Medical Behavioral Hospital of Indianapolis

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to acknowledge, investigate, document and respond to verbal and written grievances for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Patient Grievance Procedure”, PolicyStat ID 13517667, last revised 01/2020, indicated under PROCEDURE: All complaints/grievances may be submitted verbally, in writing to a member of hospital personnel, either by the patient, the patient’s representative or a staff member to whom the complaint/grievance was reported or by means of the Compliance Hotline. Upon notification of a complaint/grievance, information sufficient to identify the individual registering the concern will be recorded: The name of the patient (if not the individual submitting the information). Date of receipt. Nature of the concern. The hospital will investigate the grievance, reviewing any documentation, obtaining statements if needed, and reviewing patient records (as needed). All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are to be considered a grievance that requires immediate redress. The CEO or designee will interview the patient and/or patient’s representative for additional information as needed. The Compliance Officer or designee will also query other members of the healthcare team that have been involved in the care of the patient as necessary. After thorough research has been conducted, the CEO or designee will work in tandem with the Compliance Officer and any staff identified as key individuals critical to problem resolution for the specific identified concern. All efforts will be made to effectively and expeditiously resolve the patient’s grievance. A complaint is considered resolved when the patient is satisfied with the actions taken on his/her behalf. All complaints and grievances will be addressed in a timely manner. This organization will make every attempt to provide a response within seven (7) business days of receiving a complaint/grievance. All complaints and grievances will be logged into a reporting system. 2. Facility policy titled,”Patient Rights and Responsibilities”, PolicyStat ID 13517670, last revised 09/2021, indicated under PROCEDURE:You have the right to: 25. Have complaints/concerns of yours or your representative addressed in a respectful manner as soon as possible. 26. File a grievance or complaint verbally, by phone or in writing to any staff member. All grievances will be addressed in a timely manner. This organization will make every attempt to provide a response within seven (7) days of receiving a grievance. All grievances will be investigated with efforts made toward resolution within seven (7) days of receiving a grievance. 3. Review of P1’s MR (Medical Record) indicated nursing note documentation dated 4/8/26 at 7:00 pm indicated P1 requested to speak with police, social work, and patient advocate. At 10:00 pm P1 was going to notify the patient advocate that P1 misunderstood why he/she was in the hospital. Patient advocate notified of P1’s request. 4. Facility fax documentation dated 4/9/26 at 3:53 pm indicated P1’s POA sent the first of two written grievances r/t (related/to) discharge objections. A second fax was received by the facility on 4/10/26 at 6:54 am. Neither grievance was logged, acknowledged, investigated, nor resolved in a timely manner. Neither of these grievances were listed on the facility’s complaint/grievance logs. 5. In interview on 6/3/26 at approximately 10:30 am with SW1 (Licensed Mental Health Therapist) confirmed he/she had a fabulous relationship with P1’s POA. SW1 endorsed that the patient did not want to be discharged to a LTC (Long Term Care) facility. P1’s POA was threatening to sue H1 (Psychiatric Hospital). The POA voiced concerns and grievance against a proposed option of P1 discharging to home. SW1 relayed concerns to A1 (Chief Executive Officer) verbally, but he/she did not file the complaint and/or grievance related to the POA’s concerns. SW1 confirmed relaying to the POA that NP1(Nurse Practitioner) planned to discharge the patient to home. At which point the POA became upset. 6. In interview on 6/3/26 at approximately 11:30 am with PA1 (Patient Advocate) confirmed spoke with P1, P1 felt that his/her POA (Power of Attorney) was forcing the patient to go to a nursing home. PA1 then spoke with SW1(Licensed Mental Health Therapist) relaying P1’s concerns, SW endorsed that he/she was aware of P1’s concerns. At that point PA1 felt that the situation was already being handled by SW1. PA1 did not file a complaint/grievance on behalf of P1 but should have. 7. In interview on 6/3/26 at approximately 12:30 pm with A1 (Chief Executive Officer) confirmed a complaint/grievance should have been filed by SW1 but was not. Faxed complaint/grievances/ discharge objections should have been addressed and resolved in a timely manner and logged on the facility’s log but were not. Leading to the grievance(s) launched by P1’s POA not being investigated/handled per facility policy/procedure.”

“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 weekly skin assessments in 5 of 10 (Patients 1, 3, 5, 6, and 10) medical records reviewed, failed to document patient belongings upon admission in 3 of 10 (patients 1, 6, and 7) medical records reviewed, failed to document patient belongings were returned to patients upon discharge in 3 of 10 (patients 3, 5, and 9) medical records reviewed. Findings include: 1. Facility policy titled, Skin Assessment, PolicyStat ID 12385990, last approved on 09/2022 indicated under Procedure: Assessment, 1. A head-to-toe assessment should be done prior to or upon admission to the unit. Additional skin assessments should be completed one time per week or as ordered by provider. 2. Facility policy titled, Management of Patient Belongings, PolicyStat ID 13950524, last approved 07/2023, indicated under Procedure:, Admission, 4. Upon admission, staff will inventory all patient belongings, and sign the Personal Belongings Inventory Form. Patient will then sign the form. 3. Review of patient 1’s medical record indicated the following: a. The patient was admitted on 01/30/2026 for a brief psychotic disorder. MR indicated a skin assessment was completed on admission. b. On 02/04/2026, medical record lacked documentation of the weekly skin assessment. c. Medical record lacked documentation of the Patient Personal Effects Inventory form. d. The patient did not return to the facility and was discharged on 02/10/2026. 4. Review of patient 3’s medical record indicated the following: a. The patient was admitted on 04/03/2026 for unspecified mood disorder. Medical record indicated a skin assessment was completed on admission. b. On 04/07/2026, medical record lacked documentation of the weekly skin assessment. c. On 04/14/2026, medical record lacked documentation of the weekly skin assessment. d. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. f. The patient was discharged on 04/19/2026. 5. Review of patient 4’s medical record indicated the following: a. The patient was admitted on 04/25/2026 for unspecified psychosis. b. Medical record lacked the Patient Personal Effects Inventory form. c. The patient was discharged on 04/28/2026. 6. Review of patient 5’s medical record indicated the following: a. The patient was admitted on 04/03/2026 for unspecified mood disorder and suicidal ideations. MR indicated a skin assessment was completed on admission. b. On 04/07/2026, medical record lacked documentation of the weekly skin assessment. c. On 04/14/2026, medical record lacked documentation of the weekly skin assessment. d. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. e. The patient was discharged on 04/17/2026. 7. Review of patient 6’s medical record indicated the following: a. The patient was admitted on 03/18/2026. Admission skin assessment indicated patient had a bruise on their left wrist and partial right middle finger. b. On 03/22/2026, the day shift daily nursing assessment for skin was not completed. c. On 03/23/2026, the day shift daily nursing assessment for skin was not completed. d. On 03/24/2026, the day shift daily nursing assessment for skin was not completed. e. On 03/25/2026, medical record lacked documentation of the weekly skin assessment. f. On 03/26/2026, the day and night shift daily nursing assessment for skin was not completed. g. Medical record lacked documentation of the Patient Personal Effects Inventory form. h. The patient was discharged on 03/27/2026. 8. Review of patient 7’s medical record indicated the following: a. The patient was admitted on 03/20/2026 for schizoaffective disorder and suicidal ideations. b. Medical record lacked documentation of the Patient Personal Effects Inventory form indicating the patient received their personal belongings at discharge. c. The patient was discharged on 04/06/2026. 9. Review of patient 9’s medical record indicated the following: a. The patient was admitted on 03/25/2026 for schizophrenia. b. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. c. The patient was discharged on 04/07/2026. 10. Review of patient 10’s medical record indicated the following: a. The patient was admitted on 04/01/2026 for major depressive disorder with psychotic symptoms. b. On 04/07/2026, medical record lacked documentation of the weekly skin assessment. c. On 04/14/2026, medical record lacked documentation of the weekly skin assessment. d. The patient was discharged on 04/22/2026. 11. Interview with A3 (Chief Executive Officer) on 05/07/2026 at approximately 2:15 p.m. confirmed patient 1, 3, 4, 5, 6, 7 and 9 were missing documentation on the Patient Inventory Form. A3 confirmed patients 1, 3, 5, 6, and 10 were missing weekly skin assessments.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to ensure that a transfer order was written in 1 of 10 (Patients 1) medical records reviewed and failed to ensure that a provider order was written to start intravenous catheter in 1 of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled Physician Orders/Receipt and Notation, last approved 08/2022, indicated under Procedure, 1. Provider orders will be received in a written or telephone format from a credentialed provider. Provider orders are to be dated, timed, and signed. 2. Provider telephone orders may be accepted by an RN, LPN or Pharmacist. Telephone orders are to be verified by a “read back and verified” system. The orders are to be read back to the provider who verbalized the orders, by the individual receiving the orders. Documentation of the “read back” verification process will be indicating utilizing Telephone Order Read Back “TORB” as part of the written order. Provider telephone orders are to be dated, timed and signed. 2. Review of patient 1’s medical record indicated the following: a. The patient was admitted on 01/30/2026. b. On 01/31/2026, Patient Transfer/Transfer Report indicated patient was transferred at 7:55 a.m. to emergency room (Emergency Room); Medical record lacked documentation of a provider order to transfer the patient to the emergency room. c. On 02/10/2026, medical record indicated the patient was transferred to the hospital. Medical record lacked documentation of a provider order to transfer the patient to the emergency room. d. The patient was discharged on 02/10/2026. 4. Review of patient 4’s medical record indicated the following: a. The patient was approved for admission on 04/25/2026; admission note indicated patient arrived at the facility on 04/26/2026 at 7:00 a.m. b. On 04/28/2026, provider note indicated patient with altered mental status, appears somnolent with dry mucous membranes; an attempt to start IV was made but unsuccessful. Due to altered mental status and signs of dehydration, patient sent to ED via EMS. Medical record lacked documenation of provider order to place intravenous catheter and start intravenous fluids. c. The patient did not return to the facility and was discharged on 04/28/2026. 5. Phone interview with P2 (Physician Assistant) on 05/06/2026 at approximately 4:05 p.m. indicated nursing attempted to start an intravenous catheter and informed P2 when they could not place intravenous catheter . 6. Interview with A3 (Chief Operating Officer) on 05/07/2026 at approximately 2:15 p.m. indicated patient 1 was missing transfer orders and patient 6 was missing provider orders to start intravenous catheter . 7. Interview with N1 (Registered Nurse) on 05/07/2026 at approximately 2:35 p.m. indicated notified provider that they were unable to start an intravenous catheter.”

