Doctors Neuropsychiatric Hospital

“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: 14445 Based on document review and interview, nursing services failed to complete blood glucose checks as ordered by provider for 1 of 10 patient MR’s (Medical Record) reviewed. (Patient # 5) Findings include: 1. Review of policy titled: Patient Care Management, Policy Stat ID 12197166; on page 6, under Fluid/Electrolyte Balance, 1. Lab (laboratory) values are monitored. Last approved 8/2022. 2. Review of Patient # 5 MR, indicated the following: a. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 1/28/2026. b. Patient’s history, included. but not limited to Diabetes. c. Provider order on 1/29/2026 at 9:55 pm, reflected BID (twice a day) glucose checks. d. MARs (Medication Administration Record) - Treatments/Labs, reflected for blood glucose checks BID the following (checks at 7:30 am & 4:30 pm): No results documented on 1/30/2026 and no results documented for remainder of stay (prior to death): 2/3/2026 - 2/13/2026 (am/morning); no noted sheet/form/record. 3. In interview on 3/25/2026 at approximately 4:18 pm, with A # 3 (Quality/Risk), indicated the following: a. Patient # 5’s medical record lacked documented results on MAR (Medication Administration Record) - Treatment/Labs for blood glucose checks for 1/30/2026 and 2/3/2026 to 2/13/2026 am. b. No further records were found/located for patient # 5’s MR. c. Hospital policy not followed by Nursing staff.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44532 Based on document review, observation, and interview, the facility failed to provide care in a safe setting that resulted in patient injury, and failed to complete an incident report for 1 of 10 patient medical records (MRs) reviewed (P10); failed to provide a patient with protection from abuse in one instance (P10); and failed to complete 15-minute observations for 5 of 10 patient medical records reviewed. (P3, P7, P8, P9, and P10) The cumulative effect of this systemic problem resulted in the hospitals inability to promote Patient Rights in a safe setting.”

“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: 44532 Based on document review, observation, and interview, facility failed to provide care in a safe setting and failed to complete an incident report for 1 of 10 patient medical records (MRs) reviewed; failed to complete 15-minute checks per provider order for 5 of 10 patients reviewed. (P3, P7, P8, P9, and P10). Findings Include: 1. Review of policy “Patient Rights and Responsibilities”, Policy Stat ID 13517670, last revised 9/2021, Page 3, 18. indicated patients receive care in a safe setting, free from verbal abuse or harassment. 2. Review of policy “Patient Observation” PolicyStat ID: 12931622, last approved 10/2024 indicated under Procedure: 1. On admission, each patient will be assessed for the level of observation: and under Level 1- General Observation: a. All patients on this level are on every 15-minute observation, at a minimum. 3. Review of policy “Incident Reports”, PolicyStat ID 13033981, last approved 01/2023: Indicated under Purpose: it is the policy of the hospital to support a culture of shared accountability for the identification, reporting, and management of patient events that may impact the quality of care provided. Any hospital staff member who witnesses, discovers or has direct involvement in and/or knowledge of an event must complete an incident report or give a detailed report to the person completing the incident report. 4. Review of P10 medical record indicated the following: a. Patient was admitted on 12/19/2025 under a 72 hour hold for bipolar disorder. b. Daily Nursing Assessment dated 12/24/2025 at 0900 hours indicated a dark purple hematoma to P10’s right mid-leg with swelling and warmth, along with swelling and bruising of the right hand. P10 complained of significant pain and stated staff “hurt me”. c. Behavioral Health Patient Observation Sheets dated 12/20/2025 at 0013 hours through 12/24/2025 at 1135 hours indicated facility failed to complete 15-minute checks for P10 on at least 147 occasions. Review of the Observation sheets dated 12/23/2025 from 2000 hours to 2235 hours lacked 15-minute checks. P10 was in the milieu in a wheelchair propelling himself/herself prior to fall at 2020 hours and 2027 hours. d. Provider note dated 12/24/2026 indicated send out today for traumatic wound noted on left hand and right leg which were not present last night and noted this morning rounds. Send out to medical hospital for imagery and further work up. 5. Review of P3 MR indicated that he/she was admitted to facility on 12/12/2025 with a diagnosis of Psychosis. Behavioral Health Patient Observation Sheets indicated 17 missed 15-minute checks on 12/12/2025 from 0000 hours to 2400 hours. P3 was discharged on 12/25/2025. 6. Review of P7 MR indicated that he/she was admitted to facility on 12/10/2025 with a diagnosis of psychotic episode. Review of Behavioral Health Patient Observation Sheets indicated 107 missed 15-minute checks on 12/10/2025-12/13/2025. P7 was discharged on 12/15/25. 