Assurance Health Psychiatric Hospital

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 48704 Based on document review and interview, the provider failed to authenticate an order in 1 of 10 (Patient 4) medical records reviewed and failed to communicate patient’s discharge and condition to receiving hospital in 1 of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility failed to follow policy titled, Validating the Accuracy of Verbal or Telephone Orders, Policy No: NR 18. under Policy, 7. All verbal and telephone orders must be authenticated within 48 hours by the responsible practitioner or another practitioner providing coverage for the care of the patient, according to the rules and regulations of the medical staff. 2. Review of Facility #1’s Medical Staff Bylaws last reviewed 05/2022, indicated under 2.2 Responsibilities, The responsibilities of the Medical Staff include: 2.2 (a) (1) Assist the Board and CMO and their designees in data compilation, medical record administration, and other such functions necessary to meet accreditation and licensure standards as well as federal and state law requirements. Under 3.3 Basic Responsibilities of Staff Membership, Each member of the Medical Staff shall: 3.3(f) Adequately prepare and complete in a timely fashion the medical and other required records for all patients he/she admits or, in any way provides care to, in the Hospital; 3.3(g) Adequately enter all orders for treatment within the timeframe required by the applicable Medical Staff Rules, Regulations; 3. Review of Patient 4’s medical record indicated the following: a. The patient was admitted on 06/26/2026 for neurocognitive disorder with agitation. b. Medical record indicated in A2’s (Chief Executive Officer) note order received from P3 (Nurse Practitioner) to transfer patient 4 out of facility. c. Patient was transferred and discharged on 06/26/2026. d. Medical record indicated on 06/30/2026 at 9:40 a.m. an administrative discharge to ER (emergency room) via 911 for severe aggression order was written. Order was written 3 days, 13 hours, and 40 minutes after the patient was discharged from the facility and discharge order lacked provider authentication. e. Medical record lacked documentation of communication of communication with Facility #2 by provider. 4. Interview with A2 on 08/17/2026 at approximately 12:45 p.m. indicated the following: a. A2 received the verbal order from P3 for patient 4 to be sent out. b. A2 indicated they were not aware that neither P2 (Nurse Practitioner) nor P3 communicated patient 4’s discharge to a provider at Facility #2 (Acute Care Facility). c. A2 indicated that patient 4’s MR lacked documentation of communication with Facility #2 regarding patient 4’s disposition and condition. 5. Interview with A3 (Director of Quality) on 08/17/2026 at approximately 3:50 p.m. confirmed patient 4’s medical record lacked documentation of a discharge order and was noted on a chart review. The order was written on 06/30/2026 at 9:40 a.m.”

“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: 48704 Based on document review and interview, the facility failed to document a verbal order for discharge in 1 of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility failed to follow policy titled, Validating the Accuracy of Verbal or Telephone Orders, Policy No: NR 18. under Policy, 3. Simply repeating back the order is not sufficient. The receiver of the order will write down the complete order, then read it back, and receive communication from the provider who gave the order. The EMR will ask how the order was obtained, if the order was obtained verbally, the EMR will ask for verification. And under 5. The licensed health care professional shall sign, date, and time the order when was obtained and also document the “read back”. This information will be entered into the EMR. 2. Facility policy titled, Discharge of Patients, Policy No: CC.17, last revised 09/2024, indicated under Procedure: 1. A written order from the physician is required for discharge. 3. Review of Patient 4’s medical record indicated the following: a. The patient was admitted on 06/26/2026 for neurocognitive disorder with agitation. b. Medical record indicated in A2 (Chief Executive Officer) note order received to transfer patient 4 out of facility. A2 failed to document verbal order in medical record. c. Patient was transferred and discharged on 06/26/2026. d. Medical record indicated on 06/30/2026 at 9:40 a.m. an administrative discharge to ER (emergency room) via 911 for severe aggression order was written. Order was written 3 days, 13 hours, and 40 minutes after the patient was discharged from the facility. 4. Interview with A2 on 08/17/2026 at approximately 12:45 p.m. indicated they received the verbal order from P3 (Nurse Practitioner) for patient 4 to be sent out. 5. Interview with A3 (Director of Quality) on 08/17/2026 at approximately 3:50 p.m. confirmed patient 4’s medical record lacked documentation of a discharge order and was noted on a chart review. The order was written on 06/30/2026 at 9:40 a.m.”

“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: 48704 Based on document review, the facility failed to provide patient privacy in 1 of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled Psychiatric Patient Rights, Policy RE.16, last revised 08/2018, indicated under Procedure: You have the right to: 4. Be treated in a safe environment, with respect for personal dignity, autonomy and privacy in accordance with existing federal, state, and local laws and regulations. 11. Privacy and to be free from excessive intrusion by visitors, guests, and non-hospital surveyors, construction crews or others. 2. Review of Patient 4’s medical record on 12/14/2025 indicated the patient’s bed was brought into the milieu to prevent the patient from falling. Medical record indicated the patient fell after exiting the bed; post fall intervention indicated the patient’s mattress was placed on floor in milieu.”

“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: 48704 Based on document review and interview, the facility failed to provide care in a safe setting in 1 of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled Psychiatric Patient Rights, Policy RE.16, last revised 08/2018, indicated under Procedure: You have the right to: 4. Be treated in a safe environment, with respect for personal dignity, autonomy and privacy in accordance with existing federal, state, and local laws and regulations. 2. Facility policy titled, Fall-Risk Assessment and Prevention, Policy No: NR.02, last reviewed 11/2024, indicated under Interventions: Low Risk Fall Interventions: d) Bed alarms on when patient in bed and always on high sensitivity and High Risk Fall Interventions/Identifiers: a) Chair alarm on the chair, wheelchair or recliner and clipped to the patient clothing. 3. Review of Patient 4’s medical record indicated the following: a. The patient was admitted on 11/26/2025 for major depressive disorder with psychotic symptoms. b. On 11/27/2025 provider ordered 15-minute observation checks. a. On 12/08/2025, medical record lacked documentation of 5:45 a.m., 6:00 a.m., and 6:15 a.m. 15-minute observation checks; patient was found by an aide on the floor beside their bed at 6:30 a.m. Medical record lacked documentation bed alarm was on prior to fall and lacked documentation of new interventions post fall. b. On 12/09/2025, medical record indicated patient’s roommate witnessed the patient fall; Medical record lacked documentation bed alarm was on prior to fall and lacked new interventions post fall. c. On 12/11/2025 medical record indicated patient had a witnessed fall after patient left their wheelchair to go into their room; Medical record lacked documentation wheelchair alarm on prior to fall and lacked documentation of new interventions post fall. d. On 12/13/2025, medical record lacked documentation of the 1:45 a.m. and 2:00 a.m. 15-minute observation checks, patient was found at 2:30 a.m. on the floor. Medical record lacked documentation bed alarm on prior to fall and lacked documentation of new interventions post fall. e. On 12/14/2025, medical record indicated patient had a witnessed fall after patient stood up from their bed. Medical record lacked documentation bed alarm on prior to fall and lacked documentation of new interventions post fall. f. On 12/15/2025, patient was discharged via emergency medical services at 11:45 a.m. 4. Review of Incidents Reports from 09/01/2025 through 12/29/2025 indicated the following incident reports for patient 4: a. Incident report dated 12/8/2025 for an unwitnessed fall at 6:30 a.m. in patient room. b. Incident report dated 12/8/2025 for an unwitnessed fall at 1:45 p.m. in patient room. c. Incident report dated 12/9/2025 for a witnessed fall by patient’s roommate at 10:40 p.m. in patient room. d. Incident report on 12/11/2025 for a witnessed fall at 9:00 a.m. in milieu near kitchen hallway. e. Incident report on 12/13/2025 for an unwitnessed fall in bathroom at 2:30 a.m. The 2:15 p.m. observation was falsely documented per the facility’s camera footage review; no staff member was in room patient fell approximately at 2:01 a.m. and was not found until the 2:30 a.m. observation check. f. Incident report on 12/14/2025 for a witnessed fall near milieu near admin hallway at 10:15 p.m. 5. Review of the Root Cause Analysis dated 12/16/2025 indicated staff brought out the patient’s bed, the patient’s bed was not plugged into the wall due to safety concerns of other patients; therefore, the bed alarm was not able to alarm when the patient stood up from the bed. 6. Interview with A2 (Director of Nursing) on 12/29/2025 at approximately 1:30 p.m. indicated that nursing documentation does not include safety documentation such as bed alarm on, chair alarm on, and non-skid socks on.”