“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 complete and document every 15-minute safety observation checks for 2 of 10 medical records reviewed. (P1 and P2) Findings include: 1. Facility policy titled, “ObservSMART Rounding Policy”, PolicyStat ID 12931622, last revised 12/2025, indicated under III. Procedure: 6. Routine Rounds: Regular 15-minute safety rounds are done throughout each shift on every patient until the patient is discharged. Patient admitted to an inpatient unit will be monitored with paper rounding tool during the admission process. Active ObservSmart rounds will begin once the patient is admitted into the system. At that time, the until BHA will immediately log into the patient and begin rounding. 2. Review of P1’s MR (Medical Record) lacked every 15-minute safety rounds documentation on 2/10/26 from 7:45 pm -10:44 pm. 3. Review of P2’s MR indicated lacked every 15-minute safety rounds documentation on 2/10/26 from 9:30 pm until 7:30 am on 2/11/26. 4. In interview on 3/26/26 at approximately 3:10 pm with N2 (Director of Nursing) confirmed P1/P2 every 15-minute safety observations were not completed by nursing staff but 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 document patient observations in 1 of 10 (Patient 4) medical records reviewed and failed to reassess pain interventions in 1 of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled, Patient Observation, PolicyStat ID: 12931622, Last Approved: 10/2024, indicated under Procedure: 6. Documentation: A. Documentation of all observations will be completed in the patient’s record per their ordered observation status. 2. Facility policy titled, Pain Assessment, Reassessment, Management and Care Plan, PolicyStat ID: 12197199, Last Approved 08/2022, indicated under Procedure: 3. Ongoing Pain Assessment and Effectiveness of Interventions - Completed by all disciplines participating in the care of the patient. If applicable, efficacy of interventions shall be documented prior to the end of the shift. 3. Review of patient 4’s medical record indicated the following: a. On 12/16/2025, the patient was admitted for physical aggression and auditory and visual hallucinations. Admission orders indicated 15 minute observation levels. b. On 12/26/2025, nursing assessment indicated the patient rated their pain at a 9 on a scale from 0 no pain at all, to 10 worst possible pain. Patient administered Tylenol 650 milligrams by mouth at 11:09 a.m. Medical record lacked documentation of effectiveness of intervention. c. On 12/29/2025, medical record lacked documentation of the 15 minute observations checks at 4:15 p.m., 4:30 p.m., 4:45 p.m., 5:00 p.m., 5:15 p.m., 5:30 p.m., 5:45 p.m., 6:00 p.m., and 6:15 p.m. 4. Interview with A2 (Director of Risk and Quality) at approximately 5:35 p.m. confirmed the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to monitor the condition of a chemically restrained patient in 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Restraint of Seclusion Use”, Policy Stat ID 13483128, last revised 01/2025, indicated under ONGOING ASSESSMENT, MONITORING AND EVALUATION DURING RESTRAINT/SECLUSION: A nurse shall observe and assess patients in restraint or seclusion approximately every 60 minutes including respiratory and circulatory status, skin integrity and vital signs. The patient’s response to the intervention or interventions used shall be documented every fifteen(15) minutes throughout the duration of the restraint or seclusion. The fifteen (15) minute monitoring must include the monitoring of the patient’s physical and psychological condition including, but not limited to: Respiratory and circulatory status; Skin integrity; Vital signs. Nursing assessments shall be documented using the restraint/seclusion packet. 2. Review of P1’s MR (Medical Record) indicated on 11/21/25 at 8:20 pm a verbal order for 5 mg (milligrams) of Haldol to be given IM (Intramuscular) was obtained by N1 (Registered Nurse) for P1. P1 was given the chemical restraint injection by N1. Restraint/Seclusion packet documentation indicated P1 was given the chemical restraint d/t (due/to) striking peers/nursing staff. Restraint/seclusion packet documentation for P1 lacked patient’s: reaction to the intervention, medical and behavioral condition, the need to discontinue or continue the restraint, documentation of activity/observations including every 15 minute vital signs and observed behaviors, and patient’s debriefing of the restraint. 3. In interview on 1/2/26 at approximately 4:00 pm with A1 (Chief Executive Officer), confirmed nursing staff should have but did not complete restraint/seclusion packet documentation as required by facility policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to evaluate a chemically restrained patient one hour after the initiation of the chemical restraint for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Restraint of Seclusion Use”, Policy Stat ID 13483128, last revised 01/2025, indicated under ONE-HOUR FACE -TO-FACE ASSESSMENT: A LP or Registered Nurse with a working knowledge of the restraint/seclusion policy and trained to do so will provide a Face-to-Face assessment in person within 1 hour of the use of restraint/seclusion using the restraint/seclusion packet. The one -hour face-to-face assessment will include; An evaluation of the patient’s immediate situation. The patient’s reaction to the intervention. The patient’s medical and behavioral condition. The need to continue or terminate the restraint or seclusion. 2. Review of P1’s MR (Medical Record) indicated on 11/21/25 at 8:20 pm, a verbal order for 5 mg (milligrams) of Haldol to be given IM (Intramuscular) was obtained by N1 (Registered Nurse) for P1, patient was given the chemical restraint injection by N1. Restraint/Seclusion packet documentation indicated P1 was given the chemical restraint d/t (due/to) striking peers/nursing staff. Restraint/seclusion packet documentation for P1 lacked a 1-hour face-to-face assessment that included P1’s immediate situation, P1’s reaction to the intervention, P1’s medical and behavioral condition, the need to discontinue or continue the restraint, consultation of the attending physician or other licensed provider upon completion of the 1-hour face-to-face assessment conducted by a registered nurse, documentation of activity/observations including every 15 minute vital signs and observed behaviors, and P1’s debriefing of the restraint. 3. In interview on 1/2/26 at approximately 4:00 pm with A1 (Chief Executive Officer), confirmed nursing staff should have but did not complete restraint/seclusion packet documentation as required by facility policy.”

“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 ensure every 15 minute patient safety observations were conducted and documented, and failed to document daily bathing and/or showering was offered daily for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Patient Observation”, PolicyStat ID 12931622, last revised 10/2024, indicated under PROCEDURE: 6. Documentation: A. Documentation of all observations will be completed in the patient’s record per their ordered status. B. Staff will complete the patient observation record using a coding system described on the Patient Observation Monitoring Form. C. Staff will initial, date and/or time appropriate documentation in the designated areas for observation of a patient. 2. Facility policy titled,”Patient Personal Care”, PolicyStat ID 12197137, last revised 1/2020, indicated under Education. All patients will be provided education upon admission regarding the process for ADLs, including but not limited to: Unit routine for bathing/showering, toileting, meals, etc. Bathing /showers will be offered daily. 3. Review of P1’s MR (Medical Record) indicated P1 was ordered to be on an observation level of every 15-minutes by a provider on 11/19/25 at 3:35 pm. P1’s MR lacked documentation of every 15-minute safety observation checks completed by facility nursing staff for dates including, but not limited to: 11/20/25 from 8:56 pm-12:13 am; on 11/21/25 at 9:48 pm- 11/22/25 at 12:29 am; on 11/25/25 from 7:15 pm -11:53 pm. P1’s MR lacked documentation of daily bathing/showering completed for dates 11/19/25-11/25/25. 4. In interview on 1/2/26 at approximately 4:00 pm with A1 (Chief Executive Officer), confirmed nursing staff should have but did not complete every 15-minute patient observation documentation as order by a provider, and did not document daily showering and/or bathing.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48704 Based on document review and interview, the facility failed to file an Emergency Detention Order for voluntarily admitted patients who were denied request for release for 2 of 10 (patient 2 and 4) medical records reviewed and failed to discharge an approved request for release in 1 of 10 (patient 3) medical records reviewed. The cumulative effect of this systemic problem resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to file an Emergency Detention Order for voluntarily admitted patients who were denied request for release in 2 of 2 (patient 2 and 4) medical records reviewed and failed to discharge an approved request for release in 1 of 1 (patient 3) medical records reviewed. Findings include: 1. Facility policy titled Patient Discharge-AMA, PolicyStat ID: 13916075, last approved 06/2023, indicated under Policy: Patients will be discharged only upon orders of the attending licensed practitioner. A competent, adult patient cannot be detained from leaving the hospital. Under Procedure: 6. Follow provider orders to place patient on 24-hour hold or discharge the patient AMA. 2. Facility policy titled Emergency Detention Order, Policy Stat ID: 12197144, last approved 08/2024, indicated under Procedure: Emergency Detainment Order (EDO), Within this report, the attending physician must complete one of three paragraphs outlining the current status of the patient (paragraph 3, 4, or 5). Under Paragraph 5 states that the patient has voluntarily signed themselves into a hospital for treatment. In this instance, both the Report Following Emergency Detention and Voluntary Submission Page must be faxed to the Superior Court Probate Division. 3. Review of the Request for Release from Responsibility Form indicated that if the patient request for discharge is denied, the facility within 5 days of the patient’s requests, excluding Saturdays, Sundays, and legal holidays, the court must be petitioned for commitment. 4. Review of patient 2’s medical record indicated the following: a. On 07/18/2025, medical record indicated patient 2 signed a Request for Release From Hospital form at 8:30 p.m. b. On 07/21/2025, medical record indicated P1 (Nurse Practitioner) denied the request for release form at 1:30 p.m.; provider note indicated that patient was denied due to patient’s Emergency Detention Order. c. On 07/22/2025, provider note indicated that Emergency Detention Order was filed. d. The medical record lacked documentation of an Emergency Detention Order. e. The patient was discharged on 07/24/2025. 5. Review of patient 3’s medical record indicated the following: a. On 07/30/2025, medical record indicated patient 3 signed a Request for Release From Hospital form at 8:25 p.m. c. On 07/31/2025, the Request for Release From Hospital form was signed by the provider at 1:34 p.m. granting approval for the patient’s release and indicated patient has been cleared for discharge. e. The medical record indicated the patient was discharged on 08/02/2025; medical record lacked documentation providing explanation for delay in patient’s discharge. 6. Review of patient 4’s medical record indicated the following: a. On 07/27/2025, medical record indicated patient signed a Request for Release From Hospital form and provider denied request for discharge. Provider note indicated the patient was required to finish their Emergency Detention Order. b. The medical record lacked documentation of an Emergency Detention Order. c. The patient was discharged on 08/07/2025. 7. Interview with A1 (Chief Executive Officer) on 12/09/2025 at approximately 3:45 p.m. confirmed that patient 2 and patient 4 did not have Emergency Detention Orders filed after their request for release was declined; confirmed unable to provide documentation why patient 3 was not discharged after provider approved patients release from the 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: 48704 Based on document review and interview, nursing services failed to document daily hygiene care in 9 of 10 (patients 1, 2, 3, 4, 5, 6, 7, 8, and 9) medical records reviewed and failed to document wound care consultation in 1 of 10 (patient 2) medical record reviewed. Findings include: 1. Facility policy titled Patient Personal Care, PolicyStat ID: 12197137, last approved 08/2022, indicated under Education, All patients will be provided education upon admission regarding the process for ADLs, including but not limited to: Unit routine for bathing/showering, toileting, meals, etc.; Bathing/showers will be offered daily. 2. Facility policy titled Wound Care and Treatment, PolicyStat ID 12385988, last approved 09/2022, indicated under Wound Consults, 1. A wound consult may be ordered as determined by the provider; 2. A Wound Care Nurse will meet the patient and assess the wound. 3. Review of patient 1’s medical record lacked documentation of hygiene care on 07/15/2025, 07/16/2025, 07/17/2025, 07/19/2025, 07/20/2025, 07/21/2025, 07/22/2025, 07/23/2025, 07/24/2025, 07/25/2025, 07/26/2025, 07/27/2025, 07/28/2025, and 07/29/2025. 4. Review of patient 2’s medical record indicated the following: a. On 07/18/2025, medical record indicated patient was admitted with a stab wound to the abdomen that was approximately 4 inches deep. b. On 07/19/2025, provider ordered a wound consultation. c. Medical Record lacked documentation of hygiene care on 07/18/2025, 07/20/2025, 07/21/2025, and 07/22/2025 and lacked documentation of a completed wound consultation. 5. Review of patient 3’s medical record lacked documentation of hygiene care on 07/22/2025, 07/23/2025, 07/24/2025, 07/25/2025, 07/26/2025, 07/27/2025, 07/28/2025, 07/29/2025, 07/30/2025, and 07/31/2025. 6. Review of patient 4’s medical record lacked documentation of hygiene care on 07/26/2025, 07/27/2025, 07/28/2025, 07/29/2025, 07/30/2025, 07/31/2025, 08/01/2025, 08/02/2025, 08/03/2025, 08/04/2025, 08/06/2025, and 08/07/2025. 7. Review of patient 5’s medical record lacked documentation of hygiene care on 09/16/2025, 09/18/2025, 09/19/2025, 09/20/2025, 09/21/2025, 09/22/2025, 09/23/2025, 09/24/2025, 09/25/2025, 09/28/2025, 09/30/2025, and 10/01/2025. 8. Review of patient 6’s medical record lacked documentation of hygiene care on 09/11/2025, 09/13/2025, 09/15/2025, 09/16/2025, 09/17/2025, 09/18/2025, and 09/19/2025. 9. Review of patient 7’s medical record lacked documentation of hygiene care on 09/25/2025, 09/26/2025, 09/27/2025, 09/28/2025, 09/29/2025, 09/30/2025, 10/01/2025, 10/02/2025, and 10/03/2025. 10. Review of patient 8’s medical record lacked documentation of hygiene care on 09/21/2025, 09/23/2025, 09/24/2025, 09/25/2025, 09/27/2025, 09/29/2025, 09/30/2025, and 10/01/2025. 11. Review of patient 9’s medical record lacked documentation of hygiene care on 09/29/2025, 09/30/2025, 10/01/2025, 10/02/2025, 10/03/2025, 10/04/2025, 10/05/2025, 10/06/2025, 10/07/2025, 10/08/2025, 10/09/2025, and 10/10/2025. 12. Interview with A2 (Director of Risk & Quality) on 12/09/2025 at approximately 3:55 p.m. confirmed that patient 2’s medical record lacked documentation of wound consultation and patients 1, 2, 3, 4, 5, 6, 7, 8, and 9 lacked documentation of hygiene care as stated above.”