7. Review of P8 MR indicated that he/she was admitted to facility on 11/04/2025 with a diagnosis of bipolar. Review of Behavioral Health Patient Observation Sheets indicated 119 missed 15-minute checks on 11/04/2025-11/24/2025. P8 was discharged on 11/24/2025. 8. Review of P9 MR indicated that he/she was admitted to facility on 12/07/2025 with a diagnosis of psychosis. Review of Behavioral Health Patient Observation Sheets indicated 75 missed 15-minute checks 12/07/2025-12/20/2025. P9 was discharged on 12/20/2025. 9. The Incident Report Log was reviewed for July 1,2025 through December 30, 2025, P10 had a fall reported on 12/22/2025 and a change of condition on 12/24/2025. Incident report log lacked documentation for 2 falls on 12/23/2025 that occurred at approximately 2000 hours and 2027 hours, and the abuse incident by N4 (Registered Nurse) to P10. 10. On 12/30/2025 at approximately 1400 hours, this surveyor, accompanied by A1 (Chief Executive Officer), viewed video footage of an incident that occurred on 12/23/2025. Video review started at 1900 hours on 12/23/2025, P10 was viewed propelling self in a wheelchair throughout the milieu. At 2019 hours P10 went towards the refrigerator, he/she stood up from the wheelchair and took the key to the refrigerator off the counter. Staff intervened and attempted to get the keys from the patient. P10 appeared to be aggressive throwing self on the floor. P10 laid on the floor until 2023 hours, then was helped back into the wheelchair by facility staff. N6 (Behavioral Health Assistant) proceeded to wheel P10 in the wheelchair towards his/her room 111. N6 was pulling the wheelchair backwards into room number 111. The patient is seen leaning forward out of the wheelchair onto the floor. Then he/she pulls the wheelchair on top of his/her body. There is a struggle with N5 (Behavioral Health Assistant) and N6 trying to get the wheelchair free from the patient. P10 continues to struggle and attempts to keep the wheelchair on his/her body. N4 came to assist with patient, he/she was able to get the wheelchair off P10 then very aggressively grabbed P10’s right ankle and drug him/her into room number 111. 11. Interview on 12/30/2025 with A1 (Chief Executive Officer) at 1300 hours, confirmed that the facility did not keep P10 safe during stay at facility by causing P10 injuries to his/her right leg and left arm swelling and bruising. A1 also confirmed that 15 minute checks were not being completed as ordered. A1 verified that there was not an incident report filed for 1 of P10 falls on 12/23/2025. .”

“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: 44532 Based on document review, observation and interview, the facility failed to provide the patient with protection from abuse in one instance. (P10) Findings include: 1. Review of the policy “Patient Rights and Responsibilities”, Policy Stat ID 13517670, last revised 9/2021, indicated patients receive respectful care; appropriate assessment, management of care; participate in plan of care; care in safe setting; with required documentation for same. 6. Reasonable protection from physical or emotional abuse or harassment. 2. Review of the policy titled “Patient Abuse and Neglect” (no policy number), last approved 04/2024). All patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may have occurred. 3. Provider note dated 12/24/2026 indicated send out today for traumatic wound noted on left hand and right leg which were not present last night and noted this morning rounds. Send out to medical hospital for imagery and further work up. 4. On 12/30/2025 at approximately 1400 hours, this surveyor, accompanied by A1 (Chief Executive Officer), viewed video footage of an incident that occurred on 12/23/2025. Video review started at 1900 hours on 12/23/2025, P10 was viewed propelling self in a wheelchair throughout the milieu. At 2019 hours P10 went towards the refrigerator, he/she stood up from the wheelchair and took the key to the refrigerator off the counter. Staff intervened and attempted to get the keys from the patient. P10 appeared to be aggressive throwing self on the floor. P10 laid on the floor until 2023 hours, then was helped back into the wheelchair by facility staff. N6 (Behavioral Health Assistant) proceeded to wheel P10 in the wheelchair towards his/her room 111. N6 was pulling the wheelchair backwards into room number 111. The patient is seen leaning forward out of the wheelchair onto the floor. Then he/she pulls the wheelchair on top of his/her body. There is a struggle with N5 (Behavioral Health Assistant) and N6 trying to get the wheelchair free from the patient. P10 continues to struggle and attempts to keep the wheelchair on his/her body. N4 came to assist with patient, he/she was able to get the wheelchair off of P10 then very aggressively grabbed P10’s right ankle and drug him/her into room number 111. 5. Interview with A1 on 12/30/2025 at approximately 1445 hours, confirmed they thought N4 was too aggressive with P10 during an incident on 12/23/2025.”