“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: 48704 Based on document review and interview, nursing services failed to document 15-minute observation checks in 1 of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled Patient Rounding and Observation, Policy No. NR.23, last reviewed 12/2024, indicated under Policy: Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period and under Procedure: Patient Rounds are recorded on the daily rounds sheet or in the electronic medical record by assigned staff member. 2. Review of Patient 4’s medical record indicated the following: a. On 11/26/2025 patient was admitted for major depressive disorder with psychotic symptoms. b. On 11/27/2025 provider ordered 15-minute observation checks. c. On 12/08/2025, medical record lacked documentation of 5:45 a.m., 6:00 a.m., and 6:15 a.m. 15-minute observation checks. Medical record indicated the patient had an unwitnessed fall and was found on the floor by an aide at 6:30 a.m. in their room. d. On 12/09/2025, medical record lacked documentation of the 10:00 p.m. 15-minute observation check. Medical record indicated patient had a witnessed fall by the patient’s roommate at 11:40 p.m. and was found on the floor in their room. e. On 12/13/2025, medical record lacked documentation of the 1:45 a.m. and 2:00 a.m. 15-minute observation checks. Medical record indicated the patient had an unwitnessed fall of an unknown time as nursing found patient lying on the floor at 2:30 a.m. 3. Interview with A2 (Director of Nursing) on 12/30/2025 at approximately 4:45 p.m. indicated patient 4’s medical record lacked documentation of 15-minute observations as mentioned above and the 2:15 a.m. observation was falsely documented as indicated by camera footage review.”

“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 immediately after a patient fall with injury, failed to notify a family member of a patient fall with injury, and failed to complete post fall neurological checks after an unwitnessed fall for 1 of 10 medical records reviewed. (P1) Findings Include: 1. Facility policy titled,” FALL-RISK ASSESSMENT AND PREVENTION”, policy number NR.02, last revised 11/2024, indicated under PROCEDURE: Nursing Responsibility Post Fall: In the event of a patient fall moving the patient the Registered Nurse will: 3. Complete neuro-checks for every unwitnessed fall; witnessed falls where patients hits their head; or as ordered by the provider. 5. Notify the provider immediately and determine if a patient requires a higher level of care. 2. Facility policy titled,” INCIDENT REPORTS”, policy number NU.28, last revised 7/2018, indicated under PROCEDURE: TAKING ACTION AND COMPLETING THE INCIDENT REPORT: The completed incident report reflects documentation that the following actions have occurred: Family/significant other of the patient notified of incident/injury after physician is notified. 3. Review of P1’s MR (Medical Record) indicated P1 suffered an unwitnessed fall at approximately 1:18 am on 11/2/25. P1 was discovered in his/her room on the floor. P1 was noted to have a small abrasion above the right eye. P1’s range of motion was intact post fall. No other injuries were noted. Documentation did not specify which parties were notified. Post fall documentation lacked neurological check data post fall. 4. Incident report documentation for P1 indicated on 11/2/25 at approximately 1:20 am P1 had an unwitnessed fall and was found on the side of the bed during rounding. P1 sustained an abrasion above the right eye and hematoma. Incident report for P1 lacked documentation of family notification of P1’s fall with injury. 5. In interview on 12/17/25 at approximately 11:12 am with N3 (Licensed Practical Nurse) confirmed when a patient has a unwitnessed fall the provider, chief executive officer, director of nursing, and family of the patient are to be notified immediately as protocol indicates, neurological checks are to be documented either in the electronic medical record or in paper form which is then scanned into the electronic medical record. If a patient’s fall is unwitnessed neurological checks are mandatory. 6. In interview on 12/16/25 at approximately 4:20 pm A2 (Chief Executive Officer) nursing staff did not notify a provider immediately after P1’s fall with injury, N1 (Licensed Practical Nurse) did not notify P1’s family of his/her fall with injury, nursing staff did not initiate, conduct, and/or document completed post fall neurological checks, but should have.”

“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: 48704 Based on documentation and interview, nursing services failed to document 15-minute observation checks in 1 of 10 (Patient 3) medical records reviewed. Findings include: 1. Facility policy titled Patient Rounding and Observation, Policy No. NR.23, last reviewed 12/2024, indicated under Policy: Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period and under Procedure: Patient Rounds are recorded on the daily rounds sheet or in the electronic medical record by assigned staff member. 2. Review of Patient 3’s medical record indicated the following: a. On 09/05/2025, the patient was admitted for psychiatric care. Medical record indicated patient admission orders included precautions as indicated which include 15-minute observations. b. On 09/15/2025, the patient was diagnosed with Shingles and placed in contact isolation. Medical record lacked documentation of 22 of 96 15-minute patient observation checks including but not limited to 1:45 p.m. and 11:15 p.m. d. On 09/16/2025 medical record lacked documentation of 33 of 96 15-minute patient observation checks including but not limited to 7:45 a.m. and 5:15 p.m. e. On 09/17/2025 medical record lacked documentation of 34 of 96 15-minute patient observation checks including but not limited to 4:45 a.m. and 8:45 p.m. f. On 09/18/2025 medical record lacked documentation of 34 of 96 15-minute patient observation checks including but not limited to 10:30 a.m. and 7:15 p.m. g. On 09/19/2025 medical records lacked documentation of 54 of 96 15-minute patient observation checks including but not limited to 8:30 a.m. and 8:45 p.m. h. On 09/20/2025 medical records lacked documentation of 64 of 96 15-minute patient observation checks including but not limited to 11:15 a.m. and 5:45 p.m. i. On 09/21/2025 medical records lacked documentation of 17 of 96 15-minute patient observation checks including but not limited to 4:30 p.m. and 8: 15 p.m. j. On 09/22/2025 medical records lacked documentation of 21 of 96 15-minute patient observation checks including but not limited to 1:15 a.m. and 8:30 p.m. k. On 09/23/2025 medical records lacked documentation of 10 of 96 15-minute patient observation checks including but not limited to 2:45 a.m. and 2:45 p.m. l. On 09/24/2055 medical records lacked documentation of 6 of 43 15-minute patient observation checks including but not limited to 1:45 a.m. and 6:30 a.m. 3. Interview with A1 on 11/06/2025 at approximately 4:25 indicated patient 3’s medical record lacked documentation of 15-minute observations as mentioned above between 09/15/2025 through 09/24/2025.”