“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, nursing services failed to file an incident report for a medication error in 1 of 1 (patient 5) medical record reviewed. Findings include: 1. Facility policy titled General Medication Administration, PolicyStat ID: 12386373, last approved 09/2022, indicated under Process: Medication errors occurring during administration will be reported immediately to the provider on call. A medication variance report will be sent to the Director of Nursing and Pharmacy Services by the end of the shift in which the error occurred. An incident report will be completed. 2. Review of patient 5’s medical record indicated the following: a. Medical record lacked documentation of hygiene care on 09/16/2025, 09/18/2025, 09/19/2025, 09/20/2025, 09/21/2025, 09/22/2025, 09/23/2025, 09/24/2025, 09/25/2025, 09/28/2025, 09/30/2025, and 10/01/2025. b. Medical record indicated the provider ordered to continue Invega 9 milligrams (mg) PO (by mouth) every morning. b. On 09/17/2025, provider ordered to increase Invega to 12 mg PO every morning. c. On 09/24/2025, 09/25/2025, and 09/26/2025, the medication administration record indicated patient was administered Invega 9 mg PO at 9:00 a.m.; Medical record indicated that the provider ordered Invega 12 mg PO on 09/17/2025 and the order was active. 3. Interview with A2 (Director of Risk & Quality) on 12/09/2025 at approximately 3:55 p.m. confirmed an incident report should be filled out by nursing staff for medication errors, confirmed patient 5 received the wrong dose of medication on 09/24/2025, 09/25/2025, and 09/26/2025, and there was not an incident report filed for the above medication errors.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 48704 Based on document review and interview, social services failed to complete timely progress notes for 2 of 10 (Patient 5 and 10) medical records reviewed. Findings include: 1. Facility policy titled Discharge Planning, last approved 03/2024, indicated under Documentation: The Social Worker documents discharge information on social services notes and the Master Treatment Plan utilized by the multidisciplinary team. 2. Facility policy titled, Assessment-Psychological, PolicyStat ID: 12197139, last approved 08/2022, indicated under Documentation: Communication with patients, family, or agencies in the interdisciplinary progress notes and will meet the standards of confidentiality. 3. Review of patient 5’s medical record indicated patient was admitted on 09/16/2025. Medical record lacked documentation of social services progress notes after 09/18/2025; patient was discharged on 10/02/2025. 4. Review of patient 10’s medical record indicated patient was admitted on 09/05/2025. Medical record lacked documentation of social services progress notes between 09/19/2025 through 10/09/2025 and 11/18/2025 through 12/09/2025; at time of survey, patient was a current inpatient. 5. Interview with A4 (Director of Clinical Services) on 12/09/2025 at approximately 4:30 p.m. confirmed that social services should document all communication regarding the patient and patient’s discharge on social services progress notes.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 48704 Based on document review and interview, social services failed to complete the bio-psychosocial assessment within 72 hours of patient admission in 5 of 10 (patients 2, 3, 4, 7, and 8) medical records reviewed. Findings include: 1. Facility policy titled Assessment-Psychological, PolicyStat ID 12197139, last approved 08/2022, indicated under Procedure, The Social Worker will complete the bio-psychosocial assessment. Initial contact will be made with the patient and/or family member within 72 hours following admission. Under Documentation, Communication with the patient, family or agencies/organizations in the community will be documented in the interdisciplinary progress notes and will meet the standards of confidentiality. 2. Review of patient 2’s medical record indicated the following: a. The patient was admitted on 07/18/2025 at 2:00 p.m. b. On 07/24/2025, medical record indicated the patient’s psychosocial assessment was completed at 10:50 a.m., 2 days, 20 hours, 50 minutes late per policy. 3. Review of patient 3’s medical record indicated the following: a. The patient was admitted on 07/22/2025 at 6:15 p.m. b. On 07/31/2025, medical record indicated the patient’s psychosocial assessment was completed on 07/31/2025 at 10:11 a.m.; 5 days, 15 hours, 56 minutes late per policy. 4. Review of patient 4’s medical record indicated the following: a. The patient was admitted on 07/26/2025 at 3:30 a.m. b. On 07/31/2025, medical record indicated the patient’s psychosocial assessment was completed at 12:18 p.m.; 2 days, 8 hours, 48 minutes late per policy. 5. Review of patient 7’s medical record indicated the following: a. The patient was admitted on 09/25/2025 at 3:45 a.m. b. Medical record indicated the patient’s psychosocial assessment was completed on 09/28/2025 at 1:45p.m.; 10 hours late per policy. 6. Review of patient 8’s medical record indicated the following: a. The patient was admitted on 09/19/2025 at 7:00 p.m. b. MR indicated the patient’s psychosocial assessment was completed on 09/24/2025 at 12:30 p.m.; 1 day, 16 hours, and 30 minutes late per policy. 7. Interview with A1 (Chief Executive Officer) on 12/09/2025 at approximately 3:55 p.m. confirmed social services have 72 hours from admission to complete the bio-psychosocial assessment and patients 2, 3, 4, 7, and 8’s bio-psychosocial assessments were not completed on time as indicated 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: 48704 Based on document review and interview, nursing services failed to notify the provider of patient’s refusal of nutrition and weight loss, failed to obtain provider order for patient transfer and nutritional supplement, and failed to document patient’s weekly weight in patient’s medical record in 1 of 10 (Patient 5) medical records reviewed. Findings include: 1. Facility policy titled, Vital Signs and Weight, PolicyStat ID; 12386461, last approved 09/2022, indicated under Procedure: Weights will be taken a minimum of once a week, unless diagnosis deems need for increased frequency weighing and the provider orders a more frequent schedule. Nurses will notify the provider of findings outside patient’s normal range. Record vital signs and weekly weights in the patient’s medical record. 2. Facility policy titled, Change of Condition, PolicyStat ID, 12197218, indicated under Procedure: 1. All nursing staff members will communicate any noted changes of condition that a patient has to the assigned nurse of the patient. 3. Review of Patient 5’s medical record indicated the following: a. The patient was admitted on 08/02/2025 for major depressive disorder, suicidal ideations, and anxiety. Patient admission orders indicated patient was placed on a regular diet; patient’s admission weight was 112 pounds (lbs.). a. On 08/06/2025, Medical record indicated the patient’s weight was 117.1 lbs. Medical record indicated patient refused dinner and lacked documentation that provider was notified. b. Between 08/07/2025 and 08/12/2025, medical record indicated patient consumed all meals with greater than 80% consumption for every meal. c. On 08/13/2025, Medical record indicated the patient’s weight was 112.7 lbs. with a loss of 4.4 pounds in 7 days. Medical record lacked documentation that provider was notified. d. On 08/14/2025, MR indicated that patient was in bed and refused breakfast. Nursing note indicated that patient wanted to stay in bed and did not want breakfast. MR lacked documentation that provider was notified. e. On 08/19/2025, nursing note indicated the patient refused dinner and evening snack; patient drank a nutritional supplement. Medical record lacked documentation that provider was notified and provider order for Ensure supplements. Nursing note indicated patient had a change in condition, provider notified; patient transferred to Facility #2 (Acute Care Facility) at 11:30 a.m. for change in condition, lethargy. Medical record lacked provider order for transfer. f. On 08/20/2025, the patient’s weight in unit weight book was 108 lbs. with a loss of 4.7 lbs. in 7 days. Medical record indicated patient drank a nutritional supplement. Medical record lacked documentation of provider order for nutritional supplements, of patient’s weight in the medical record, and provider notification of weight loss. g. On 08/21/2025, nursing note indicated patient was not responsive and provider ordered to send patient to Facility #2 for evaluation and treatment. Patient was admitted to Facility #2 and did not return to Facility #1 (Psychiatric Care Facility). 4. Interview with A3 (Director of Risk/Quality) on 11/18/2025 at approximately 11:40 a.m. confirmed the following: a. Patient 5’s medical record indicated total weight loss for hospitalization was 9.1 pounds in 20 days. b. Patient 5’s weight was documented in unit weight binder and was not documented in patient’s medical record. c. Medical record lacked documentation of provider notification of refusal of meals and loss of weight. d. Provider order for nutritional supplements on 08/19/2025 and 08/20/2025 and provider order for patient transfer on 08/19/2025.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to schedule a care conference involving family in 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Team-Family Conference”, PolicyStat ID 12197127, last revised 01/2020, indicated under PROCEDURE: Family Care Conference. The hospital will make every attempt to schedule a care conference involving the family, guardian/POA (Power of Attorney), and patient (if possible) as well as the interdisciplinary care team within the first week of the patient’s admission. 2. Review of P1’s MR (Medical Record) lacked documentation of facility staff making every effort schedule a family care conference with P1’s family/POA/guardian within the first week of admission. 3. In interview on 9/3/25 at approximately 4:00 pm with A1 (Chief Executive Officer) confirmed there was no family care conference with the interdisciplinary team for P1 during hospitalization. Confirmed a care conference should have been offered but P1’s MR lacked documentation of an offer and/or refusal by P1’s POA/family/representative. Confirmed a care conference should have been offered to the POA but was not.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to complete documentation on the patient effects inventory form upon discharge for 2 of 10 medical records reviewed (P1 & P2), and failed to notify a provider of abnormal patient vital signs in 1 of 10 medical records reviewed. (P1) Findings Include: 1. All Staff Meeting minutes dated 8/8/24 at 7:30 am, 1:30 pm, and 4:00 pm indicated that Inventory Patient Belongings, At discharge, BHAs can gather the patient belongings but IT IS THE NURSES RESPONSIBILITY TO ENSURE THE DISCHARGING PATIENT HAS THEIR BELONGINGS AND HAS SIGNED THEIR INVENTORY SHEET PRIOR TO LEAVING THE UNIT. 2. Facility policy titled, “Provider Communication”, PolicyStat ID 92275841, last revised 01/2025, indicated under POLICY: Licensed nursing staff are responsible for notifying providers of any changes in patient conditions that may negatively impact treatment or medical well-being. Communication ensures timely interventions to support patient safety and care. PROCESS: 2. Notification Process: Primary Notification: Notify the in-house medical and/or psychiatric provider immediately. Document the notification and result in the patient’s chart. On-Call Notification: If the in-house provider is unavailable, notify the on-call provider. Document the notification and result. Escalation to Medical/Psychiatric Director: If the first provider cannot be contacted or fails to respond within 15 minutes, place a second call to the same provider. If no response is received within an additional 15 minutes, contact the second listed provider. Allow 15 minutes for the second provider to respond. If neither the in-house nor on-call provider responds, escalate the issue to the Medical/Psychiatric Director. 3. Review of P1’s MR (Medical Record) Personal Effects Inventory form dated 5/21/25 indicated an itemized inventory of P1’s personal effects were documented by nursing staff. Vital signs documentation dated 5/26/25 at 8:00 am indicated P1’s temperature was 103.7 degrees Fahrenheit, pulse was 117 beats per minute, respirations of 13 breaths per minute, blood pressure of 146/64 mmHg (millimeters of mercury), no pain score documented. No provider notification was documented for abnormal vital signs. P1’s MR lacked documentation of discharge patient effects inventory by nursing staff that should have included nursing staff signature, signature of patient and/or patient representative, date and time of returning P1’s effects to the patient and/or representative. Lacked notification to a provider of P1’s abnormal vital signs from 5/26/25 at 8:00 am. 4. Review of P2’s MR indicated the patient personal effects inventory documentation dated 8/16/25 at 8:00 pm indicated an inventory of P2’s effects were taken by nursing staff upon admission. P2’s MR lacked documentation of a completed exit inventory of P2’s personal effects that included a signature by discharge nursing staff, patient and/or representative, with date and time. 5. In interview on 9/3/25 at approximately 2:30 pm with A4 (Director of Quality) confirmed P1 and P2’s patient effects inventory form should have been completed at discharge containing signature(s) of both nursing personnel and/ or family/representative, date, and time but was not.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to notify a hospital provider of the existence of an advanced directive and failed to communicate to a receiving hospital the existence of an advanced directive for 1 of 10 medical records reviewed. (P2) Findings include: 1. Facility policy titled, “Advanced Directives in Hospital”, PolicyStat ID 13517664, last revised 06/2021, indicated under PROCEDURE: 10. The patient’s hospital provider will be notified of the existence of an Advance Directive. 11. If the patient is transferred, referred or discharged to another organization, the existence of any Advance Directives for care is communicated to the receiving organization. 2. Review of P2 MR from H2 (Psychiatric Hospital) indicated an advance directive dated 5/7/25, P2 was designated to be a DNR (Do Not Resuscitate) with comfort measures only (allowing a natural death). This document was signed by P2’s child and P2’s doctor on 5/7/25. This document indicated P2’s child was his/her Healthcare Power of Attorney. P2’s MR lacked documentation of a provider notification of P2’s advance directive as required by facility policy. Transfer documentation dated 5/26/25 at 12:50 pm indicated P2 was transferred to H3 (Acute Care Hospital) d/t (due/to) mental status changes. Transfer documentation indicated P2 was a full code. 3. Review of P2 MR from H3, Discharge Summary documentation dated 6/6/25 indicated P2 arrived at H3 on 5/26/25 at 1:11 pm. P2 was subsequently intubated on 5/26/25 for airway protection related to hypoxia and decreased level of consciousness. 4. Interview on 8/22/25 at approximately 10:10 am with A2 (Chief Executive Officer) confirmed the advance directive was present in the medical record of P2. A2 confirmed he/she could not determine when P2’s advanced directive was received by H1. A2 confirmed P2’s full code status was not updated to a DNR (Do Not Resuscitate) status when P2’s advance directive was received 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: 48061 Based on document review and interview, facility nursing staff failed to notify a medical provider in a timely manner of a patient’s change in condition requiring emergency medical treatment and/or transfer to higher level of care for 2 of 10 medical records reviewed (P1, P2); failed to notify a medical provider of an unwitnessed patient fall within a timely manner for 1 of 10 medical records reviewed (P1). Findings include: 1. Facility policy titled,”Change of Condition”, PolicyStat ID 12197218, last revised 05/2021, indicated under POLICY: It is the policy of the hospital that providers will be notified of patients that have changes in their condition in a timely manner. Nursing staff will document these changes, provider notifications, and an interventions and/or orders regarding the change of condition in the patient’s medical record. PROCEDURE: 2. The nurse will evaluate the patient and notify the provider with findings. 3. Findings, provider notification, and any interventions and/or orders received will be documented. The change of condition will continue to be monitored and provider updated as needed. 4. A sample list of possible changes in condition would include but not be limited to: b. Falls. c. Change in mental status. 2. Facility policy titled, “Provider Communication”, PolicyStat ID 92275841, last revised 01/2025, indicated under POLICY: Licensed nursing staff are responsible for notifying providers of any changes in patient conditions that may negatively impact treatment or medical well-being. Communication ensures timely interventions to support patient safety and care. PROCESS: 2. Notification Process: Primary Notification: Notify the in-house medical and/or psychiatric provider immediately. Document the notification and result in the patient’s chart. On-Call Notification: If the in-house provider is unavailable, notify the on-call provider. Document the notification and result. Escalation to Medical/Psychiatric Director: If the first provider cannot be contacted or fails to respond within 15 minutes, place a second call to the same provider. If no response is received within an additional 15 minutes, contact the second listed provider. Allow 15 minutes for the second provider to respond. If neither the in-house nor on-call provider responds, escalate the issue to the Medical/Psychiatric Director. 3. Review of P1’s MR post fall huddle form documentation dated 5/26/25 at 2:35 am, indicated P1 was found on the hallway floor after an unwitnessed fall. P1 was with his/her wheelchair and sustained approximately 1 inch skin tear to the right elbow. Provider notification time was documented as 4:27 am. P1’s MR indicated change in condition notification to medical provider was completed at approximately 8:00 am. P1’s MR lacked documentation of immediate nursing interventions used to stabilize the patient. 4. Review of P2’s MR nursing note dated 5/26/25 at 8:00 am indicated P2 was found resting in bed, eyes closed, and difficult to arouse. At 8:30 am N1 tried to get P2 up but his/her mental status was declining. At 10:00 am N1 called NP1 notifying the provider of the change in condition. Transfer time was documented as 12:50 pm on 5/26/25. 5. Interview on 8/21/25 at approximately 1:15 pm with N1 (Registered Nurse) confirmed he/she was the primary nurse for both P1 and P2 on 5/26/25 at the time of their transfers to H2 (Acute Care Hospital). N1 indicated was not the primary nurse for P1 when he/she had an unwitnessed fall. N1 confirmed provider notification related to change in condition was to be as soon as possible, but was not for P1. N1 confirmed his/her documentation times on 5/26/25 for P2 were correct, but could not recall why there was a delay in notifying NP1 (Nurse Practitioner) of P2’s decline in mental status and/or a delay in calling emergency medical transportation. 6. In interview on 8/21/25 at approximately 2:00 pm with NP1 (Registered Nurse) confirmed provider notification should have been as soon as possible for both P1 and P2’s change in conditions on 5/26/25, but was not notified until a later time. 7. Interview on 8/22/25 at approximately 2:00 pm with N2 (Registered Nurse) confirmed he/she was the primary nurse for P1 when he/she had an unwitnessed fall on 5/26/25 at approximately 2:30 am. N2 could not confirm a reason for the delay in provider notification related to P1’s fall. N2 confirmed notification of the medical provider should have been as soon as possible but wasn’t. 8. Interview on 8/22/25 at approximately 3:15 pm with A5 (Director of Nursing) confirmed nursing staff are trained to notify providers if there is any change in condition as soon as possible. Confirmed provider notification for P1 and/or P2’s change condition was not completed in a timely manner and should have been.”