“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: 14445 Based on document review and interview, nursing services failed to complete daily bathing for 4 of 10 patient MR’s (Medical Record) reviewed. (Patients # 2, # 4, # 5 & # 6). Findings include: 1. Review of hospital policy titled: Patient Personal Care, Policy Stat ID 12197137; on page 1, under Education, indicated Bathing/showers will be offered daily, and under General Care, indicated All patients shall be encouraged or assisted in grooming daily or more often as needed. Last revised 1/2020. 2. Review of Patient # 2 MR, indicated the following: a. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 2/6/2025. b. MR lacked documentation in daily flowsheets and/or daily notes for ADL’s (activities of daily living) - hygiene care/bathing, offered or completed or refused, for the following days: 2/6/2025, 2/7/2025, 2/8/2025 and 2/10/2025. 3. Review of Patient # 4 MR, indicated the following: a. Patient admitted to APH # 40 on 2/4/2025. b. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 2/4/2025, 2/5/2025, 2/6/2025, 2/7/2025, 2/8/2025, 2/9/2025 and 2/10/2025. 4. Review of Patient # 5 MR, indicated the following: a. Patient admitted to APH # 40 on 1/3/2025. Patient discharged on 1/10/2025. b. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 1/4/2025, 1/5/2025, 1/8/2025 and 1/9/2025. 5. Review of Patient # 6 MR, indicated the following: a. Patient admitted to APH # 40 on 12/21/2024. Patient discharged on 12/27/2024. b. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 12/22/2024, 12/23/2024 and 12/24/2024. 6. In interview on 2/11/2025 at approximately 4:08 pm, and at approximately 5:28 pm, with A # 2 (Quality), confirmed/verified the following: a. That hygiene documentation is to be charted on flowsheet in MR; for daily completed, or chart if patient refused. b. That the above noted MRs (Patients # 2, # 4, # 5 & # 6) lacked hygiene documentation. 7. In interview on 2/11/2025 at approximately 5:27 pm, with A # 1 (Chief Executive Officer), confirmed/verified that the above noted MRs (Patients # 2, # 4, # 5 & # 6) lacked daily hygiene documentation.”