“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: 49709 Based on document review and interview, nursing services failed to obtain weights at least three times per week for 3 of 10 medical records reviewed (P1, P2, and P3); provide timely physician notification for weight loss for 3 of 10 medical records reviewed (P1, P2, P3, and P4); failed to notify physician of continuous patient intake refusal and nursing services failed to administer medication as ordered for 1 of 10 medical records reviewed (P5). Findings include: 1. Review of policy/procedure titled, “Weights,” Policy No.: CC.08, last revised 09/2024; indicated under policy: 2. Weights will be obtained at least three times a week. Indicated under procedure: 3. Nursing will notify the physician when weight loss exceeds 5 pounds in one week. 2. Review of P5 medical record indicated the following: a. Medical record lacked documentation of provider notification of P5 consecutive meal refusals. b. Review of P5’s Dietary Tracking indicated the following: 05/28/25: P5 refused breakfast, 50% of their breakfast fluids, a.m. snack, a.m. snack fluids, lunch, lunch fluids, dinner, 50% of their dinner fluids, p.m. snack, and HS (night time) snack. 05/29/25: P5 refused breakfast, breakfast fluids, 25% of their a.m. snack, lunch, lunch fluids, p.m. snack, dinner, and HS snack. 05/30/31: P5 refused breakfast, 75% of their breakfast fluids, 25% of their a.m. snack, lunch, p.m. snack, dinner, and HS snack. 05/31/25: P5 refused breakfast, breakfast fluids, 25% of their a.m. snack, lunch, 25% of lunch fluids, p.m. snack, dinner, and 25% of their dinner fluids. 06/01/25: P5 refused breakfast, breakfast fluids, a.m. snack, lunch, lunch fluids, p.m. snack, p.m. snack fluids, dinner, and HS snack. 06/02/25: P5 refused breakfast, breakfast fluids, a.m. snack, lunch, 75% of their lunch fluids, p.m. snack, dinner, and HS snack. 06/03/25: P5 refused breakfast, 75% of their breakfast fluids, a.m. snack, a.m. snack fluids, lunch, lunch fluids, p.m. snack, dinner, 75% of their dinner fluids, and HS snack. 06/04/25: P5 refused breakfast, 75% of their a.m. snack, 75% of their a.m. snack fluids, lunch, p.m. snack, 25% of their p.m. snack fluids, dinner, and HS snack. 06/05/25: P5 refused breakfast, 75% of their a.m. snack, 75% of their a.m. snack fluids, lunch, lunch fluids, p.m. snack, dinner, and HS snack. 06/06/25: P5 refused breakfast, breakfast fluids, a.m. snack, a.m. snack fluids, lunch, p.m. snack, p.m. snack fluids, dinner fluids, dinner, and HS snack. 06/07/25: P5 refused breakfast, a.m. snack, lunch, p.m. snack, dinner, and HS snack. 06/08/25: P5 refused breakfast, a.m. snack, lunch, p.m. snack, dinner, and HS snack. c. P5 medical record indicated on 06/02/25 provider note indicated: An order for P5 to receive Fosfomycin 3 gram every 72 hours, 3 doses from 06/02/25 to 06/09/25 based on 05/30/25 lab results of leukocytosis and urinalysis findings. On 06/04/25 psych Nurse Practitioner (NP), noted P5 was agitated this morning and using restroom frequently. The NP inquired to find out why P5 had not received Fosfomycin yet. The medication time was adjusted in the computer, and they asked the Registered Nurse (RN) to give the first dose now. The Unit Manager and Director of Nursing (DON) are aware, regarding antibiotic missed dose. 3. Review of P1 medical record indicated the following: a. Medical record lacked documentation of provider notification of weight loss of 5 lbs (pounds) or more in one week. Review of P1’s biometrics as follows: 07/12/25: 3:43 a.m., P1 weighed 158.6 lbs. 07/14/25: 7:42 a.m., P1 weighed 151.2 lbs. b. P1’s medical record lacked documentation of weight being obtained at least three times per week. Review of P1’s biometrics as follows: 06/24/25: 7:15 p.m., P1 weight of 160.8 lbs. 06/28/24: 8:01 a.m., P1 weighed 162 lbs. 4. Review of P2 medical record indicated the following: a. Medical record lacked documentation of provider notification of weight loss of 5lb or more in one week. Review of P2’s biometrics as follows: 07/03/25: 6:27 a.m., P2 weighed 184.4 lbs. 07/05/25: 7:10 a.m., P2 weighed 164.4 lbs. b. P2’s medical record lacked documentation of weight being obtained at least three times per week. Review of P2’s biometrics as follows: 06/23/25: 12:27 a.m., P2 weighed 188.8 lbs. 06/29/24: 7:00 a.m., P2 weighed 185.8 lbs. 5. P3’s medical record lacked documentation of provider notification of weight loss of 5lb or more in one week and weight being obtained at least three times per week. Review of P3’s biometrics as follows:. 05/26/25: 8:43 a.m., P3 weighed 114.4 lbs. 06/04/24: 7:30 a.m., P3 weighed 108.2 lbs. 6. Review of P4 medical record indicated the following: a. Medical record lacked documentation of provider notification of weight loss of 5lb or more in one week. Review of P4’s biometrics as follows: 05/31/25: 5:21 a.m., P4 weighed 180.2 lbs. 06/03/25: 7:12 a.m., P4 weighed 173.4 lbs. 7. Interview with A1 (Chief Executive Officer [CEO]) on 07/23/25 at approximately 3:35 p.m., confirmed P1, P2, P3, P4, and P5 medical record information related to weights and nutrition.”