“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: 48061 Based on document review and interview, nursing services failed to complete incident reports related to emergent transfers in 2 instances (P1, P2) Findings include: 1. Facility policy titled,”Incident Reports”, PolicyStat ID 13033981, last revised 01/2023, indicated under PROCEDURE: Time Frame for Completing an Incident Report: A. After providing for the needs of the individuals involved, hospital staff must complete and submit an incident report as soon as possible. Preferably, the report should be submitted before leaving the hospital at the end of the work shift, but no later than twenty-four (24) hours from the time the even occurred. 2. Facility incident report log was reviewed for the months of 1/1/25-8/22/25. This log lacked a filed incident report related to P1’s change in condition requiring emergent transfer to H3 on 5/26/25, and lacked filed incident report related to P2’s change in condition requiring emergent transfer to H3 on 5/26/25. 3. Interview on 8/21/25 at approximately 1:15 pm with N1 (Registered Nurse) confirmed incident reports are to be completed on all patients who are transferred emergently. 4. Interview on 8/22/25 at approximately 3:15 pm with A5 (Director of Nursing) confirmed incident reports related to P1 and P2’s emergency medical transfer was not completed by N1.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to implement increased post fall nursing interventions for 1 of 10 medical records reviewed. (P1) Findings Include: 1. Facility policy titled,”Fall Prevention Program”, PolicyStat ID 13554604, last revised 04/2023, indicated under POLICY: It is the policy of the Hospital to assess and appropriately identify patients who are at risk for possible falls while hospitalized. A Fall Prevention Program will be implemented and maintained to assure the safety of all patients admitted to the facility. The program will in inclusive of measures which determine the individual needs of each patient by assessing the risk of falls, and implementation appropriate staff interventions to assure a safe environment is maintained, adequate supervision is provided, and assistive devices are utilized when necessary. All falls occurring during hospitalization will be evaluated to determine the potential causative factors and discern appropriate interventions. PROCEDURE: POST FALL EVALUATION: 1. Each time a patient falls, the patient will be assessed by the nurse directly after the fall and the nurse will notify the provider to obtain any necessary orders. 2. Review of P1’s MR (Medical Record) indicated: a. P1 was admitted to H1 (Psychiatric Hospital) on 5/28/2025. Patient suffered a fall at H1 on 6/3/25 at approximately 8:30 pm. P1 hit his/her head causing an injury with bleeding to the back of the head. P1 required an emergency send out to H2 (Acute Care Hospital) where he/she received two staples as closure for a laceration to the back of the head sustained from the fall. At the time of this fall the patient was on every 5 minute observation precautions and non-skid socks. MR lacked documentation of additional fall precautions initiated/implemented by nursing staff. b. P1 was medically cleared at H2 and transferred back to H1 at approximately 2:10 am on 6/4/25. While being assisted by H1 staff to bed the patient fell a second time onto his/her bottom. P1 was transferred from unit 400 to unit 100 for the use of a medical bed that was closer to the floor. MR lacked documentation of additional precautions initiated/implemented by nursing staff. c. P1 suffered a third fall on 6/4/25 at approximately 6:30 am. This fall was unwitnessed by nursing staff. P1 hit his/her head, reopening the stapled laceration, and bleeding was noted from the wound. P1 required an emergency transfer to H2 for assessment and treatment related to the third fall. P1 did not return to H1 after being transferred to H2. 4. Telephone interview on 6/17/25 at approximately 4:28 pm with N1 (Registered Nurse) confirmed after a patient falls the falls protocol would be initiated that includes documenting about the fall, implementing nursing measures as needed, notifying the provider or provider on-call, calling 911 for an emergency send out if needed. Bed alarms can be initiated as a nursing safety measure without a provider order but a 1:1 observation may not. 5. Telephone interview on 6/17/25 at approximately 4:35 pm with MD1 (Medical Doctor) confirmed he/she was the on call provider notified of P1’s three falls. MD1 confirmed the nursing staff should follow the post fall protocol/instructions for guidance on implementing nursing measures related to falls. MD1 confirmed no 1:1 level of observation was requested by nursing staff in relation to his/her falls. 6. In interview on 6/17/25 at approximately 4:45 pm with A2 (Risk Management) confirmed no bed alarm was initiated/implemented for P1.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to report significant change in patient weight to a provider, failed to complete point of care blood glucose checks as order by provider, failed to complete laboratory blood testing as ordered by provider, failed to notify a supervisory practitioner of patient care concerns, and failed to review and update a care plan for 1 of 10 medical records 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: 48061 Based on document review and interview, facility nursing staff failed to report significant change in weight to a provider, failed to complete point of care blood glucose checks as order by provider, failed to complete laboratory blood testing as ordered by provider, and failed to notify a supervisory practitioner of patient care concerns in 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled, “Vital Signs and Weight”, PolicyStat ID 12386461, last revised 09/2022, indicated under PROCEDURE: Staff is to report any significant changes or abnormal findings to the nurse. Nurses will notify the provider of findings outside patient’s normal range. 2. Facility policy titled, “Patient Refusal of Food”, PolicyStat ID 12522835, last approved 10/2022, indicated under PROCEDURE: 4. If meal refusal or poor food consumption continues to be a problem, weekly weights are to be initiated. If a significant weight loss is incurred, the physician is to be contacted. If an insulin-dependent diabetic continues to eat poorly or refuse meals, the physician will be contacted by the nursing staff. 3. Facility policy titled,”Laboratory Process”, PolicyStat ID 12197196, last approved 08/2022, indicated under PROCEDURE: 1. Provider orders lab. 2. Nurse transcribes order onto patient lab sheet, which is with the patient’s MAR. 3. Nurses place order for laboratory tests on lab website. 4. Nurses and/or phlebotomist obtains specimen for ordered tests. 8. Nurses/Unit Clerks obtain laboratory results for lab website and print results. 1. Nurse updates provider of abnormal results as needed, including obtaining any new orders. 9. Nurses/Unit Clerks place printed results in the patient’s medical record for the provider to review. 10. Lab Refusals shall be documented on the lab sheet in the patient’s MAR and/or the Nursing narrative. 4. MR (Medical Record) review for P1 indicated provider orders were placed on 12/25/24 at 6:30 pm for laboratory tests including CBC (Complete Blood Count) with Differential, BMP (Basic Metabolic Panel, CMP (Comprehensive Metabolic Panel), TSH (Thyroid Stimulating Hormone), and Urinalysis with C & S (Culture & Sensitivity). On 12/26/24 at 3:00 pm provider orders for laboratory tests for P1 included BMP, TSH, Vitamin D level, and Accu checks (point of care blood glucose testing) before meals and at bedtime. Rationale for the provider order was P1’s decreased appetite. On 12/29/25 at 1:07 pm provider orders for P1 included laboratory tests of CBC and CMP. Rationale for the provider order was P1’s refusal of meals, medications, and drinks. Nursing narrative documentation for dates 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/2/25, 1/3/25, 1/4/25 indicated nursing staff notified in-house and/or on-call provider notification of P1’s refusal of meals, drinks, and medications. P1’s MR indicated his/her admission weight was 137.5 lbs, weekly weight on 1/1/25 was 113 lbs. MR for P1 lacked supervisory provider notification of P1’s refusal to eat, drink, or take medications after nursing concerns were not satisfied by either the in-house and/or on-call provider, lacked documentation of completed laboratory orders performed by nursing as ordered on 12/25/24, 12/26/24, and 12/29/24, lacked notification to a provider of a 24 lb weight loss in a seven day period by P1. 5. In interview on 1/23/25 at approximately 12:00 pm with N1 (Registered Nurse) confirmed provider notification of P1 not eating, drinking, and refusal of medications to both medical and psychiatric providers numerous times. Confirmed knowing how to escalate concerns to the supervisory medical doctor if concerns are not being met. Confirmed he/she did not escalate his/her concerns to the attending physician but should have. 6. In interview on 1/23/24 at approximately 12:30 pm, A4 (Director of Quality and Risk) confirmed ordered laboratory studies for P1 were not completed by nursing and should have been. 7. In interview on 1/24/25 at approximately 10:47 am with MD1 (Medical Doctor), confirmed he/she was not notified by nursing staff with concerns of P1 refusing, meals, medications, drinks, or significant weight loss in a seven-day period. 8. In interview on 1/24/25 at approximately 11:30 am with NP2 (Nurse Practitioner) confirmed he/she was the main medical provider for P1, does not remember if he/she followed up on the orders placed for laboratory work and accuchecks, confirmed he/she completes face-to-face assessments with the patients, confirmed he/she doesn’t know why or does not have a good answer for the lack of interventions established by him/her despite nursing notification of continued refusal of medications, meals, and drinks by P1.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48061 Based on document review, facility nursing staff failed to review and update a care plan for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Plan of Care-Protocol for the Use of the Interdisciplinary Format”, PolicyStat ID 12197123, last approved 08/2022, indicated under PROCEDURE: Phase II: Formulating the Interdisciplinary Treatment Plan (Initial Session). The Interdisciplinary Treatment Team will meet on a weekly basis to ensure the preparation, review, and update of each patient’s individualized problem, goals, and approaches through an interdisciplinary approach. The Interdisciplinary Treatment Team meetings will be attended by at least the Psychiatrist or designee, Director of Nursing or designee, Social Worker, Psychology, Therapy Services, Medical Provider (or designee), Utilization Review, Dietary, and Pharmacy. 2. MR (Medical Record) review for P1 indicated nursing documentation of P1 was refusing meals, medications, and liquids on 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/2/25, 1/3/25, and 1/4/25. Interdisciplinary care plan for refusing meals was created 12/25/24 at 5:10 pm by N1 (Registered Nurse). Short term goals included P1 was to maintain or increase his/her body weight during hospitalization. Nursing interventions initiated on 12/25/24 included weighing the patient weekly, monitoring fluid and food intake/output and assessing daily for signs or symptoms of nutritional issues along with notifying the provider if signs or symptoms worsened. No Provider interventions were documented on this care plan. On 12/27/24 dietary services initiated an intervention for nutritional supplements three times a day. MR for P1 lacked documentation of P1’s nutritional care plan being reviewed per policy by nursing, lacked documented nursing interventions to aid P1 in increasing intake of meals, medications, or liquids.”