“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: 32952 Based on document review and interview, the facility failed to ensure wound/skin assessments were completed and were accurate for 1 of 10 medical records reviewed (Patient #1); and failed to notify Physician/family/guardian of patient injuries, falls and wounds/skin issues for 1 of 10 medical records reviewed. (Patient #1). Findings include: 1. Facility policy titled “Wound Care and Treatment”, PolicyStat ID: 12385988, last revised on 9/2022 indicated the following: “PURPOSE: To ensure consistent, accurate identification and assessment of all wounds, and to ensure appropriate treatment is implemented timely in accordance with professional standards of practice for wound treatment. POLICY: B. The medical provider will be notified upon identification of a wound or skin related issue. If consent is given, the family or legal representative will be notified of new skin breakdown post admission. PROCEDURE FOR WOUND TREATMENT: 1. A treatment order will be obtained upon identification of a wound. 2. Facility policy titled “Skin Assessment”, PolicyStat ID: 12385990, last revised on 9/2022 indicated the following: “PURPOSE: 1. To provide proper skin assessment guidelines for nursing staff. 2. To identify any existing or new wounds, injuries, bruises, skin conditions, self-harm behaviors, and/or contraband. POLICY: The guidelines in this policy are to identify and document any areas of concern related to patient skin. PROCEDURE: Assessment: 1. Additional skin assessments should be completed one time per week or as ordered by provider. 2. The assessment process should include: e. Identification of any wounds, injuries, bruises, skin conditions, self-harm behaviors, and/or contraband. 3. Facility policy titled “Assessment/Reassessment”, PolicyStat ID: 12386392, last revised on 9/2022 indicated the following: “PURPOSE: To ensure that all patients receive the appropriate screening, assessment, and reassessment by qualified individuals within the organization. The assessment process will be continuous, collaborative effort with all of the health care members functioning as a team. Communication among the health care team is an essential element of the assessment process. POLICY: 5. Assessment is ongoing as appropriate throughout the hospital stay. 7. Nursing will re-assess each patient every shift and as warranted by the patient’s medical condition and document findings. 4. Review of Patient #1’s medical record indicated the following: (A) The patient was admitted on 10/26/24 at 11:35 a.m. and left AMA (Against Medical Advice) with (Family Member #2) on 10/9/24 at 1:35 p.m. (B) The patient’s nursing admission assessment dated 10/26/24 at 11:35 a.m. indicated the patient’s skin was intact with no skin issues upon admission to the facility. (C) A review of a nurse’s note for Patient #1 dated 11/5/24 at 7:55 p.m. indicated the following: At around (7:45 p.m.) pt. was crawling around on (his/her) floor and informed writer (he/she) hit (his/her) head on the wall. 1 inch swelling on (his/her) L (left) forehead. The medical record lacked documentation that a provider and/or Patient #1’s family/guardian were notified of the incident/wound. (D) A review of a nurse’s note for Patient #1 dated 11/6/24 at 12:57 p.m. indicated the following: Patient walking in milieu, slipped/tripped over own feet, fell to (the) floor, witnessed by staff. Pt. able to move all extremities w/o (without) difficulty, did not hit head. Assisted (Patient #1) up to chair by staff. The medical record lacked documentation that a provider and/or Patient #1’s family/guardian were notified of the fall. (E) The patient’s nursing skin assessments indicated the following: (a.) On 11/6/24, dayshift nursing staff noted that Patient #1 had no abnormal finding related to (his/her) skin assessments. (b.) On 11/6/24, Patient #1’s medical record lacked documentation of a skin reassessment on night shift by nursing staff and/or patient refusal of a skin assessment. (c.) On 11/7/24 and 11/8/24, dayshift and night shift nursing staff noted that Patient #1 had no abnormal finding related to (his/her) skin assessments. (d.) On 11/9/24, Patient #1’s medical record lacked documentation of a skin reassessment on day shift by nursing staff and/or patient refusal of a skin assessment. 5. During a phone interview with NP2 (Nurse Practitioner/Adult Gerontology) with A2 (Chief Executive Officer) present on 1/16/25 at 1:52 p.m., NP2 verified the lack of documentation in (his/her) provider notes related to Patient #1’s incident on 11/5/24, where the patient hit (his/her) head on a wall, a contusion on the patient’s forehead and incident on 11/6/24, where the patient had a witnessed fall and/or any additional skin issues of black eyes. 6. During an interview with A1 (Market Director of Quality/Risk) on 1/16/25 at 2:40 p.m., A1 verified the lack of documentation in Patient #1’s medical record related to bruising to the patient’s eyes and/or head. A1 verified the lack of documentation of skin reassessments for Patient #1’s one inch contusion from an incident on 11/5/24. A1 verified that the medical record lacked documentation that the provider and/or guardian were notified of Patient #1’s incidents on 11/5/24, where the patient hit (his/her) head on a wall and on 11/6/24, where the patient had a witnessed fall without injury. A1 verified that incident reports are not part of a patient’s medical record. 7. During an interview with N8 on 1/16/25 at 3:20 p.m., N8 indicated that (he/she) did not remember Patient #1 having any black eyes, but did remember that the patient had a bruise that was more on the left side of (his/her) forehead that went down the side of (his/her) head to (his/her) eyebrow. N8 indicated that the bruise was green/yellow in color. 8. During an interview with N13 (Registered Nurse) on 1/16/25 at 4:00 p.m., N13 indicated that Patient #1 had bruising to (his/her) forehead and possibly to at least one of (his/her) eyes. N13 indicated that the bruising was in different stages of healing, the center of the bruising was darker and then it got lighter as it went outwards. 9. During an interview with N14 (Registered Nurse) on 1/16/25 at 4:10 p.m., N14 indicated that Patient #1 did have bruising to (his/her) forehead and to both (his/her) eyes from underneath their eyes up. N14 indicated that (Family Member #2) was upset that (he/she) was not notified of Patient #1 hitting (his/her) head on the wall and the bruising.”

