30 pm and 7:45 pm. No other patient observation checks were documented as completed for P1 after 7:45 pm on 8/23/24. 3. MR for P4 lacked documentation related to the incident that occurred on 8/29/24 that included MHT1 (Mental Health Tech) abusing P4. 4. P1 was listed on the incident report log on 8/23/24 for an elopement from the facility. On 8/23/24 at approximately 6:45 pm P1 climbed a tree in the courtyard while he/she was unsupervised by facility staff members during a smoke break. P1 was found by law enforcement at a local hospital with a fracture injury related to the elopement. Since this event all trees in that courtyard have had their limbs trimmed to a non-reachable height. 5. In interview on 10/2/24 at approximately 11:30 am with A2 ( Director of Risk Management) confirmed N1 (Registered Nurse) did not follow restraint/seclusion/hand with care training and was suspended until retrained. Confirmed a provider should have been notified of the abuse that resulted in injury but was not, confirmed skin assessment with wound documentation should have been charted in P4’s medical record but was not. MHT4 and MHT5 did not make direct visual contact with their assigned P1 during observation rounding while in the courtyard but should have.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48061 Based on document review, observation and interview, the facility failed to ensure patient was free from abuse and failed to report an occurrence of patient abuse by a staff member to G1 (Government Agency) and G3 (Government Agency) within 24 hours of the abuse for 1 of 10 medical records reviewed. (P4). Findings include: 1. Facility policy titled, Patient Rights and Responsibilities, PolicyStat ID 15601140, last revised 03/2017, indicated under Adult Patient Rights: 7. You will be free from mental or physical abuse, and from chemical and physical restraints except those restraints authorized in writing by the physician when necessary for your protection or the protection of others. When restraints are necessary, they will be applied under the direction of a physician 2. Facility policy titled, Abuse Assessment and Reporting, PolicyStat ID 15678512, last revised 02/2020, by indicated under PROCEDURE: Suspected abuse/neglect occurred while receiving services at H1: 4. If the suspected abuse is reported abuse or neglect occurs to an adult while an inpatient, the report must be called to G1. 6. G3 shall be contacted within 24 hours by Risk Manager is designee if the alleged or reported abuse or neglect occurred on any acute inpatient unit. The report should be called or faxed (using D3 Incident Report) to the G3. 3. Medical Record review for P4 lacked documentation of patient abuse by MHT1 (Mental Health Technician) that occurred on 8/29/24. 4. Facility Incident log indicated on 8/29/24, P4 was listed for aggression by staff (MHT1) towards patient. P4 came out his/her room and staff tried to redirect to his/her room. According to the filed incident report, while being redirected the patient ran into his/her door causing an injury that required first aid. When assessed by the practitioner on 8/30/24 the patient was sent out for assessment and treatment of a puncture wound. An update entered by A2 (Director of Risk Management) indicated video footage of the incident was reviewed, and it was determined that staff (MHT1) aggressively moved the patient down the hallway, causing the patient to fall at one point and when the patient got up, staff (MHT1) continued to aggressively move the patient and appeared to push the patient into his/her room. 5. Video footage review on 10/2/24 at approximately 11:30 am with A2, this writer observed the following: a. 8/29/24 at approximately 11:22 pm P4 can been seen walking naked towards and entering the day room. b. 8/29/24 at approximately 11:22 pm P4, N1 (Registered Nurse) and MHT1 can be seen in the day room. c. 8/29/24 at approximately 11:23 pm MHT1 can be seen violently shoving P4 multiple times with both hands out of the day room door and down the unit hallway towards the patient’s room. While in the unit hallway MHT1 can be seen violently shoving P4 to the floor with both hands, then MHT picked P4 up with both hands under his/her posterior underarms then P4 went into his/her room. MHT1 remained present close to or within the patient’s doorway. d. 8/29/24 at approximately 11:23:34 pm P4 attempts to exit his/her room and was met by MHT1 who then violently shoved with both hands P4 back into his/her room. MHT1 can be seen entering P4 room during these actions. e. 8/29/24 at approximately 11:23:48 pm MHT1 can be seen exiting the patient’s room and signaling for help. f. 8/29/24 at approximately 11:24 pm N1 enters P1’s room/doorway for approximately 20 seconds but does not appear to be keeping the patient from leaving. g. The incident footage ends at 11:24 pm on 8/29/24 and this writer is unable to determine when first aid was rendered to the patient after the abuse. 