“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, facility nursing staff failed to prevent a patient from being physically assaulted in 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”PSYCHIATRIC PATIENT RIGHTS”, policy number RE.16, last reviewed 3/2023, indicated under PROCEDURE: You have the right to: 6. Reasonable protection from physical or emotional abuse or harassment. 2. P1’s MR (Medical Record) review indicated the following: Nursing note documentation dated 4/28/25 at 7:30 pm indicated loud yelling was heard coming from P2’s room. When staff arrived they witnessed P2 hitting P1 approximately 3-4 times in the face and/or head. Staff immediately intervened separating the two patients. P1 was noted to have bruising and swelling to the lower left eye when assessed. After assessment P1 was escorted to his/her room without further incident. Nursing note documentation dated 5/1/2025 at 2:54 am indicated P1 was pushed to the floor by P2 on 4/30/25 around 7:00 pm. At that time P1 was pushed down to the floor by P2. P1 fell on his/her buttocks. P1 was assessed . No injuries were noted. P2 indicated P1 came into P2’s room, P1 pulled wool from P1’s own brief and poured it on P2 while he/she was sleeping. P2 stated he/she got out of bed and went after P1. P2 pushed P1 out of anger. Nursing note documentation dated 5/12/25 at 5:30 pm indicated P1 was physically assaulted by P11. P1 sustained a small laceration above the right eye. P1 was assessed, laceration cleaned, and bandage applied. 3. Incident Report documentation indicated the following: On 4/28/25 at 6:40 pm indicated P1 was laying on P2’s bed, P2 attempted to coax P1 out of P2’s bed, P1 refused, P2 then struck P1 in the face and or head multiple times before staff separated the patients. P1 sustained a bruise to his/her left cheek below the eye. On 4/30/25 at 7:00 pm indicated P1 entered P2 room reached into his/her brief and pulled a portion of the soiled material out then discarded the soiled material on the floor of P2’s room. P2 then followed P1 to the milieu and pushed P1 causing him/her to fall, bottom first, to the floor. On 5/12/25 at 1:45 pm P1 was head-butted by P11 without provocation. P1 sustained a small laceration above the right eye. 4. Camera footage was reviewed with A2 (Chief Executive Officer) on 5/27/25 at approximately 5:00 pm and indicated the following: On 4/28/25 at 8:37 pm P1 can been seen laying in P2’s bed. P2 enters the room, appears to attempt to wake P1 multiple times, when attempts were unsuccessful P2 pulled the pillow out from underneath P1’s head. P1 attempts to take the pillow from P2, P2 then rapidly hits P1 in the head and/or face approximately 10 times before staff members separate the patients. The entire incident lasted approximately 1 minute. On 4/30/25 at approximately 6:58 pm P1 can be seen entering the room of P2. P2 was laying in bed. P1 walks towards P2 bed, stops, P1 his/her hand down the front of their own brief, P2 motions for P1 to leave the room numerous times, P1 then turns to leave the room, removes his/her hand from the brief throwing what appeared to be a portion of the soiled brief to the side before exiting the room. P1 exits the room into the milieu. P2 follows P1 into the milieu, staff can be seen rushing to separate the two patients, but were unsuccessful. P2 pushed P1 forcefully causing P1 to fall to the floor on his/her backside. Nursing staff can be seen assessing P1. P2 was escorted back to their room by nursing staff. The incident lasted approximately 2 minutes. On 5/12/25 at approximately 1:45 pm P11 can be seen at the doorway of his/her room. P1 was seen walking around the unit without being intrusive. As P1 was walking P11 initiated verbal contact with P1. P1 stopped walking and moved closer to P11. P11 then head-butted the patient quickly at close range once. Staff member responded quickly separating the patients. 5. In interview on 5/27/25 at approximately 2:00 pm with N1 (Registered Nurse) confirmed P2 attacked P1 on 4/28/25 and 4/30/35. N1 indicated P1 displayed wandering intrusive behaviors which contributed to his/her being assaulted by P2 twice. N1 indicated P11 attacked P1 without provocation on 5/12/25.”

“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, observation, and interview, facility nursing staff failed to complete and document patient observation checks as ordered by provider for 3 of 11 medical records reviewed. (P1, P2, & P11) Findings include: 1. Facility policy titled,”PATIENT ROUNDING AND OBSERVATION”, policy number NR.23, last reviewed 12/2024, indicated under PROCEDURE: Patient Rounds are recorded on the daily rounds sheet or in the electronic medical record by assigned staff member. All staff assigned will update the round sheets during their shift to reflect any changes in precaution level, room or bed changes. A new sheet will be started for patients at the time of admission. Staff initials will be used to indicate completion of rounds and must be legible and identified signature at the bottom of the page. 2. Review on P1’s MR (Medical Record) indicated the following: Order documentation dated 4/17/25 indicated P1 was ordered a standard level of observation. On 4/29/25 at 11:48 am P1 was placed on a Line of Sight level of observation as a result of an incident that occurred on 4/28/25. The duration of this increased level of observation was 24 hours and ended at 4/30/25 at 11:48 am. Patient Checks documentation for P1 indicated the following: Lacked documentation of patient checks including but not limited to 4/28/25 at 6:00 pm, 6:15 pm, 7:15 pm, 7:45 pm, 8:30 pm, and 11:45 pm. Lacked documentation of patient checks including but not limited to 4/29/25 at 1:15 am , 2:00 am, 4:00 am, 8:30 am, 9:30 am, 12:15 am, 3:15 am, 3:30 pm, 4:15 pm, 5:15 pm, 6:15 pm, 6:45 pm, 9:00 pm. Lacked documentation of patient checks including but not limited to 4/30/25 at 12:00 am, 2:45 am, 5:00 am, 5:45 am, 6:30 am, 7:15 am, 7:30 am, 9:30 am, 10:15 am, and 10:45 am. On 5/1/25 P1 was placed on a 1:1 (one to one) level of observation at 10:22 am. 1:1 level of observation was implemented for ongoing confusion and altercations with P2. The duration of the 1:1 order was 24 hours ending at 5/2/25 at 10:22 am. Patient Checks documentation for P1 indicated the following: Lacked documentation of patient checks including but not limited to 5/1/25 at 10:45 am, 12:00 pm, 12:45 pm, 2:15 pm, 3:45 pm, 5:00 pm, 6:00 pm, 7:00 pm, 7:30 pm, 8:00 pm, 8:30 pm, 9:15 pm, 9:30 pm, 10:00 pm, 11:00 pm. On 5/12/25 at 2:49 pm P1 was placed on a Line of Sight level of observation as a result of P11 head-butting P1. P1 remained on a Line of Sight level of observation until 5/15/25 at 1:30 pm. Patient Checks documentation for P1 indicated the following: Lacked documentation of patient checks including but not limited to 5/12/25 at 8:15 am, 8:45 am, 9:15 am, 10:45 am 11:15 am, 11:45 am, 12:00 pm, 12:15 pm, 12:45 pm, 1:30 pm, 1:45 pm, 2:15 pm, 2:30 pm, 2:45 pm, 3:15 pm, 3:30 pm, 3:45 pm, 4:15 pm, 4:30 pm, 4:45 pm, 3. Review of P2’s MR indicated on 4/29/25 at 11:52 am P2 was placed on Line of Sight level of observation. The increased level of observation lasted 24 hours ending at 4/30/25 at 12:00 pm. Patient Checks documentation for P2 indicated the following: Lacked documentation of patient checks including but not limited to 4/28/25 at 4:00 pm, 4:15 pm, 5:15 pm, 6:00 pm, 6:15 pm, 7:00 pm, 7:30 pm, 9:30 pm, and 11:45 pm. Lacked documentation of patient checks including but not limited to 4/29/25 at 12:00 pm, 12:45 pm, 3:15 pm, 4:30 pm, 5:15 pm, 5:30 pm, 6:15 pm, and 8:30 pm. Lacked documentation of patient checks including but not limited to 4/30/25 at 4:15 pm, 5:15 pm, 5:30 pm, 6:15 pm, 6:45 pm, 7:15 pm, 7:30 pm, 8:15 pm, 8:30 pm, 9:30 pm, and 11:00 pm. 4. Review of P11’s MR indicated on 5/12/25 P11 head-butted P1, received 25 mg (milligram) IM (Intramuscular) Benadryl. MR for P11 lacked documentation of an increased level of observation initiated after the incident. Patient Checks documentation for P11 indicated the following: Lacked documentation of patient checks including but not limited to 5/1/25 at 11:15 am, 11:45 am , 12:00 pm, 12:15 pm, 12:45 pm, 1:30 pm, 1:45 pm, 2:15 pm, 2:30 pm, 2:45 pm, 3:15 pm, 3:30 pm, 4:15 pm, 4:30 pm, and 4:45 pm. 5. In interview on 5/27/25 at approximately 5:30 pm with A1 (Chief Executive Officer) confirmed patient observations for P1, P2, and P11 were not completed by nursing staff as ordered and should have been.”

“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: 48704 Based on document review and interview, nursing services failed to obtain provider ordered labs in 1 of 10 (Patient 2) medical records reviewed. Findings include: 1. Review of Patient 2’s medical record indicated the following: a. The patient was admitted on 12/27/2024 b. On Saturday, 01/04/2025, at 6:09 p.m. the provider ordered a Basic Metabolic Panel (BMP) and a Lithium level to be drawn on Mondays and Thursdays. MR indicated the order was noted on Sunday, 01/05/2025, at 7:39 a.m. MR lacked documentation that lab was drawn and completed as ordered on Monday, 01/06/2025. c. Patient 2 was discharged on Tuesday, 01/07/2025, in stable condition. 2. Interview with A1 (Quality Manager) on 03/03/2025 at approximately 10:45 a.m. confirmed nursing staff failed to obtain Basic Metabolic Panel and Lithium level as ordered by the provider during patient 2’s hospitalization.”