“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: 32952 Based on document review and interview, the facility failed to ensure wound assessments were completed and accurate for 1 of 10 medical records reviewed (Patient #1); and failed to notify Physician of wounds for 1 of 10 medical records reviewed. (Patient #1). Findings include; 1. Facility policy titled “Wound Care and Treatment”, PolicyStat ID: 12385988, last revised on 9/2022 indicated the following: “PURPOSE: To ensure consistent, accurate identification and assessment of all wounds, and to ensure appropriate treatment is implemented timely in accordance with professional standards of practice for wound treatment. POLICY: A. Wounds will be measured on admission (length, height, width). B. The medical provider will be notified upon identification of a wound or skin related issue. PROCEDURE: ADMISSION WOUND ASSESSMENT: 3. Measurements will be obtained and documented in centimeters by length, width, and then depth. 4. The wound bed will be described. 5. If wound exudate is present, the type and amount of drainage will be described. 6. If wound odor is present, the description of odor will be documented. 7. The peri wound tissue will be assessed and documented. 8. All of the above will be documented on the Nursing Admission assessment. 2. Facility policy titled “Assessment/Reassessment”, PolicyStat ID: 12386392, last revised on 9/2022 indicated the following: “PURPOSE: To ensure that all patients receive the appropriate screening, assessment, and reassessment by qualified individuals within the organization. The assessment process will be continuous, collaborative effort with all of the health care members functioning as a team. Communication among the health care team is an essential element of the assessment process. POLICY: 2. Nursing staff completes the Nursing Admission Assessment upon admission. 5. Assessment is ongoing as appropriate throughout the hospital stay. 7. Nursing will re-assess each patient every shift and as warranted by the patient’s medical condition and document findings. 3. Review of Patient #1’s medical record indicated the following: (A) The patient was admitted on 10/1/24 at 3:50 a.m. and was discharged to home on 10/8/24 at 10:20 a.m. (B) The patient’s nursing admission assessment dated 10/1/24 indicated the patient had a left heel pressure ulcer upon admission to the facility. (C) The patient’s nursing skin assessments indicated the following: (a.) On 10/2/24 and 10/6/24, dayshift nursing staff noted that Patient #1 had no abnormal finding related to (his/her) skin assessments. Patient #1’s medical record lacked documentation of a skin reassessment on night shift by nursing staff on 10/2/24 and 10/6/24 and/or patient refusal of a skin assessment. (b.) On 10/3/24 and 10/4/24, dayshift and night shift nursing staff noted that Patient #1 had no abnormal finding related to (his/her) skin assessments. (c.) On 10/5/24 and 10/7/24, Patient #1’s medical record lacked documentation of a skin reassessment on dayshift and/or night shift by nursing staff and/or patient refusal of a skin assessment. (D) The patient’s nursing skin assessment on discharge dated 10/8/24, indicated that the patient had a foot blister. (E) The patient’s medical record lacked documentation of a description of the left heel pressure ulcer and foot blister, including wound measurements, wound bed description, whether exudate was present, type and amount of drainage, any wound odor present, description of the odor, and the peri wound tissue. The patient’s medical record also lacked documentation of provider notification of the wounds. 4. During an interview with A1 (Market Director of Quality/Risk) on 12/11/24 at 3:00 p.m., A1 verified the lack of documentation in Patient #1’s medical record related to skin/wound assessments and provider notification of any wounds/skin issues. 5. During an interview on 12/12/24 beginning at 10:35 a.m. with MD1 (Doctor of Medicine/Psychiatrist) and NP2 (Nurse Practitioner/Adult Gerontology) indicated that they were not notified of any wounds/skin issues on Patient #1’s feet.”