“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 notify a change in the patient’s condition to a provider in 1 out 13 patient (Patient 4) medical record reviewed; failed to document medications administered in 1 out of 10 patient (Patient 1) medical records reviewed; failed to obtain discharge orders in 2 out of 10 patient (Patients 3 and 5) medical records reviewed; and failed to notify providers of patient weight loss in 3 out of 10 patient (Patients 4, 11, and 13). The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to obtain consents for treatment in 1 out of 13 (Patient 13) patient medical records reviewed. Findings include: 1. Facility policy titled, Emergency Detention Order (EDO), PolicyStat ID 12197144, last approved 08/2024, indicated under PROCEDURE: Emergency Detainment Order (EDO), After the 14 days have expired the Report Following Emergency Detainment must be completed and signed by the attending physician. This document will be faxed back to the Superior Court Probate Division. Within this report, the attending physician must complete one of three paragraphs outlining the current status of the patient (paragraph 3, 4, or 5). Paragraph 3 states that the attending physician still believes that the patient still requires attention and treatment and the patient is not willing to voluntarily sign themselves into the facility. If the attending physician completes this paragraph the temporary commitment process will begin which will include a court hearing. Paragraph 4 states that a patient no longer meets criteria for involuntary commitment and has been discharged from the hospital. Paragraph 5 states the patient has voluntarily signed themselves into a hospital for treatment. 2. Review of Patient 13’s medical record indicated the patient was admitted on 12/03/2024 with a 14-day Emergency Detention Order which ended on 12/17/2024. Medical record lacked documentation of a temporary commitment or patient informed consents for voluntary admission. Patient was discharged on 01/01/2025. 3. Interview with A1 (Chief Executive Officer) on 01/162/2025 at approximately 3:48 p.m. confirmed the facility failed to obtain a temporary commitment or obtain consents from Patient 13 for voluntary admission.”

“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 medications administered in 1 out of 10 patient (Patient 1) medical records reviewed; failed to obtain discharge orders in 2 out of 10 patient (Patients 3 and 5) medical records reviewed; and failed to notify providers of patient weight loss in 3 out of 10 patient (Patients 4, 11, and 13). Findings include: 1. Facility policy titled, General Medication Administration, PolicyStat ID 12386373, last approved 09/2022, indicated under Process, Each dose of medication administered must be properly recorded in the patient’s medical record. “PRN” medications administered will be documented on the patient’s MAR along with the times of administration and monitoring parameters if ordered (i.e., patient’s blood sugar, blood pressure). Medications administered as PRN require follow up of patients’ response to medication within one (1) hour after administration. The nurse shall document the date and time administered, medication name, dose, rationale, patients’ response to medication (effective or ineffective) and follow up date and time. 2. Facility policy titled, Patient Discharge - AMA, PolicyStat ID: 13916075, last approved 06/2023, indicated under POLICY: Patients will be discharged only upon orders of the attending licensed practitioner. 3. Facility policy titled, Vital Signs and Weight, PolicyStat ID 12386461, last approved 09/2022, indicated under PROCEDURE: Nurses will notify the provider of findings outside patient’s normal range. 4. Review of Patient 1’s medical record indicated on 11/15/2024, the provider ordered Ativan 1 milligram (mg) tablet every 6 hours as needed (PRN) by mouth (PO) for anxiety; on 11/20/2024, medication administration record (MAR) lacked documentation that the patient was administered Ativan 1 mg tablet. 5. Review of medDISPENSE Station report indicated that on 11/20/2024 at 8:33 a.m. Ativan 1 mg tablet was pulled from the station for patient 1. 6. Review of Patient 3’s medical record indicated patient was admitted on 12/1/2024. On 12/3/2024, the patient’s power of attorney (POA) requested the patient be discharged; medical record indicated the provider granted patient to be discharged against medical advice (AMA). Medical record lacked documentation of provider order to discharge patient AMA and patient was discharged at approximately 1:00 p.m. on 12/03/2024. 7. Review of Patient 4’s medical record indicated the following: a. Upon admission, patient 4’s home medication reconciliation indicated the patient took Zenpep three times a day by mouth; P2 (Nurse Practitioner) signed to hold medication during hospital stay on 12/06/2024 at 1:00 p.m. On 12/09/2024, medical record indicated the patient requested Zenpep; patient began to experience diarrhea. On 12/12/2024 nursing note indicated the patient’s family reached out to indicate the patient needed their medication and had sent the medication to the facility for the patient. On 12/13/2024 nursing note indicated the patient complained of abdominal pain and bloody stools; patient was transferred to an acute care facility for further evaluation. Medical record lacked documentation of nurse follow up or provider notification regarding patient’s pain and request for medication. b. Patient’s admission weight was 110 pounds (lbs.). On 12/11/2024, patient’s weight was 104.4 lbs., a loss of 5.6 lbs. in 5 days. Medical record lacked documentation that provider was notified of patient’s weight loss during hospitalization. 8. Review of Patient 5’s medical record indicated patient was admitted on 12/11/2024. On 12/13/2024, medical record indicated that the patient requested to be discharged AMA and AMA paperwork was initiated. Provider discharge summary indicated patient was psychiatrically at baseline. Medical record lacked documentation of provider order to discharge the patient; nursing note indicated patient was discharged AMA at approximately 2:45 p.m. on 12/13/2024. 9. Review of Patient 11’s medical record indicated the patient’s admission weight on 12/17/2024 was 163 lbs., on 12/18/2024 patient’s weight was 162.9 lbs., and on 12/25/2024 the patient’s weight was 151.6 lbs.; a loss of 11.3 lbs. in 8 hospitalization days. Medical record lacked documentation that provider was notified of patient’s weight loss during hospitalization. 10. Review of Patient 12’s medical record indicated the following: a. Provider order dated 01/01/2025 to transfer patient to an acute care facility for further evaluation. b. Medical record lacked documentation of nurse-to-nurse report in nursing notes and lacked fully complete documentation on the Patient Transfer/Transport Order form per facility policy on 01/01/2025. 11. Review of Patient 13’s medical record indicated patient’s admission weight was 197.9 lbs. On 12/11/2024 patient’s weight was 191.9 lbs. On 12/18/2024 patient’s weight was 190.0 lbs. On 12/25/2024 patient’s weight was 186.0 lbs. On 01/01/2025 patient’s weight was 178.1 lbs., for a total loss of 19.8 lbs. in 29 hospitalization days. Medical record lacked documentation that provider was notified of patient’s weight loss during hospitalization. 12. Interview with A2 (Director of Risk/Quality) on 01/08/2024 at approximately 3:50 p.m. confirmed the pharmacy report indicated Ativan was pulled from the medication dispensing system for patient 1 and patient 1 medical record lacked documentation of administration. A2 confirmed patient 3 and patient 5’s medical records lacked documentation of provider order for discharge and that nursing should receive order before patient is discharged. 13. Interview with A1 (Chief Executive Officer) and A2 on 01/16/2025 at approximately 3:48 p.m. confirmed the following: a. Patient 4 did not receive medication, and patient had requested multiple times for need of medication. Patient 4 lost 5.6 lbs. during hospitalization per MD documentation. b. Patient 13 lost 19.8 lbs. during hospitalization per MR documentation. Patient 13 was admitted on an Emergency Detention Order (EDO) which expired on 12/17/2024 and the facility failed to obtain a temporary commitment or a voluntary admission.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to ensure that the patient’s discharge planning included prescriptive medications at the time of discharge in 1 out of 13 (Patient 5) medical records reviewed. Findings include: 1. Facility policy titled, Evaluation Treatment and Discharge General Procedure, PolicyStat ID 12197169, last approved 08/2022, indicated under POLICY, The patient care protocol shall include, but not limited to: vi. Continuity of Care/Discharge planning, c. Medication regimen. 2. Review of Patient 5’s medical record indicated the following: a. Patient’s discharge medication list included Remeron 7.5 milligrams by mouth at bedtime daily b. Patient was discharged to home on 12/13/2024. c. Review of the patient’s prescription summary indicated the patient’s prescription for Remeron was not ordered until 12/15/2024 to the patient’s preferred pharmacy. 3. Interview with P1 (Clinical Nurse Specialist) on 01/08/2024 at approximately 2:10 p.m. confirmed Patient 5 was discharged on 12/13/2024 and the patient’s prescriptions were not ordered from the patient’s preferred pharmacy until 12/15/2024.”

“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 ensure completion of the Patient Personal Effects Inventory form in the patient chart for 7 of 10 (patient’s 1, 2, 3, 5, 7, 8, and 9) medical records (MR) reviewed. Findings include: 1. Facility policy titled, “Management of Patient Belongings,” PolicyStat ID: 13950524, last approved 07/2023, Procedure: Admission 4. Upon admission, staff will inventory all patient belongings, and sign the Personal Belongings Inventory Form. Patient will then sign the form. 2. Review of P1’s MR indicated the following: a. The patient was admitted on 07/30/24. b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon admission. c. Patient was a current patient. 3. Review of P2’s MR indicated the following: a. The patient was admitted on 07/29/24. b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon admission. c. Patient was a current patient. 4. Review of P3’s MR indicated the following: a. The patient was admitted on 05/19/24. b. MR lacked documentation of the patient having a Patient Personal Effects Inventory form. 5. Review of P5’s MR indicated the following: a. The patient was admitted on 04/16/24. b. MR indicated P5 arrived with their personal wheelchair per Nursing Admission Assessment and Interdisciplinary Discharge Plan. MR indicated P5’s Patient Personal Effect Inventory form indicated the following personal effects listed: Texas True large pink long sleeve shirt, large red long sleeve shirt, Terry Sky 2X pink long sleeve shirt, Joy Spin 2X stripped long sleeve shirt, Time true XL blue stretch pants, Buck and Buck XL brown stretch pants, Time true XL purple sweat pants, baby doll, glasses, and gold diamond ring which was also listed on the Security Receipt for Patient Belongings. MR lacked documentation of the patient signature or signature of 2nd witness on the Patient Personal Effects Inventory form on discharge on 05/03/24. 6. Review of P7’s MR indicated the following: a. The patient was admitted on 06/08/24. b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon discharge, on 06/17/24. 7. Review of P8’s MR indicated the following: a. The patient was admitted on 07/10/24. b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon admission and discharge, on 07/20/24. 8. Review of P9’s MR indicated the following: a. The patient was admitted on 05/04/24. b. MR lacked documentation of the patient signature on the Patient Personal Effects Inventory form upon admission and discharge, on 05/11/24. 9. Interview with A7 (Scheduler/trainer) on 08/01/24 at approximately 1:25 pm indicated, staff are educated if a patient is unable to sign their inventory form, staff are to sign the form and have another staff sign as a witness upon admission and/or discharge. 10. Interview with A1 (Chief Executive Officer) and A4 (Director of Nursing) on 08/01/24 at approximately 4:10 pm confirmed the Patient Personal Effects Inventory form, was not complete and in patient chart, and/or signed by the patient, or witnessed by a 2nd staff member on admission and/or discharge in 7 of 10 (patient’s 1, 2, 3, 5, 7, 8, and 9) MR’s reviewed.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48061 Based on document review and interview, nursing services failed to notify a provider in a timely manner of a patient’s injury, change of condition related to fall, new onset pain, change in mobility, decreased range of motion of an extremity in 1 of 10 medical records reviewed (P1); and failed to initiate neurological checks after a fall in 1 of 10 medical records reviewed (P1). See Tag A0395 The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48061 Based on document review and interview, the nursing staff failed to ensure care in a safe setting for 1 of 10 medical records reviewed (P1); and failed to ensure a patient’s request for emergency treatment post injury for 1 of 10 medical records reviewed (P1). Findings include: 1. The facility policy titled, “Patient Rights and Responsibilities”, PolicyStat ID 13517670, last revised 09/2021, indicated under PROCEDURE: You have the right to: 9. Request or refuse treatment, to the extent permitted by law. However, you do not have the right to demand inappropriate or medically unnecessary treatment or services. You have the right to leave the hospital even against the advice of physicians, to the extent permitted by law. 29. Humane care and protection from harm. 2. Review of P1 MR indicated the following: a. On 6/16/24 between the hours of 7:00 am - 7:00 pm indicated at approximately 4:00 pm P1 was pushed down to the floor by P2. P1 fell to the floor hitting his/her elbow. P1 also reported hitting his/her head. P1 yelled for 911 to come help him/her. P1 reported to the nursing staff of not being able to move his/her right arm after the fall. b. On 6/16/24 between the hours of 7:00 pm -7:00 am P1 was noted to be yelling/crying during shift change at 7:00 pm, had a bruise to his/her right elbow, and he/she was requesting to be sent to the emergency room for treatment of his/her right elbow. c. On 6/17/24 between the hours of 7:00 am -7:00 pm P1 was noted to have complaints of pain in his/her right elbow and groin area. d. On 6/17/24 between the hours of 7:00 pm -7:00 am P1 complained of pain in the right hand, had notable bruising and swelling to the right arm. e. On 6/18/24 between the hours of 7:00 am -7:00pm P1 complained of a headache and pain to the right elbow, was noted to have bruising and swelling to the right elbow and was noted to be guarding his/her right arm. The patient was then transferred to the emergency room for further evaluation and treatment on 6/18/24 at 11:23 am. f. MR for P1 lacked documentation of provider notification r/t P1 verbally requesting to be sent to the emergency room post fall/ injury on 6/16/24. 3. In an interview on 6/27/24 at approximately 1:00 pm with A4 (Director of Quality & Risk) confirmed the lack of provider communication by nursing staff delayed P1’s treatment for a broken right elbow. Confirmed P1’s requests to call 911 post fall and/or requests to be sent to the emergency department on 6/16/24 were not honored by facility nursing staff 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: 48061 Based on documentation review and interview, facility nursing staff failed to notify a provider in a timely manner of a patient’s injury, change on condition related to fall, new onset pain, change in mobility, decreased range of motion of an extremity in 1 of 10 medical records reviewed (P1); and failed to initiate neurological checks after a fall in 1 of 10 medical records reviewed (P1). Findings include: 1. The facility policy titled, “Change of Condition”, PolicyStat ID 12197218, last revised 05/2021, indicated under PROCEDURE: 2. The nurse will evaluate the patient and notify the provider with the findings. 4. A sample list of possible changes in condition would include but not limited to: a. Unexpected temperature elevation b. Falls c. Change in mental status d. Drop or elevation in blood pressure outside of patient’s baseline e. Weakness in an extremity or changes in speech f. Onset nausea/vomiting g. Onset of diarrhea h. Complaint of new pain i. Change in mobility or ambulation j. Change in skin condition, color, and/or integrity k. Onset of edema 2. The facility policy titled, “Fall Prevention Program”, PolicyStat ID, 13554604, last revised 04/2023, indicated under PROCEDURE: POST FALL EVALUATION: 1. Each time a patient falls, the patient will be assessed by the nurse directly after the fall and the nurse will notify the provider to obtain any necessary orders. 