“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: 49709 Based on document review, observation, and interview, the facility failed to provide patient with protection from abuse for 1 of 1 patient observed in video footage review (P5). Findings include: 1. Review of policy/procedure titled, “Psychiatric Patient Rights,” PolicyNo.: RE 16, last revised 08/2018; indicated under: You have the right to: 6. Reasonable protection from physical or emotional abuse or harassment. 2. Review of policy/procedure titled, “Recognizing And Reporting Suspected Abuse/Neglect/Exploitation,” PolicyNo.: CC.07, last revised 09/2024; indicated under Policy: Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. Indicated under types of abuse: 2. Physical Abuse: A willful infliction of injury by using physical force that may result in bodily injury, physical pain, or bodily function impairment. Examples of physical abuse include, but are not limited to, striking (with or without an object), kicking, hitting, pushing, shoving, shaking, beating, slapping, pinching, and rough handling. 3. Review of 01/09/25 comprehensive psychiatric evaluation at 1:05 p.m., P5 indicated another patient tried to attack them as they tried to go into their room and endorsed receiving a skin tear from the patient hitting their hand. 4. On 02/17/25 at approximately 11:55 a.m., this surveyor, accompanied by A1 (Quality Manager), viewed video footage of the incident on 01/08/25 involving P5 and P10. In the video, this surveyor observed P5 standing in the hall by the double doors, P10 was wandering around the unit headed towards the double doors. When P10 gets to P5 he/she reached out and grab P5’s arm, it appeared as if he/she was smacking P5 and received a skin tear to their hand in the abuse. A8 (Certified Nurse Aide [CNA]) ran to separate both patients. P5 is seen shortly after sitting in the milieu, where A7 (Registered Nurse) takes photos and bandages P5’s wound. 5. Interview with A1 on 02/17/25 at approximately 12:15 p.m., confirmed after reviewing video footage, on 01/08/25 there was an altercation between P5 and P10, and P5 sustained a skin tear from the incident.”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 49709 Based on document review and interview, facility failed to ensure all hospital nursing personnel for whom a current license is required, had a valid and current license for 1 of 5 nursing personnel files reviewed. [A7 (Registered Nurse)] Finding include: 1. Review of National Council State Boards of Nursing, Nurse Licensure Compact indicated under 1. Issued in your primary state of residence (PSOR). 4. When you change your PSOR (relocate) to another compact state, you need to apply for that state’s nursing license within 60 days of relocating. You can only practice on your former multistate license until you are issued your new multistate license from your new PSOR. The former license then becomes invalid. 2. Review of A7 personnel file indicated a professional compact licensure issued from S1 (Another State). A7’s date of hire with facility was 11/09/2022. 3. Review of A7’s driver’s license listed residence as S2 (Current State). 4. Interview with A2 (Chief Executive Officer [CEO]), on 02/17/25 at approximately 1:50 p.m., confirmed A7 is working on a compact license from S1 and has been employed at facility since 2022. A2 confirmed A7 needed an S2 nursing license and did not have one in personnel file.”

“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: 49709 Based on document review and interview, facility failed to ensure immediate completion of an incident report when a patient-to-patient incident occurred for 1 of 10 patient medical records reviewed (P5). Findings include: 1. Review of policy/procedure titled, “Reportable Incidents,” PolicyNo.: NR.36, last revised 03/2024; indicated under policy: reportable incidents are to be completed on state appropriate form and submitted to the applicable state department. Indicated under procedure: reportable incident notification must be completed within 24 hours of the date of discovery when incident occurs. Indicated under reportable incidents: assault by non-staff with injury: physical, involving a patient. 2. Review of policy/procedure titled, “Incident Reports,” PolicyNo.: NR.11, last revised 03/2024; indicated under procedure: an incident report should be completed immediately when an incident occurs. Indicated under what should be reported: assault - patient on patient. Indicated under when should the incident report be completed: all incident reports must be completed and given to charge nurse or Director of Nursing (DON) for review prior to the end of the scheduled shift. 3. Review of 01/09/25 comprehensive psychiatric evaluation at 1:05 p.m., P5 indicated another patient tried to attack them as they tried to go into their room and endorsed receiving a skin tear from the patient hitting their hand. 4. On 02/17/25 at approximately 11:55 a.m., this surveyor, accompanied by A1 (Quality Manager), viewed video footage of the incident on 01/08/25 involving P5 and P10. In the video, this surveyor observed P5 standing in the hall by the double doors, P10 was wandering around the unit headed towards the double doors. When P10 gets to P5 he/she reached out and grab P5’s arm, it appeared as if he/she was smacking P5 and received a skin tear to their hand in the abuse. A8 (Certified Nurse Aide [CNA]) ran to separate both patients. P5 is seen shortly after sitting in the milieu, where A7 (Registered Nurse) takes photos and bandages P5’s wound. 5. Interview with A1 (Quality Manager) on 02/17/25 at approximately 12:35 p.m., confirmed there was not an incident report (IR) regarding the altercation on 01/08/25 between P5 and P10. 6. Interview with A2 (Chief Executive Officer [CEO]) on 02/17/25 at approximately 12:40 p.m., confirmed there was not an IR regarding the altercation on 01/08/25 between P5 and P10.”

“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: 49709 Based on document review, observation and interview, the facility failed to provide the patient with reasonable protection from abuse for 1 of 1 patient incident reviewed (P1) and allowed an employee to continue shift after episode of abuse toward a patient. Findings include: 1. Review of policy/procedure “Patient Rights and Responsibilities,” PolicyNo.: RE 09, last revised 07/2018; indicated under: You have the right to: 6. Reasonable protection from physical or emotional abuse or harassment. 2. Review of policy/procedure titled, “Assaultive/Combative Patients - Management Of,” PolicyNo.: CC.13, last revised 09/2024; indicated under Purpose: (d) ensure that patients received the least restrictive available intervention as warranted by their behavior. Procedure: (2) Do not attempt to approach the patient until adequate help is available. 3. Review of policy/procedure titled, “Recognizing And Reporting Suspected Abuse/Neglect/Exploitation,” PolicyNo.: CC.07, Revised 09/2024; indicated under Policy: Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. Indicated under types of abuse: 2. Physical Abuse: A willful infliction of injury by using physical force that may result in bodily injury, physical pain, or bodily function impairment. Examples of physical abuse include, but are not limited to, striking (with or without an object), kicking, hitting, pushing, shoving, shaking, beating, slapping, pinching, and rough handling. The Hospital shall protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members. 4. Review of disciplinary action form for A11 (Certified Nurse Aide) regarding their suspension and termination. A11’s suspension form dated 1/16/2025 indicated they failed to intervene appropriately and provide a timely intervention with a patient which resulted in a fall. A11 was unable to work until review with an outcome occurred. A11’s termination form dated 1/20/2025 concluded A11 was found to be negligent in the care of a patient resulting in the patient hitting the floor and remaining on the floor without assistance while A11 remained in a chair. 5. On 02/05/25 at approximately 4:30 p.m., this surveyor, accompanied by A1 (Chief Executive Officer), viewed video footage of an incident on 01/16/25 at approximately 12:15 a.m. The incident involving P1 indicated they opened the refrigerator located in the milieu and at that point A11 got up from the chair and attempted to get P1 away from the refrigerator. P1 became aggressive, A11 pushed P1 into the wall, and then down to the floor. A11 walked away from P1 and sat back down in the chair. 6. Interview with A1, on 02/05/25 at approximately 2:45 p.m., A1 confirmed they thought A11 was too aggressive with P1 during an incident on 01/16/25. A1 confirmed A11 was not sent home after the 01/16/25 incident occurred and they completed their shift.”