6. In interview on 10/2/24 at approximately 11:30 am, A2 confirmed P4 was physically abused by MHT1 on 8/29/24 and should not have been, and a critical incident report was not filed but should have been with G3 nor was there notification to G1 after the discover of patient abuse until 10/1/2 7. In telephone interview on 10/8/24 at approximately 11:45 am with MHT2 (Mental Health Tech) confirmed P4 was naked, MHT1 pushed the patient hard into his/her room door causing an injury with bleeding and bruising. MHT2 also confirmed that employees are not allowed and/or trained to push or shove patients, patient abuse is not common at H1, and nursing staff was notified to come help the injured P4.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff implemented restraint or seclusion without a provider order for 1 of 10 medical records reviewed. (P4) Findings include: 1. Facility policy titled, Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion-Adult (Seclusion Restraint), PolicyStat ID 15286480, last revised 05/2024, indicated under PROCEDURE: C. Physician Orders, Consultation, and Evaluation. 1. Restraint or seclusion shall be used in emergency situations only and requires an order from a physician. Prior to initiation of restraint or seclusion, the physician and nurse will be aware of any considerations that should be taken based upon the initial assessment completed at the time of admission. 2. Review of P4 medical record indicated patient was placed in seclusion by N1 (Registered Nurse) on 8/29/2024. MR (medical record) lacked a provider order for seclusion. 3. Personnel file reviewed for N1 indicated current year required education and/or competencies including Handle with Care initial training and recertifications, completed facility and unit orientation. Status change documentation dated 9/10/24 indicated a discussion was had of the performance concerns and policy violations which have been seen including not redirecting MHT1 (Mental Health Technician) who pushed a patient, participating in physically stopping a patient from leaving their room thus doing a seclusion without a physician’s order. 4. In interview on 10/2/24 at approximately 11:30 am A2 (Director of Risk Management) confirmed N1 did not, but should have, followed restraint/seclusion/hand with care training when placing P4 in seclusion, and is suspended until retrained.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 48061 Based on document review, observation and interview, the facility failed to ensure all direct patient care staff members held a current Handle with Care and/or restraint/seclusion certification for 8 of 15 personnel files reviewed. (N3 [Registered Nurse], N4 [Licensed Practical Nurse], MHT6 [Mental Health Tech], MHT7 [Mental Health Tech], MHT8 [Mental Health Tech], MHT9 [Mental Health Tech], MHT10 [Mental Health Tech], MHT11 [Mental Health Tech]) Findings include: 1. Facility policy titled, Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion-Adult (Seclusion Restraint), PolicyStat ID 15286480, last revised 05/2024, indicated under PROCEDURE: N. Staff Training and Competence Assessment: Medical Staff, direct care staff, and RNs/PAs are oriented to the standards for the use of restraint/seclusion. Direct care staff and PAs are required to attend a nationally recognized physical/aggression management training program and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment and care of a patient in restrains or seclusion. Physician and other LIPs authorized to order restraint of seclusion must have a working knowledge of the facility’s policy regarding the use of restraint/seclusion. Nurses and PAs authorized to conduct the one-hour face-to-face evaluation will receive additional training and demonstrate competency to conduct both a physical and behavioral assessment of the patient. All records documenting completion of training and competency demonstration will be maintained in staff personnel filed or credential files. 2. Personnel file(s) were reviewed for N3 (Registered Nurse), N4 (Licensed Practical Nurse), MHT6 (Mental Health Tech), MHT7 (Mental Health Tech), MHT8 (Mental Health Tech), MHT9 (Mental Health Tech), MHT10 (Mental Health Tech), MHT11 (Mental Health Tech) indicated an expired Handle with Care certifications. 3. In interview on 10/2/24 at approximately 11:45 am with A3 (Chief Operating Officer) confirmed employees without current Handle with Care certifications were allowed to work in direct patient care while expired and should not have been. These employees should have been suspended until recertified but were not.