2. Interventions necessary to stabilize the patient will be completed in a timely manner. 3. If the patient is witnessed hitting their head, or is suspected of hitting their head, neurological checks are to be initiated. 4. The nurse must notify all applicable parties including but not limited to; the CEO, DON, Nursing Supervisor, Provider, POA/Guardian and/or patient’s family. 3. MR for P1 was reviewed and indicated the following: a. On 6/16/24 between the hours of 7:00 am - 7:00 pm indicated at approximately 4:00 pm P1 was pushed down to the floor by P2. P1 fell to the floor hitting his/her elbow. P1 also reported hitting his/her head. P1 yelled for 911 to come help him/her. P1 reported to the nursing staff of not being able to move his/her right arm after the fall. b. On 6/16/24 between the hours of 7:00 pm -7:00 am P1 was noted to be yelling/crying during shift change at 7:00 pm, had a bruise to his/her right elbow, and he/she was requesting to be sent to the emergency room for treatment of his/her right elbow. c. On 6/17/24 between the hours of 7:00 am -7:00 pm P1 was noted to have complaints of pain in his/her right elbow and groin area. d. On 6/17/24 between the hours of 7:00 pm -7:00 am P1 complained of pain in the right hand, had notable bruising and swelling to the right arm. e. On 6/18/24 between the hours of 7:00 am -7:00pm P1 complained of a headache and pain to the right elbow, was noted to have bruising and swelling to the right elbow and was noted to be guarding his/her right arm. The patient was then transferred to the emergency room for further evaluation and treatment on 6/18/24 at 11:23 am. f. The MR for P1 lacked notification of a provider post fall on 6/16/24, lacked provider notification of the patient’s change of condition on 6/16/24. Lacked completed post fall documentation which included provider notification and neurological checks. 4. In an interview on 6/27/24 at approximately 1:00 pm with A4 (Director of Quality & Risk) confirmed a provider was not notified in P1’s change of condition after a fall related to right elbow, hip, head, and/or pelvis pain, right elbow decreased range of motion, bruising and/or swelling and should have been. Confirmed the facility’s post fall evaluation procedure for P1 was not completed per policy by nursing on 6/16/24 and should have been.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, nursing administration failed to provide adequate staffing for 17 of 27 days reviewed on units 100 and 200. Findings Include: 1. The facility policy titled, “Clinical Staff (Nurse) Staffing Plan”, PolicyStat ID 12279065, last revised 08/2022, indicated under PROCEDURE: Staffing Plan: B. Core Staffing Matrix per unit: Inpatient Programs for Days (7 am-11 pm). One clinical staff member for every four (4) patients. 2. Nursing and/or Staffing Review: The Staffing Pattern Worksheets were reviewed for H1 units 100 & 200 for the dates 5/19/24 - 6/14/24 and indicated the facility was not appropriately staffed per facility policy as follows: a. Unit 100: 5/19/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a patient census (PC) of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 5/23/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 5/25/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 5/26/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 5/31/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 6/1/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present. 6/2/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 6/3/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 6/4/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 2 clinical staff members were present. 6/5/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 6/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 6/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 6/10/24 short 2 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 2 clinical staff members were present. 6/13/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 6/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 4 clinical staff members needed but only 3 clinical staff members were present. b. Unit 200: 5/22/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 5/23/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 5/26/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 5/29/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 3 clinical staff members were present. 5/31/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 6/1/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 2 clinical staff members were present. 6/2/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present. 6/3/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 4 clinical staff members needed but only 3 clinical staff members were present. 6/4/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 6/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 6/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 6/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 4 clinical staff members needed but only 3 clinical staff members were present. 3. In interview on 6/14/24 at approximately 1:30 pm with staff member A3 (Director Of Nursing) confirmed units 100 and 200 were not adequately staffed per policy 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: 48061 Based on documentation review and interview, facility nursing staff failed to document weekly weights and/or monitor fluid and food intake for 6 out of 14 medical records reviewed. (P1, P2, P3, P5, P7, and P13) Findings include: 1. The facility policy titled, “Intake & Output Monitoring”, PolicyStat ID 12386133, last revised 09/2022, indicated under Policy: Fluid and food intake is monitored for all patients. 2. The facility policy titled, “Vital Signs and Weight”, PolicyStat ID 12386461, last revised 09/2022, indicated under Procedure: Weights will be taken a minimum of once per week, unless the provider orders a more frequent schedule. Record vital signs and weekly weights in the patient’s medical record. 3. Review of P1’s MR indicated Daily Nursing Assessment for dates 4/19/24, 4/28/24, 4/29/24, 4/30/24, 5/4/24, 5/5/24, 5/6/24, 5/8/24, 5/11/24, 5/12/24, 5/13/24, 5/16/24, 5/17/24, 5/18/24, 5/19/24, 5/23/24, 5/26/24, 5/31/24, 6/2/24, 6/3/24 lacked documentation that patient food or liquid intake was monitored per facility policy. MR documentation for P1 lacked documentation of weekly weights from 4/18/24-6/9/24. 4. Review of P2’s MR indicated Daily Nursing Assessment for dates 6/2/24, 6/3/24, 6/6/24, 6/7/24, 6/8/24, and 6/9/24 lacked documentation that patient food or liquid intake was monitored per facility policy. MR documentation for P2 lacked documentation of a weekly weight on 6/7/24. 5. Review of P3’s MR indicated Nursing Admission Assessment documentation dated 5/8/24 at 5:00 pm lacked a documented admission weight. MR for P3 lacked weekly weights for the patient’s hospital duration Daily Nursing Assessment for dates 5/19/24, 5/27/24 and 5/28/24 lacked documentation that P3’s food or liquid intake was monitored per facility policy. 6. Review of P5’s MR indicated Vital Signs & Weight Flow Sheet documentation lacked weekly weights from 4/19/24-4/27/24. 7. Review of P7’s MR indicated a lack of documented weekly weights per policy from 2/17/24-3/01/24. 8. Review of P13’s MR indicated Daily Nursing Assessments for 5/2/24, 5/3/24, 5/27/24, 5/28/24, 5/29/24, 6/1/24, 6/2/24, 6/3/24, 6/4/24, 6/10/24 and 6/11/24 lacked documentation of patient food or liquid intake was monitored per facility policy. P13’s weekly weights were also ordered on 5/20/24 & 6/4/24 as a result of significant weight loss. The patients’ weekly weights were not completed as ordered per policy. 9. In an interview on 5/16/24 at approximately 1:30 pm with A3 (Director of Nursing) confirmed weekly weights and intake monitoring on all patients are not being done per policy and should have been.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to communicate patient’s plan of care in 1 out of 10 (Patient 6) medical records reviewed. Findings Include: 1. Facility policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, last approved 04/2023, indicated family and/or agent, when appropriate, be informed of your care including unanticipated outcomes in order to participate in current and future decisions affecting the patient’s care and to participate in the development and implementation of your plan of care. 2. Review of Patient 6’s medical record indicated that the patient indicated to include a family member in their treatment planning. Medical record lacked documentation of involvement of family member in the treatment plan.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to follow the staffing policy for 58 of 168 shifts reviewed and failed to staff a registered nurse on every unit for 2 of 168 shifts reviewed. Findings include: 1. Facility policy titled, Clinical Staff (Nurse) Staffing Plan, PolicyStat ID 12279065, last approved 08/2022, indicated there will be one clinical staff member for every four patients from 7:00 a.m.-11:00 p.m., one clinical staff member for every 8 patients from 11:00 p.m.-7:00 a.m. and there must be at least one Registered Nurse in every unit at all times. . 2. Review of the Staffing Pattern Worksheet completed by the facility, indicated the 100 unit was not appropriately staffed per staffing policy guidelines on the following days for the weeks of 04/14/2024 through 04/27/2024: a. 04/14/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present. b. 04/15/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present. c. 04/19/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present. d. 04/20/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present. e. 04/21/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present. f. 04/23/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present. g. 04/25/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present. h. 04/27/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 14 which required 4 clinical staff members and only 3 present. 3. Review of the Staffing Pattern Worksheet completed by the facility, indicated the 200 unit was not appropriately staffed per staffing policy guidelines on the following days for the weeks of 04/14/2024 through 04/20/2024: a. 04/14/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 14 which required 4 clinical staff members and only 3 present. b. 04/15/2024: lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 staff members and only 3 present and lacked a registered nurse from 11:00 p.m. to 7:00 a.m. with a census 12, which required 1 registered nurse and none present. c. 04/17/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present. d. 04/19/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 2 present and lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present. e. 04/20/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present. f. 04/21/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 2 present and lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present. g. 04/22/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present. h. 04/23/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present. i. 04/24/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present. j. 04/27/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present. 4. Review of the Staffing Pattern Worksheet completed by the facility, indicated the 300 unit was not appropriately staffed per staffing policy guidelines on the following days for the weeks of 04/14/2024 through 04/27/2024: a. 04/14/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 15 and one 1:1 which required 5 staff members and only 3 present and lacked 1 clinical staff member from 3:00 p.m. to 7:00 a.m. with a census of 15 and one 1:1 which required 5 staff members and only 4 present. b. 04/15/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 13 and one 1:1 which required 5 staff members and only 3 present and lacked 1 clinical staff member from 3:00 p.m. to 7:00 a.m. with a census of 13 and one 1:1 which required 5 staff members and only 4 present. c. 04/16/2024 lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 12 and one 1:1 which required 5 staff members and only 4 present and lacked 1 clinical staff member from 11:00 p.m. to 7:00 a.m. with a census of 12 and one 1:1 which required 3 clinical staff member and only 2 present. d. 04/19/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 13 which required 4 staff members and only 3 present. e. 04/20/2024: lacked a registered nurse from 11:00 p.m. to 7:00 a.m. with a census 12, which required 1 registered nurse and none present. f. 04/21/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 staff members and only 3 present. g. 04/22/2024: lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 staff members and only 3 present. h. 04/25/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 staff members and only 3 present. i. 04/27/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 14 which required 4 staff members and only 3 present. 5. Review of the Staffing Pattern Worksheet completed by the facility, indicated the 400 unit was not appropriately staffed per staffing policy guidelines on the following days for the weeks of 04/14/2024 through 04/27/2024: a. 04/14/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 staff members and only 3 present. b. 04/15/2024: lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 14 which required 4 staff members and only 2 present and lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 14 which required 4 staff members and only 3 present. c. 04/18/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 14 and one 1:1 which required 5 staff members and only 4 present. d. 04/19/2024 lacked 2 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 12 and one 1:1 which required 5 staff members and only 3 present. e. 04/20/2024: lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 staff members and only 2 present and lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 16 which required 4 staff members and only 3 present. f. 04/21/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00p.m. with a census of 16 which required 4 staff members and only 3 present; lacked 2 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 3 present. g. 04/22/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 4 present. h. 04/23/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 4 present. i. 04/24/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 4 present. j. 04/25/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 4 present. k. 04/26/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 and one 1:1 which required 5 staff members and only 4 present. l. 04/27/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 13 and one 1:1 which required 5 staff and only 3 present. 6. Interview with A4 (Director of Nursing) on 05/23/2024 at approximately 1:50 p.m. confirmed the facility was short staffed on the dates and shifts listed 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: 48704 Based on document review and interview, nursing services failed to ensure that provider orders were transcribed and noted in 1 out of 10 (patient 6) medical records, failed to ensure that dietary orders were followed in 1 of 10 (patient 6) medical records, and failed to document patient personal belongings upon admission in 1 out of 10 (patient 6) medical records reviewed. Findings include: 1. Facility policy titled, Physician Orders/Receipt and Notation, PolicyStat ID 12197185, last approved 08/2022, indicated under Procedure: 5. Provider orders are to be noted and transcribed by RNS, LPNs, or Pharmacists. 2. Facility policy titled, Standards of Nutrition of Care, PolicyStat ID 12511831, last approved 10/2022, indicated under Diet Orders: The patient’s food intake and diet acceptance will be monitored by the nursing staff, the dietary director, and other hospital staff with appropriate referrals being made accordingly to Nutrition Services staff. 