“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: 49709 Based on document review, observation and interview, nursing services failed to ensure the provider was notified within 1 hour of an incident for 1 of 1 incident reviewed (P1). Findings include: 1. Review of policy/procedure titled, “Incident Reports,” PolicyNo.: NR.11, Revised 03/2024; indicated under: Taking Action And Completing The Incident Report: Provider is notified within 1 hour of an incident/injury. 2. Review of Incident Report (IR) on 01/16/25, indicated (P1) was seen trying to open the refrigerator on 1/16/2025 at approximately 12:15 a.m., staff were redirecting P1 from the refrigerator and in the process P1 fell and sustained a skin tear. P1 denied any other injury. The physician was notified of IR at 5:00 a.m. 3. Review of disciplinary action form for A11 (Certified Nurse Aide) regarding their suspension and termination indicated they failed to intervene appropriately and provide a timely intervention with a patient which resulted in a fall. A11 was unable to work until review with an outcome occurred. A11’s termination form concluded, A11 was found to be negligent in the care of a patient resulting in the patient hitting the floor and remaining on the floor without assistance while A11 remained in a chair. 4. On 02/05/25 at approximately 4:30 p.m., this surveyor, accompanied by A1 (Chief Executive Officer), viewed video footage of an incident on 01/16/25 at approximately 12:15 a.m. The incident involving P1 indicated they opened the refrigerator located in the milieu and at that point A11 got up from the chair and attempted to get P1 away from the refrigerator. P1 became aggressive, A11 pushed P1 into the wall, and then down to the floor. A11 walked away from P1 and sat back down in the chair. 5. Interview with A1, on 02/05/25 at approximately 2:45 p.m., confirmed they thought A11 was too aggressive with P1 during an incident on 01/16/25. 6. Interview with A12 (Certified Nurse Aide), on 02/06/25 at approximately 11:55 a.m., indicated they were working in a different zone when an incident on 01/16/25 took place. They indicated they observed P1 becoming combative. A12 indicated A11 tried to lower P1 to the floor but P1 fell. A12 indicated another staff member asked them to help get P1 off the floor. A12 indicated they observed P1 bleeding, and the nurse was evaluating them.”

“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: 48704 Based on document review and interview, nursing services failed to document 15-minute patient observation checks in 2 of 10 patient medical records reviewed. (Patients 6 and 9) 1. Facility Policy titled, “Patient Rounding”, Policy No.: NU60, last revised 10/2020, indicated under Policy: Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period. 2. Review of Patient 6’s medical record from 08/13/2024 to 09/03/2024 lacked documentation of 821 of 1996, 15-minute patient observation checks including but not limited to 08/17/2024 at 8:45 p.m., 08/21/2024 at 4:00 p.m., 08/24/2024 at 1:30 p.m., 08/27/2024 at 11:15 a.m., 08/27/2024 at 11:30 a.m., and 09/02/2024 at 10:45 p.m. 3. Review of Patient 9’s medical record from 08/27/2024 to 09/04/2024 lacked documentation of 302 of 796, 15-minute patient observation checks including but not limited to 08/28/2024 at 5:15 a.m., 08/29/2024 at 3:30 p.m., 09/01/2024 at 2:30 p.m., 09/03/2024 at 3:00 p.m., and 09/04/2024 at 3:45 a.m. 4. Interview with A1 (Chief Executive Officer), A2 (Quality Manager), and A3 (Director of Nursing) on 09/04/2024 at approximately 5:00 p.m. confirmed that patient 6’s and 9’s medical record lacked 15-minute patient observation checks as mentioned above.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 48704 Based on document review, observation, and interview, the facility failed to ensure the patient the right to be from restraint for 1 of 10 (Patient 8) patient medical records reviewed. Findings include: 1. Facility policy titled, “Psychiatric Patient Rights”, Policy No. RE16, last reviewed 03/2023, indicated Under Procedure, 10. Be free from restraint or seclusion unless there is imminent risk of physical harm to self or others. 2. Review of Patient 8’s medical record indicated the provider ordered 1:1 observation on 06/18/2024 due to patient’s high risk of fall. 3. Review of video surveillance on 06/26/2024 indicated at approximately at 2:43 p.m., S1 (Certified Nursing Assistant) was caring for Patient 8. Video surveillance confirmed S1 held patient 8 down in chair, by placing their hands on the shoulders of the patient. Video confirmed S1 repeatedly forced the patient to stay seated in the chair. S1 then placed the patient in the chair and pinned the patient between the wall and the table where the patient was unable to stand, restraining the patient to the chair. 4. Review of photo from video surveillance on 06/26/2024 indicated at approximately 6:30 p.m., patient 8 was seated in a chair that was pushed up against the edge of a table, placing the patient between the chair and table. A separate chair had been placed up against the back of the chair, back-to-back, to patient 8’s chair patient 8. S2 (Certified Nursing Assistant) sat in the chair that was to the back of patient 8’s chair restraining the patient from getting up from their chair. 5. Review of S6 (Licensed Practical Nurse) investigation written statement dated 06/29/2024, confirmed restraint incident of patient 8 by S2 as indicated above. 6. Review of S3 (CNA) investigation written statement dated 06/28/2024, confirmed restraint incident of patient 8 by S1 as indicated above. 7. Interview with A2 (Regional Quality Manager) on 07/10/2024 at approximately 2:25 p.m., confirmed the incidents above occurred through video surveillance and written witness statements.”