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to notify a provider of a patient’s change in condition for 1 of 10 medical records reviewed. (P4). Findings include: 1. Facility policy titled, Changes in Patient’s Condition, PolicyStat ID 15820433, last revised 05/2024, indicated under PROCEDURE: Clinical Staff/ Nurse: When the clinical nursing staff identify symptoms in a patient that constitute a medical risk/acute change of condition they will proceed with the following steps: a. Assess whether the patients’ condition requires emergent action (transfer to medical facility emergency room) or whether the condition can wait until the nurse can consult with the medical staff. b. If the condition is emergent the clinical staff will provide immediate first aid and/or CPR and call for emergency transport. c. Charge Nurse or RN designee will call the attending physician or medical consultant immediately to provide and update and obtain necessary orders. (If medical consultant is called first due to an urgent medical condition, the attending physician must also be notified as soon as possible. 2. MR review for P4 lacked documentation of physician notification of P4’s injury sustained on 8/29/24 at approximately 11:22 pm as a result of patient abuse by MHT1 (Mental Health Tech). 3. Facility Incident log indicated on 8/29/24, P4 was listed for aggression by staff (MHT1) towards patient. P4 came out of his/her room and staff tried to redirect to his/her room. According to the filed incident report the while being redirected the patient ran into his/her door causing an injury that required first aid. When assessed by the practitioner on 8/30/24 the patient was sent out for assessment and treatment of a puncture wound. An update entered by A2 (Director of Risk Management) indicated video footage of the incident was reviewed, and it was determined that staff (MHT1) aggressively moved the patient down the hallway, causing the patient to fall at one point and when the patient got up, staff (MHT1) continued to aggressively move the patient and appeared to push the patient into his/her room. A critical incident report was not filed with G3 (Government Agency) nor was there notification to G2 (Government Agency) related this incident of patient abuse by a staff member until 10/1/24 at 4:42 pm. No notification to P4’s family was made due to the patient being involuntarily committed by a judge to facility to regain his/her competency to stand trial. An investigation timeline provided by A2 is as follows: a. 8/29/24- 11:15 pm incident occurred. b. 8/30/24 - Reviewed incident report originally documented in morning administrative/safety meeting (AKA [Also Known As] Flash). Incident reported as an accidental patient injury. c. 8/30/24 - Patient sent to local emergency room for treatment after seeing practitioner. P4 received stitches to his/her puncture wound. d. 9/3/24 - A2 received health services compliance hotline call. Video footage reviewed. MHT1 was suspended pending full investigation. e. 9/4/24 - MHT1 was interviewed in person by facility human resources. f. 9/6/24 - N1 was interviewed by telephone by facility human resources. N1 (Registered Nurse) suspended pending in person interview on 9/10/24. MHT1 terminated. g. 9/10/24 - Facility human resources and nursing leadership interviewed N1. N1 suspended rending re-education and review of corrective action documentation scheduled for 9/16/24. h. 9/16/24 - A2 interviews MHT2. N1 rescheduled training for 9/23/24. i. 9/24/24 - N1 cancels training stating he/she might be available on 9/30/24. j. 9/30/24 - N1 does not complete training. N1 remains suspended. 4. In interview on 10/2/24 at approximately 11:30 am, A2 confirmed a provider should have been notified of the abuse that resulted in P4 injury, but was not.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to include family in the patient’s plan of care in 1 of 10 patient medical records reviewed (Patient 6). Findings Include: 1. Review of policy titled, “Patient Rights and Responsibilities”, PolicyStat ID 15601140, last approved 05/2024, under Procedure: 8. Patients and families, guardian and other resources will be included in the planning of patient care as appropriate. 2. Review of Patient 6’s medical record indicated patient was court ordered to be admitted to facility due to having been deemed incompetent to stand trial. Patient’s initial psychiatric evaluation indicated patient 6 parents were his/her primary support. MR lacked documentation of communication with patient’s family regarding the patient’s plan of care and indicated Family Member #1 was patient’s contact and support person. 