3. Facility policy titled, Management of Patient Belongings, PolicyStat ID 13950524, last approved 07/2023, indicated upon admission staff will inventory all patient belongings and sign Personal Belongings Inventory Form. Patient will then sign the form. 4. Review of Patient 6’s medical record indicated an intravenous catheter (IV) with normal saline 0.9% at 50 milliliters (ml) per hour was started on 04/27/2024. Medical record lacked documentation of provider telephone IV order. On 04/21/2024, medical record indicated patient was placed on honey thick liquids and on 04/22/2024 medical record indicated that patient had multiple cups of water to drink and lacked documentation that the water was thickened. Medical record lacked documentation of the Personal Belongings Form. 5. Interview with A4 (Director of Nursing) on 05/23/2024 at approximately 3:45 p.m. confirmed that patient 6’s medical record lacked documentation of the intravenous orders on 04/27/2024. 6. Interview with A5 (Dietary Manager) on 05/23/2024 at approximately 4:30 p.m. confirmed patient 6 had a mechanical soft diet and liquids were to be thickened due to risk of aspiration ordered on 04/21/2024.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48061 Based on documentation review and interview, facility staff failed to include a patient in his/her plan of care for 1 of 10 medical records reviewed. (P1) Findings include: 1. The facility policy titled, “Patient Discharge - AMA”, PolicyStat ID 13916075, last revised 06/2023, indicated under POLICY: Patients will be discharged only upon the orders of the attending licensed practitioner. A competent, adult patient cannot be detained from leaving the hospital. 2. The facility policy titled, “Patient Rights and Responsibilities”, PolicyStat ID 13517670, last revised 09/2021, indicated under PROCEDURE: 1. Receive considerate ethical behavior and respectful care in treatments, services, and business practices. You have the right to be made comfortable and treated with dignity. You have the right to be respected for your personal values and beliefs including cultural, psychosocial, and spiritual values and beliefs. 5. Receive information about your health status, course of treatment, prospects for recovery and outcomes of care, including unanticipated outcomes, in terms you can understand, tailored to the patient’s age and language; have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes, in order to participate in current and future decisions affecting your care and to participate in the development and implementation of your plan of care. During your hospitalization, information concerning your condition, medication, treatment, and discharge plans may be shared with your personal friends and family through your designated spokesperson. 3. MR review for P1 indicated on 4/30/24, patient was noted to be alert, quiet, compliant with medications. P1’s child and sibling called several times to request a transfer to a facility closer to P1’s home and the patient indicated he/she wanted out of H1 (Psychiatric Hospital). On 5/4/24 indicated P1 was wanting out of H1 but was told not until Tuesday (5/7/24). On 5/5/24 nursing note indicated P1 expressed a desire to go home. On 5/6/24 MR note indicated the patient was cleared for discharge, was doing well and wanted to go home, A&O (alert and oriented) x (times) 4, medication compliant without side effects, no medication changes, and denied SI (suicidal ideation) / HI (homicidal ideation). LEVEL OF CARE JUSTIFICATION dated 5/5/2024, indicated the patient was doing well on current regimen, was noted to be psychiatrically stable, and was cleared for discharge to appropriate setting. P1’s MR lacked education and/or discussions with P1 on transferring to another psychiatric facility closer to home and or discharging AMA (Against Medical Advice) when he/she expressed the desire to go home and/or be transferred. P1 was held after 5/5/24 clearance for discharge, with a discharge date of 5/8/2024. MR lacked documentation that discharge was a result of patient request and/or practitioner recommendation. 4. In interview on 5/16/24 at approximately 1:50 pm with A5 (Patient Advocate) confirmed he/she did not speak with P1 nor was he/she called to speak with P1 as the patient advocate. 5. In a telephone interview on 5/20/24 at approximately 2:10 pm with L3 (Licensed Staff) confirmed was not notified that P1 was wanting to leave H1 AMA by nursing staff.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, nursing administration failed to provide adequate staffing for 8 of 14 days reviewed on unit 200. Findings Include: 1. The facility policy titled, “Clinical Staff (Nurse) Staffing Plan”, PolicyStat ID 12279065, last revised 08/2022, indicated under PROCEDURE: Staffing Plan: B. Core Staffing Matrix per unit: Inpatient Programs for Days (7 am-11 pm). One clinical staff member for every four (4) patients. 2. Staffing Pattern Worksheets review indicated unit 200 was not adequately staffed per facility policy. Unit number, dates, number of clinical staff member(s) lacked and patient census are indicated as follows: a. Unit 200: 4/21/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a patient census (PC) of 15. 4 clinical staff members needed but only 2 clinical staff members were present. 4/22/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present. 4/23/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present. 4/24/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present. 4/26/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 4/27/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 4/28/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/29/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present. 3. In interview on 5/15/24 at approximately 2:15 pm with staff member A1 (Chief Executive Officer) confirmed unit 200 was not adequately staffed per policy 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: 48061 Based on documentation review and interview, facility nursing staff failed to follow diet order policy and/or procedure in 1 of 10 medical records reviewed. (P1) Findings include: 1. The facility policy titled, “Transmission of Diet Orders”, PolicyStat ID 12511884, last revised 01/2020, indicated under PROCEDURE: 2. Changes to diet orders, supplements will be communicated via physician orders and sent via fax or written communication. 2. P1’s MR Diet Orders & Communication documentation dated 4/29/24 at 2:00 am indicated the nursing staff changed the diet for P1 from a Regular Diet to a Controlled Carbohydrate and initiated an Oral Nutrition Supplement of 2 liters of water per day and did not notify/confirm with a provider. 3. In an interview on 5/15/24 at approximately 2:10 pm with A1 (Chief Executive Officer) confirmed diet order changes for P1 should have been confirmed by a practitioner when the order was changed by nursing staff and was not.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 48061 Based on documentation review and interview, facility staff failed to discharge patients in a timely manner based on admission criteria and/or provider orders in 7 of 10 MRs (medical records) reviewed. (P1, P3, P4, P5, P6, P8, and P10) Findings include: 1. The facility policy titled, “Discharge Planning”, no policy number, last revised 03/2022, indicated under POLICY: Discharge planning begins at the time of admission. Based on input from the patient/family/Guardian/POA, physician, and members of the multidisciplinary team, a discharge plan is developed. Under DOCUMENTATION: The Social Worker documents discharge information on social service notes and the Master Treatment Plan utilized by the multidisciplinary team. 2. Review of P1MR indicated patient voluntarily admitted to H1 (Psychiatric Hospital) on 4/27/24. a. Psychiatric Progress Note documentation indicated on 5/6/24 that P1 was cleared for discharge, was doing well and wanted to go home, A&O (alert and oriented) x (times) 4, medication compliant without side effects, no medication changes, and denied SI (suicidal ideation) / HI (homicidal ideation). LEVEL OF CARE JUSTIFICATION dated 5/5/2024, indicated the patient was doing well on current regimen, was noted to be psychiatrically stable, and was cleared for discharge by provider to appropriate setting. b. P1 was discharged to home in stable condition on 5/8/24. 4. P3’s MR indicated the patient was voluntarily admitted to H1 on 5/3/24 and is currently inpatient awaiting discharge. P3’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note indicated on 5/13/24 P3 was cleared for discharge by provider. b. P3 was not discharged at the time of this survey on 5/15/24. 5. P4’s MR indicated the patient was voluntarily admitted to H1on 4/27/24. P4’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/6/24 indicated P4 was cleared for discharge by provider. b. Interdisciplinary Discharge Plan documentation indicated the patient was discharged to home on 5/8/24 at 11:00 am in stable condition. 6. P5’s MR indicated the patient was admitted to H1 from 4/27/24 on an EDO (Emergency Detention Order). P5’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/8/24 indicated the patient was cleared for discharge by provider. b. Discharge Summary documentation indicated P4 was discharged to a skilled nursing facility in stable condition on 5/14/24. 7. P6’s MR indicated the patient was admitted to H1 from 4/30/24 on an EDO (Emergency Detention Order). P6’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/9/24 indicated P6 no longer required inpatient psychiatric treatment and was cleared for discharge per psychiatry. b. Discharge Summary documentation indicated P6 was discharged to home in stable condition on 5/11/24. 8. P8’s MR indicated the patient was admitted to H1 from 5/1/24 by his/her POA/Guardian. P8’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/6/24 indicated P8 was noted to be psychiatrically stable and was cleared to discharge by provider. b. Discharge Summary documentation indicated P8 was discharged home in stable condition on 5/8/24. 9. P10’s MR indicated the patient was admitted to H1 from 5/1/24 on an EDO. P10’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/9/24 indicated P10 was noted to be psychiatrically stable and was cleared to be discharged by provider. b. Discharge Summary documentation indicated P10 was discharged to home in stable condition on 5/12/24 . 10. In an interview on 5/16/24 at approximately 12:10 pm with L1 (Licensed Staff) confirmed remembering P1 as alert and oriented. L1 did not interpret, from nursing notes reviewed, that the patient’s desire to go home was a request to leave AMA, P1’s medications were adjusted last on 4/29/24 and if there were no signs or symptoms of mania, SI (suicidal ideation), and/or HI (homicidal ideation) after a medication adjustment (which could take up to 72 hours), P1 should have been cleared for discharge on 5/2/24. 11. In a telephone interview on 5/17/24 at approximately 11:42 pm with L2 (Licensed Staff) confirmed he/she was a telehealth provider for P1, cannot clear patients for discharge because he/she does not work in person at H1, telehealth providers cannot clear patients for discharge. 12. In a telephone interview on 5/20/24 at approximately 2:10 pm with L3 (Licensed Staff) confirmed A1 (Chief Executive Officer) puts a limit of 5 discharges a day, A1 is the final say if someone can be discharged if not made by providers, it takes several days for patients to get discharged after being cleared by a provider, patients not experiencing SI/HI/adverse medication side effects would be cleared for discharge, providers are instructed by administrators not to tell patients when they are cleared for discharge, and was not notified that P1 was wanting to leave H1 AMA by nursing staff. 13. In a telephone interview on 5/23/24 at approximately 2:10 pm with L4 (Licensed Staff) confirmed providers at H1 have no control over the ongoing issue of delayed discharges of patients, after patients are cleared for discharge the hospital says they need to complete a safety plan and discharge process, discharge process for patients can take up to three days, he/she feels that H1 staff wait until the last minute to start discharge planning, delays in discharge happen frequently which puts providers in an uncomfortable situation and administration have instructed providers not to tell patients the date of their discharge.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48061 Based on documentation review and interview, facility staff failed to include a patient in his/her plan of care for 1 of 10 medical records reviewed. (P1) Findings include: 1. The facility policy titled, “Patient Discharge - AMA”, PolicyStat ID 13916075, last revised 06/2023, indicated under POLICY: Patients will be discharged only upon the orders of the attending licensed practitioner. A competent, adult patient cannot be detained from leaving the hospital. 2. The facility policy titled, “Patient Rights and Responsibilities”, PolicyStat ID 13517670, last revised 09/2021, indicated under PROCEDURE: 1. Receive considerate ethical behavior and respectful care in treatments, services, and business practices. You have the right to be made comfortable and treated with dignity. You have the right to be respected for your personal values and beliefs including cultural, psychosocial, and spiritual values and beliefs. 5. Receive information about your health status, course of treatment, prospects for recovery and outcomes of care, including unanticipated outcomes, in terms you can understand, tailored to the patient’s age and language; have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes, in order to participate in current and future decisions affecting your care and to participate in the development and implementation of your plan of care. During your hospitalization, information concerning your condition, medication, treatment, and discharge plans may be shared with your personal friends and family through your designated spokesperson. 3. MR (medical record) documentation for P1 indicated on 4/30/24 was noted to be alert, quiet, compliant with medications, P1’s child and sibling called several times to request a transfer to a facility closer to P1’s home and the patient indicated he/she wanted out of H1. On 5/4/24 indicated P1 was wanting out of H1 but was told not until Tuesday (5/7/24). On 5/5/24 indicated P1 expressed a desire to go home. On 5/6/24 indicated the patient was cleared for discharge, was doing well and wanted to go home, A&O (alert and oriented) x (times) 4, medication compliant without side effects, no medication changes, and denied SI (suicidal ideation) / HI (homicidal ideation). LEVEL OF CARE JUSTIFICATION dated 5/5/2024, indicated the patient was doing well on current regimen, was noted to be psychiatrically stable, and was cleared for discharge to appropriate setting. P1’s MR lacked education and/or discussions with P1 on transferring to another psychiatric facility closer to home and or discharging AMA (Against Medical Advice) when he/she expressed the desire to go home and/or be transferred. P1 was held after 5/5/24 clearance for discharge, with a discharge date of 5/8/2024. MR lacked documentation that discharge was a result of patient request and/or practitioner recommendation. 4. In an interview on 5/16/24 at approximately 1:50 pm with A5 (Patient Advocate) confirmed he/she did not speak with P1 nor was he/she called to speak with P1 as the patient advocate. 5. In a telephone interview on 5/20/24 at approximately 2:10 pm with L3 (Licensed Staff) confirmed was not notified that P1 was wanting to leave H1 AMA by nursing staff.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 48061 Based on documentation review and interview, facility staff failed to discharge patients in a timely manner based on admission criteria and/or provider orders in 7 of 10 MRs (medical records) reviewed. (P1, P3, P4, P5, P6, P8, and P10) Findings include: 1. The facility policy titled, “Discharge Planning”, no policy number, last revised 03/2022, indicated under POLICY: Discharge planning begins at the time of admission. Based on input from the patient/family/Guardian/POA (power of attorney), physician, and members of the multidisciplinary team, a discharge plan is developed. Under DOCUMENTATION: The Social Worker documents discharge information on social service notes and the Master Treatment Plan utilized by the multidisciplinary team. 2. Review of MR for P1 indicated patient voluntarily admitted to H1 (psychiatric hospital) on 4/27/24. a. Psychiatric Progress Note documentation indicated on 5/6/24 that P1 was cleared for discharge, was doing well and wanted to go home, A&O x 4, medication compliant without side effects, no medication changes, and denied SI (suicidal ideation)/HI (homicidal ideation). LEVEL OF CARE JUSTIFICATION indicated the patient was doing well on current regimen, was noted to be psychiatrically stable, and was cleared for discharge to appropriate setting. This note serves as provider order for discharge. b. P1 was discharged to home in stable condition on 5/8/24. 