“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: 48704 Based on document review and interview, nursing services failed to document 15-minute patient observation checks in 10 out of 10 patient medical records (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) reviewed with negative outcome for 1 out of 10 patients medical records (Patient 2) reviewed. 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: 48704 Based on document review and interview, nursing services failed to document 15-minute patient observation checks in 10 out of 10 patient medical records (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) reviewed. Findings include: 1. Facility policy titled, “Patient Rounding and Observation”, Policy No.: NR.23. last revised 03/2024, indicated under Policy: Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period. 2. Review of Patient 1’s medical record from 06/07/2024 to 06/7/2024, lacked documentation of 659 of 955, 15-minute patient observation checks, including but not limited to, 06/07/2024 at 8:45 p.m., 06/11/2024 at 4:30 a.m., 06/13/2024 at 4:30 p.m., and 06/16/2024 at 10:00 a.m. 3. Review of Patient 2’s medical record from 06/12/2024 to 06/19/2024, lacked documentation of 480 of 707, 15-minute patient observation checks, including but not limited to, 06/13/2024 at 8:45 p.m., 06/14/2024 at 7:30 p.m., 06/18/2024 at 8:00 p.m., and 06/19/2024 at 6:45 p.m.. Medical record indicated last 15-minute patient observation check on 06/19/2024 was at 6:31 p.m., Medical record lacked 15-minute patient observations between 6:45 p.m. to 8:30 p.m. on 06/19/2024. At approximately 8:30 p.m. on 06/19/2024, the patient was found in their bed covered in blood from a self-inflicted injury that resulted in the patient removing their left eye from the eye socket and had made an attempt to remove their right eye. 4. Review of Patient 3’s medical record from 05/20/2024 to 06/06/2024, lacked documentation of 1191 of 1536, 15-minute patient observation checks, including but not limited to, 05/21/2024 at 2:30 a.m., 05/23/2024 at 3:15 p.m., 05/29/2024 at 4:45 a.m., and 06/02/204 at 2:30 p.m. 5. Review of Patient 4’s medical record from 05/31/2024 to 06/01/2024, lacked documentation of 83 of 180, 15-minute patient observation checks, including but not limited to, 05/31/2024 at 3:00 a.m., 05/31/2024 at 12:30 p.m., 06/01/2024 at 1:00 a.m., and 06/01/2024 at 5:30 a.m. 6. Review of Patient 5’s medical record from 06/11/2024 to 06/21/2024, lacked documentation of 698 of 947, 15-minute patient observation checks, including but not limited to, 06/11/2024 at 06/12/2024 at 1:30 a.m., 06/13/2024 at 2:30 p.m., 06/17/2024 at 11:30 p.m., and 06/18/2024 at 1:15 p.m. 7. Review of Patient 6’s medical record 06/05/2024 to 06/25/2024, lacked documentation of 1283 of 1915, 15-minute patient observation checks, including but not limited to, 06/07/2024 at 3:30 a.m., 06/13/2024 at 8:00 p.m., 06/18/2024 at 11:45 a.m., and 06/23/2024 at 12:30 p.m. 8. Review of Patient 7’s medical record from 06/14/2024 to 06/25/2024, lacked documentation of 682 of 1088, 15-minute patient observation checks, including but not limited to, 06/15/2024 at 5:30 a.m., 06/19/2024 at 7:45 p.m., 06/21/2024 at 4:45 p.m., and 06/24/2024 at 9:30 a.m. 9. Review of Patient 8’s medical record from 06/18/2024 to 06/25/2024, lacked documentation of 362 of 736, 15-minute patient observation checks, including but not limited to, 6/18/2024 at 5:00 p.m., 06/21/2024 at 8:00 p.m., 06/23/2024 at 6:15 p.m., and 06/24/2024 at 10:00 p.m. 10. Review of Patient 9’s medical record from 06/18/2024 to 06/25/2024, lacked documentation of 396 of 709, 15-minute patient observation checks, including but not limited to, 06/18/2024 at 10:15 p.m., 06/20/2024 at 1:30 p.m., 06/22/2024 at 5:30 a.m., 06/24/2024 at 9:45 a.m. 11. Review of Patient 10’s medical record from 06/18/2024 to 06/25/2024, lacked documentation of 333 of 713, 15-minute patient observation checks, including but not limited to, 06/18/2024 at 5:30 p.m., 06/19/2024 at 8:45 p.m., 06/22/2024 at 5:00 a.m., and 06/24/2024 at 10:00 a.m. 12. Interview with A2 (Regional Quality Manager) on 06/25/2024 at approximately 1:00 p.m. confirmed that patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10’s medical record lacked 15-minute patient observation checks as mentioned above.”

“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: 48704 Based on document review and interview, nursing services failed to document 15-minute patient observation checks in 10 out of 10 patient medical records reviewed (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) with negative outcome for 1 out of 10 patient medical records reviewed (Patient 2). 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: 48704 Based on document review and interview, nursing services failed to document 15-minute patient observation checks in 10 out of 10 patient medical records reviewed (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) . Findings include: 1. Facility policy titled, “Patient Rounding and Observation”, Policy No.: NR.23. last revised 03/2024, indicated under Policy: Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period. 2. Review of Patient 1’s medical record from 06/07/2024 to 06/7/2024, lacked documentation of 659 of 955, 15-minute patient observation checks, including but not limited to, 06/07/2024 at 8:45 p.m., 06/11/2024 at 4:30 a.m., 06/13/2024 at 4:30 p.m., and 06/16/2024 at 10:00 a.m. 3. Review of Patient 2’s medical record from 06/12/2024 to 06/19/2024, lacked documentation of 480 of 707, 15-minute patient observation checks, including but not limited to, 06/13/2024 at 8:45 p.m., 06/14/2024 at 7:30 p.m., 06/18/2024 at 8:00 p.m., and 06/19/2024 at 6:45 p.m.. Medical record indicated last 15-minute patient observation check on 06/19/2024 was at 6:31 p.m.; Medical record lacked 15-minute patient observations between 6:45 p.m. to 8:30 p.m. on 06/19/2024. At approximately 8:30 p.m. on 06/19/2024, the patient was found in their bed covered in blood from a self-inflicted injury that resulted in the patient removing their left eye from the eye socket and had made an attempt to remove their right eye. 4. Review of Patient 3’s medical record from 05/20/2024 to 06/06/2024, lacked documentation of 1191 of 1536, 15-minute patient observation checks, including but not limited to, 05/21/2024 at 2:30 a.m., 05/23/2024 at 3:15 p.m., 05/29/2024 at 4:45 a.m., and 06/02/204 at 2:30 p.m. 5. Review of Patient 4’s medical record from 05/31/2024 to 06/01/2024, lacked documentation of 83 of 180, 15-minute patient observation checks, including but not limited to, 05/31/2024 at 3:00 a.m., 05/31/2024 at 12:30 p.m., 06/01/2024 at 1:00 a.m., and 06/01/2024 at 5:30 a.m. 6. Review of Patient 5’s medical record from 06/11/2024 to 06/21/2024, lacked documentation of 698 of 947, 15-minute patient observation checks, including but not limited to, 06/11/2024 at 06/12/2024 at 1:30 a.m., 06/13/2024 at 2:30 p.m., 06/17/2024 at 11:30 p.m., and 06/18/2024 at 1:15 p.m. 7. Review of Patient 6’s medical record 06/05/2024 to 06/25/2024, lacked documentation of 1283 of 1915, 15-minute patient observation checks, including but not limited to, 06/07/2024 at 3:30 a.m., 06/13/2024 at 8:00 p.m., 06/18/2024 at 11:45 a.m., and 06/23/2024 at 12:30 p.m. 8. Review of Patient 7’s medical record from 06/14/2024 to 06/25/2024, lacked documentation of 682 of 1088, 15-minute patient observation checks, including but not limited to, 06/15/2024 at 5:30 a.m., 06/19/2024 at 7:45 p.m., 06/21/2024 at 4:45 p.m., and 06/24/2024 at 9:30 a.m. 9. Review of Patient 8’s medical record from 06/18/2024 to 06/25/2024, lacked documentation of 362 of 736, 15-minute patient observation checks, including but not limited to, 6/18/2024 at 5:00 p.m., 06/21/2024 at 8:00 p.m., 06/23/2024 at 6:15 p.m., and 06/24/2024 at 10:00 p.m. 10. Review of Patient 9’s medical record from 06/18/2024 to 06/25/2024, lacked documentation of 396 of 709, 15-minute patient observation checks, including but not limited to, 06/18/2024 at 10:15 p.m., 06/20/2024 at 1:30 p.m., 06/22/2024 at 5:30 a.m., 06/24/2024 at 9:45 a.m. 11. Review of Patient 10’s medical record from 06/18/2024 to 06/25/2024, lacked documentation of 333 of 713, 15-minute patient observation checks, including but not limited to, 06/18/2024 at 5:30 p.m., 06/19/2024 at 8:45 p.m., 06/22/2024 at 5:00 a.m., and 06/24/2024 at 10:00 a.m. 12. Interview with A2 (Regional Quality Manager) on 06/25/2024 at approximately 1:00 p.m. confirmed that patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10’s medical record lacked 15-minute patient observation checks as mentioned above.”