3. Interview with A2 (Chief Operating Officer) on 06/24/2024 at approximately 2:45 p.m. confirmed that patient 6’s chart lacked documentation of communication with family regarding patient’s plan of care. 4. Interview with S1 (Licensed Mental Health Counselor) on 06/24/2024 at approximately 3:40 p.m. confirmed patient 6 was a participant in a jail based program to restore competency of jailed patients with serious mental health issues. S1 confirmed that patient had a mental health diagnosis of Schizophrenia, had previously been a patient at this facility, had the same rights as all patients, and had the right to have family participate in the treatment plan. S1 confirmed that they had not spoken to any family member regarding the patient’s treatment plan.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 48061 Based on document review and interview, the facility failed to ensure a grievance resolution letter was sent in a timely manner to the patient and/or family for 1 of 10 patient medical records reviewed. (P1) Findings include: 1. The facility policy titled, “Patient/Family Grievances”, PolicyStat ID 13420947, last revised 04/2021, indicated the Patient Advocate/designee responding to the grievance shall inform the patient or family the timeframe within he/she will follow-up. This time frame shall not exceed 7 days unless there are extenuating circumstances, at which point the patient shall be notified of the need for an extended time frame and an agreement is made as to when follow-up will occur. Once the issue has been resolved, the Patient Advocate/designee shall provide a timely written response to the patient/resident and/or family. The response shall include: the name of the contact person, the steps taken to investigate the grievance, and the results of the grievance process. 2. A complaint/grievance was received for P1 on 2/2/24 with concerns of the patient not receiving heart medications and was sent to the emergency room for this reason and sleeping arrangements that would facilitate the use of his/her CPAP (Continuous Positive Air Pressure) machine. No resolution letter had been sent at the time of survey. 3. In interview on 2/29/24 at approximately 2:00 pm with A1 (Director of Performance Improvement & Regulatory) indicated no letters had been issued/sent to P1 or family about the complaint/grievance filed on 2/2/24.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, nursing services failed to ensure an MD (Medical Doctor) and/or NP (Nurse Practitioner) was notified of severe range blood pressures in 1 of 10 medical records reviewed (P1); nursing services failed to document home medications and/or medical supplies per policy for 1 of 10 medical records reviewed. (P1) Findings include: 1. The facility policy titled, “Vital Signs”, PolicyStat ID 13467438, last revised 03/2020, indicated the RN (Registered Nurse) will notify the MD/NP if : BP (Blood Pressure) systolic >160 or < 80, BP diastolic >100 or <50 2. The facility policy titled, “Patient’s Own Medications (POM)”, PolicyStat ID 13480353, last revised 04/2022, indicated the following: Medications brought by the patient to the facility will be logged on the Home Medication/ Medical Supply Inventory form at the time of admission. The following will be documented by the nurse: a. If medication is sent home at admission, “Y” or “N” b. If medication will be administered during hospitalization, “Y” or “N” c. Medication Name d. Strength of medication e. Number of Pills at time of admission 2. The patient/guardian or other staff member will sign as a witness to the medications logged on the form. 9. Medications brought from home and stored in the facility are to be returned to the patient or family/guardian upon discharge or destroyed per physician order. Medication not returned to the patient at discharge or not claimed by the patient will be destroyed via Rx Destroyer no sooner than one month after discharge. a. For each medication kept at the hospital, the discharging nurse will count the number of pills in each vial and document on the Home Medication/Medical Supply Inventory form. b. The patient/guardian or other staff member will sign as a witness to the stored medications logged on the form. 3. MR for P1 lacked documentation that a physician and/or NP was notified of P1’s blood pressure(s) on 1/31/24: 187/11 at 4:03 pm, 187/111 at 6:38 pm; on 2/1/24: 174/95 at 8:16am and 206/111 at 3:24pm. 4. MR for P1 lacked documentation on Home Medication/Medical Supply Inventory form indicating if medication was sent home at admission, strength, number of pills on admission, number of pills at discharge, or medical supplies present on admission or discharge. 5. In interview on 2/29/24 at approximately 11:00 am with A3 (Director of Nursing) confirmed there was no documentation that a provider had been notified of P1 severe range blood pressures and should have been as policy dictates. 6. In interview on 2/29/24 at approximately 11:30 am with RN1 (Registered Nurse) confirmed he/she did not notify a provider about P1 severe range blood pressures.”