“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 complete an incident report for a patient exposing him/herself and assaulting a staff member in 1 of 10 medical records reviewed. (P1) Findings Include: 1. Facility policy titled, INCIDENT REPORTS, policy number NU.28, last reviewed 6/2021, indicated PROCEDURE: An incident report should be completed immediately when an incident occurs. Staff will complete an incident report regarding events occurring within the organization that are out of scope of expected events. All sections of the report that pertain to the event should be completed and the incident report form should be filled out. What WHAT SHOULD BE REPORTED: Any event that falls outside of the “norm” of expected event or any situation where there has been harm or potential for harm to a patient, family member, visitor, contractor, or employee requires the completion of an H1 Incident Report. Examples include but are not limited to: Falls, Medication errors / variances, Needle Sticks, Restraint, Assault-patient on staff, Assault-patient on patient, Suicide, Suicide attempt / self-harm attempt / self-inflicted injury, Elopement, Property damage, Allegation of abuse or neglect, Discharge against placing agency recommendation, Inappropriate sexual behavior, Physical illness, Deaths, Any physical injury. 2. MR (medical record) documentation for P1 indicated on 3/25/24, P1 walked up to another patient in the milieu and exposed himself/herself, staff intervened, P1 became physically aggressive towards staff punching the staff member in the chest and head. 3. In an interview on 4/16/24 at approximately 2:52 pm with A1 (Chief Executive Officer) confirmed an incident report was not filed for P1 in relation to him/her exposing him/herself and/or assault of a staff member on 3/25/24 and should have been.”

“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: 48704 Based on document review, observation, and interview, the facility failed to provide care in a safe environment for 1 of 10 patient medical records reviewed. (Patient #10) Findings include: 1. Review of policy titled “Patient Rights and Responsibilities”, Policy Number RE 09, last reviewed 06/2021, indicated patients will be treated in a safe environment. 2. Review of Patient 10’s medical record indicated that on 02/08/2024, patient experienced shortness of breath and A4 (Charge Nurse) placed a plastic bag over patient’s mouth and nose. A6 (Licensed Practical Nurse) requested A4 to remove the plastic bag; the plastic bag was removed. A6 resumed care of the patient. 3. Observation of incident video on 02/08/2024 indicated that A4 obtained a plastic bag from the nurse’s station and placed it over Patient 10’s head for approximately 30 seconds. 4. Interview with A1 (Director of Nursing) on 02/28/2024 at approximately 3:40 p.m. confirmed that A4 placed a plastic bag over Patient 10’s head on 02/08/2024. A1 indicated that A4 was dismissed from staffing.”

“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: 48704 Based on document review and interview, nursing services failed to document vital signs according to policy; discharged or transferred a patient without a written order for 9 of 10 patient medical records reviewed. (Patients 2, 3, 4, 5, 6, 7, 8, 9, and 10). Findings include: 1. Review of policy titled, “Vital Signs”, Policy Number CC.28, last reviewed 06/2021, indicated vital signs will be taken a minimum of three times daily. 2. Review of policy titled “Discharge of Patients”, Policy Number CC.63, last reviewed 06/2021, indicated all patients require a formal discharge and an order from the physician is required for discharge. 3. Review of patient 2’s medical record lacked documentation of vital signs according to policy on 12/14/2023, 12/16/2023, and 12/17/2023; nursing transferred patient to the emergency room on 12/17/2023 without a transfer order. 4. Review of patient 3’s medical record lacked documentation of vital signs according to policy on 12/8/2023 and 12/09/2023; nursing transferred patient to the emergency room on 12/09/2023 and discharged patient on 12/10/2023 without a discharge or transfer order. 5. Review of patient 4’s medical record lacked documentation of vital signs according to policy on 11/26/2023, 11/28/2023, 11/29/2023, 12/1/2023, 12/05/2023, 12/07/2023, 12/09/2023, 12/11/2023, and 12/12/2023; nursing transferred patient to the emergency room on 12/11/2023 and discharged patient on 12/13/2023 without a discharge or transfer order. 6. Review of patient 5’s medical record lacked documentation of vital signs according to policy on 01/03/2024 and 01/06/2024; nursing transferred patient to the emergency room on 01/06/2024 without a transfer order. 7. Review of patient 6’s medical record lacked documentation of vital signs according to policy on 01/19/2024, 01/22/2024, 01/25/2024, 01/27/2024, 01/28/2024, and 01/29/2024; nursing transferred patient to emergency room on 01/25/2024 and discharged patient on 01/29/2024 without a discharge or transfer order. 8. Review of patient 7’s medical record lacked documentation of vital signs according to policy on 02/11/2024, 02/15/2024, 02/21/2024, 02/24/2024, and 02/25/2024; nursing transferred patient to the emergency room on 02/16/2024 and discharged patient on 02/26/2024 without a discharge or transfer order. 9. Review of patient 8’s medical record lacked documentation of vital signs according to policy on 02/01/2024, 02/02/2024, 02/05/2024, 02/06/2024, 02/07/2024, 02/09/2024, 02/10/2024, 02/11/2024, 02/12/2024, 02/14/2024, and 02/16/2024; nursing transferred patient to the emergency room on 02/17/2024 without a transfer order. 10. Review of patient 9’s medical record lacked documentation of vital signs according to policy on 01/16/2024, 01/18/2024, 01/19/2024, 01/20/2024, 01/21/2024, 01/22/2024, 01/23/2024, and 01/24/2024; nursing discharged patient on 01/24/2024 without a discharge order. 11. Review of patient 10’s medical record lacked documentation of vital signs according to policy on 02/08/2024, 02/13/2024, 02/15/2024, 02/16/2024, 02/20/2024, 02/21/2024, and 02/22/2024; nursing discharged patient on 02/22/2024 without a discharge order. 12. Interview with A2 (Regional Quality Manager) on 02/28/2024 at approximately 5:30 p.m. confirmed patients 2, 3, 4, 5, 6, 7, 8, 9,and 10’s medical record lacked documentation of vital signs according to policy and nursing services discharged or transferred patients without written orders. 13. Interview with A1 (Director of Nursing) on 02/28/2024 at approximately 5:30 p.m. confirmed that a discharge or transfer order must be written for patients who are discharged or transferred to the Emergency Room.”

“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: 48704 Based on document review and interview, the facility failed to ensure that agency staff received orientation of facility in 1 of 1 personnel records (A4) reviewed. Findings include: 1. Review of policy titled “Employee Orientation”, Policy Number HR23, last reviewed 09/2018, indicated the purpose of orientation is to ensure all employees develop skills and competencies to effectively and safely perform their duties and responsibilities. The policy indicated an additional policy addressing orientation specifics for contract, registry, and temporary agency staff. 2. Review of A4’s (Registered Nurse) personnel files lacked documentation of facility orientation and competencies related to facility and role. 3. Interview with A1 (Director of Nursing) on 02/28/2024 at approximately 4:45 p.m. confirmed that A4’s personnel file lacked documentation of orientation and competencies related to facility and role. 4. Interview with A2 (Regional Quality Manager) on 02/28/2024 at approximately 5:15 p.m. confirmed the policy referenced in the above policy could not be located.”