3. P3’s MR indicated the patient was voluntarily admitted to H1 on 5/3/24 and is currently inpatient awaiting discharge. P3’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note indicated on 5/13/24 P3 was cleared for discharge. b. P3 was not discharged at the time of this survey on 5/15/24. 4. P4’s MR indicated the patient was voluntarily admitted to H1 from 4/27/24. P4’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/6/24 indicated P4 was cleared for discharge. b. Interdisciplinary Discharge Plan documentation indicated the patient was discharged to home on 5/8/24 at 11:00 am in stable condition. 5. P5’s MR indicated the patient was admitted to H1 from 4/27/24 on an EDO (Emergency Detention Order). P5’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/8/24 indicated the patient was cleared for discharge. b. Discharge Summary documentation indicated P4 was discharged to a skilled nursing facility in stable condition on 5/14/24. 6. P6’s MR indicated the patient was admitted to H1 from 4/30/24 on an EDO. P6’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/9/24 indicated P6 no longer required inpatient psychiatric treatment and was cleared for discharge per psychiatry. b. Discharge Summary documentation indicated P6 was discharged to home in stable condition on 5/11/24. 7. P8’s MR indicated the patient was admitted to H1 from 5/1/24 by his/her POA/Guardian. P8’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/6/24 indicated P8 was noted to be psychiatrically stable and was cleared to discharge. b. Discharge Summary documentation indicated P8 was discharged home in stable condition on 5/8/24. 8. P10’s MR indicated the patient was admitted to H1 from 5/1/24 on an EDO. P10’s medical record was reviewed and indicated the following: a. Psychiatric Progress Note documentation dated 5/9/24 indicated P10 was noted to be psychiatrically stable and was cleared to be discharged. b. Discharge Summary documentation indicated P10 was discharged to home in stable condition on 5/12/24 . 9. In an interview on 5/16/24 at approximately 12:10 pm with L1 (Licensed Staff) confirmed remembering P1 as alert and oriented, did not interpret from nursing notes reviewed that the patient’s desire to go home was a request to leave AMA, P1’s medications were adjusted last on 4/29/24 and if there were no signs or symptoms of mania, SI (suicidal ideation), and/or HI (homicidal ideation) after a medication adjustment (which could take up to 72 hours) P1 should have been cleared for discharge on 5/2/24. 10. In a telephone interview on 5/17/24 at approximately 11:42 pm with L2 (Licensed Staff) confirmed he/she was a telehealth provider for P1, cannot clear patients for discharge because he/she does not work in person at H1, telehealth providers cannot clear patients for discharge. 11. In a telephone interview on 5/20/24 at approximately 2:10 pm with L3 (Licensed Staff) confirmed A1 (Chief Executive Officer) puts a cap of 5 discharges a day, A1 is the final say if someone can be discharged is not made by providers, it takes several days for patients to get discharged after being cleared by a provider, patients not experiencing SI/HI/adverse medication side effects would be cleared for discharge, providers are instructed by administrators not to tell patients when they are cleared for discharge, and was not notified that P1 was wanting to leave H1 AMA by nursing staff. 12. In a telephone interview on 5/23/24 at approximately 2:10 pm with L4 (Licensed Staff) confirmed providers at H1 have no control over the ongoing issue of delayed discharges of patients, after patients are cleared for discharge the hospital says they need to complete a safety plan and discharge process, discharge process for patients can take up to three days, he/she feels that H1 staff wait until the last minute to start discharge planning, delays in discharge happen frequently which puts providers in an uncomfortable situation and administration has instructed providers not to tell patients the date of their discharge.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48061 Based on document review, observation and interview, nursing administration failed to provide adequate staffing for 20 of 28 days on units 100, 200, 300 and 400. Findings Include: 1. The facility policy titled, “Clinical Staff (Nurse) Staffing Plan”, PolicyStat ID 12279065, last revised 08/2022, indicated under PROCEDURE: Staffing Plan: B. Core Staffing Matrix per unit: Inpatient Programs for Days (7 am-11 pm). One clinical staff member for every four (4) patients. 2. Staffing Pattern Worksheets review indicated units 100, 200, 300 and 400 were not adequately staffed per facility policy. Unit numbers, dates, number of clinical staff member(s) lacked and patient census are indicated as follows: a. Unit 100: 3/24/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a patient census (PC) of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 3/25/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 3/31/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 11. 3 clinical staff members needed but only 2 clinical staff members were present. 4/3/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 2 clinical staff members were present. 4/4/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present. 4/7/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present. 4/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present. 4/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present. 4/12/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present. 4/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present. 4/15/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present. 4/19/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present. 4/20/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present. b. Unit 200: 3/24/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 3/26/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/1/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 11. 3 clinical staff members needed but only 2 clinical staff members were present. 4/5/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 2 clinical staff members were present. 4/6/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a P C of 13. 4 clinical staff members needed but only 3 clinical staff members were present. 4/7/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 3 clinical staff members were present. 4/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 4/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 4 clinical staff members needed but only 3 clinical staff members were present. 4/15/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 4/17/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. 4/19/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present. 4/20/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present. c. Unit 300: 3/24/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 4 clinical staff members were present. 3/25/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 14. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 3 clinical staff members were present. 4/12/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 15. 2 Patients requiring 1:1 observation. 5 clinical staff members needed but only 3 clinical staff members were present. 4/13/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 1 Patient requiring 1:1 observation. 4 clinical staff members needed but only 4 clinical staff members were present. 4/14/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 15. 2 Patients requiring 1:1 observation. 6 clinical staff members needed but only 4 clinical staff members were present. 4/15/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 4 clinical staff members were present. 4/19/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 3 clinical staff members were present. d. Unit 400: 3/24/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 2 clinical staff members were present. 4/3/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 11. 3 clinical staff members needed but only 2 clinical staff members were present. 4/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/11/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/12/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/13/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/15/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present. 4/18/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 4 clinical staff members were present. 4/19/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 1 Patient requiring 1:1 observation. 4 clinical staff members needed but only 3 clinical staff members were present. 4/20/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 3 clinical staff members were present. 4. In interview on 5/3/24 at approximately 5: pm with staff member A6 (Director Of Nursing) confirmed units 100, 200, 300, 400 were not adequately staffed per policy and should have been.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 48061 Based on documentation review and interview the medical staff failed to review pertinent patient care conditions and requirements prior to admission , provide adequate G-tube feeding orders and/or supplies, and colostomy care orders and/or supplies for 1 of 10 medical records reviewed. (P1) Findings include: 1. The facility policy titled, “Criteria for Admission”, no policy number, last revised 03/2024, indicated exclusionary criteria includes patients that cannot be managed safely and adequately at the hospital due to his/her medical problems as determined by his/her medical doctor. 2. After Visit Summary documentation provided by H2 (Acute Care Hospital) to H1 (Psychiatric Hospital) for Pre-Admission Screening on 3/15/24 indicated discharge instructions for enteral supplies set up through H2 along with the instructions and contact information for services to be set up for P1 upon discharge of H2, indicated the patient’s diet required tube feedings and a regular diet. Discharge Summary documentation indicated the patient was s/p colostomy placement in 10/2024, underwent a G-tube (Gastrostomy tube) placement on 3/10/24, started G-tube feedings 3/11/24, feeding was advanced to 50 ml (milliliters)/h (hour) with a plan on moving towards bolus feeding at the time of discharge. P1 was discharged from H2 on 3/15/24 then admitted to H1 on 3/15/24 at 7:55 pm. 3. Pre-Admission Patient Screening documentation, completed by H1, dated 3/15/23 indicated P1 was referred to H1 (Psychiatric Hospital) by H2 (Acute Care Hospital) d/t (due/to) unspecified psychosis with a wish to harm him/herself or others. Pre- Admission Patient Medical Evaluation indicated P1 required minimal assistance, was ambulatory, used a wheelchair, required a medical psychiatric bed, could take medication by mouth whole, and had a foley catheter. This medical evaluation did not indicate the patient had either a colostomy and/or PEG (Percutaneous endoscopic gastrostomy)/G-tube present requiring medical supplies and/or enteral nutritional needs. 4. In an interview on 4/2/24 at approximately 2:00 pm with A1 (Chief Executive Officer) confirmed H1 did not get clarification on G-tube feeding and/or ostomy care needs prior to the admittance to H1 on 3/15/23 and should have preventing adequate care of P1. Supplies that H1 lacked for P1’s medical care included replacement colostomy bags and enteral feeding supplies.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48061 Base on document review and interview the facility failed to adequately staff per the facilities policy for one inpatient unit (Unit 200) for 7 of 14 days reviewed. Finding include: 1. The facility policy titled, “Clinical Staff (Nurse) Staffing Plan”, PolicyStat ID 12279065, last revised 08/2022, indicated the core staffing matrix per inpatient unit was to be staffed with one (1) clinical staff member for every four (4) patients from 7:00 am - 11:00 pm. 2. The Staffing Pattern Worksheet was reviewed for the dates 3/10/24 - 3/23/24 indicated the following: a. 3/10/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 13. b. 3/11/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 13. c. 3/12/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 14. d. 3/14/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 13. e. 3/16/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 14. f. 3/17/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 14. g. 3/122/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 15. 3. In an interview on 4/2/24 at approximately 3:15 pm with A4 (Director of Nursing) confirmed the facility was understaffed by lacking one clinical staff member for 7 of 14 days reviewed on the 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: 48061 Based on documentation review and observation, facility nursing staff failed to complete an incident report by no later than 24 hours after a patient transfer, send all appropriate patient documents with the ambulance service at the time of transfer for 1 of 10 medical records reviewed. (P1) Findings include: 1. The facility policy titled, “Incident Reports”, PolicyStat ID 13033981, last revised 01/2023, indicated an incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees, medical staff, visitors, consultants, or property of, regardless of whether and actual injury is involved or not. After providing for the care needs of the individuals involved, hospital staff must complete and submit an incident report as soon as possible. Preferably, the report should be submitted before leaving the hospital at the end of the work shift, but no later than twenty-four (24) hours from the time the event occurred. 2. The facility policy titled, “Transfer of Patient”, PolicyStat ID 10623375, last revised 06/2023, indicated copies of all of the following inpatient admission will include, but are not limited to: Face Sheet, Advance Directives, H&P, Psychiatric Evaluations, Care Plan, Laboratory and Radiology Reports, Medication Administration Record, Physician progress notes, Medication Reconciliation, Patient Belonging Inventory List were provided to the transporting entity in order to be given to the accepting facility at the time of arrival. 3. Patient Transfer/Transfer Report documentation dated 3/17/24 for P1 indicated paperwork provided to S1 (Ambulance Service)at the time of transfer to H2 (Acute Care Hospital) included P1’s psychiatric evaluation, History & Physical (H&P), Medication Administration Records, Medication Reconciliation, and Face Sheet. P1’s EDO, Care Plan, Laboratory and Radiology Reports, and a Patient Belonging Inventory List documents were not included in the transfer documents given to S1 at the time of discharge 4. The facility’s incident report log was observed to lack an incident report for the transfer of P1 from H1 to H2 on 3/17/24. 5. In an interview on 4/2/24 at approximately 3:00 pm with N1 (Registered Nurse) confirmed transfer paperwork sent with the patient on 3/17/24 included a face sheet, medication administration record, but does not remember if EDO paperwork was included. 6. In an interview on 4/2/24 at approximately 2:00 pm with A4 (Director of Nursing) confirmed no incident report was completed by nursing staff for the transfer of P1 from H1 to H2 on 3/17/24 when there should have been.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to communicate patient’s plan of care in 1 out of 10 (Patient 4) medical records reviewed. Findings Include: 1. Facility policy titled, “Patient Rights and Responsibilities” PolicyStat ID 13517670, last approved 04/2023, indicated family and/or agent, when appropriate, be informed of your care including unanticipated outcomes in order to participate in current and future decisions affecting the patient’s care and to participate in the development and implementation of your plan of care. 2. Review of Patient 4’s medical record lacked documentation of notification to patient’s family of changes in medical condition and plan of care as follows: a. Patient’s diet change on 02/12/2024 from a regular diet to mechanical soft diet due to choking concerns. b. Intravenous (IV) infusions were ordered on 02/14/24 and 02/21/24; IV access was placed by nursing personnel on 02/14/24 and 02/21/24; fluids administered per provider order. c. Patient’s refusal to eat or drink fluids and take medications from 02/15/2024 through 02/22/2024. 3. Interview with S1 (Clinical Therapist) on 03/20/24 at approximately 2:55 p.m. confirmed Patient 4’s medical record lacked documentation of notification to patient’s family of change in medical condition prior to 02/21/24. 4. Interview with A4 (Director of Clinical Services) on 03/20/24 at approximately 3:10 p.m. confirmed Patient 4’s medical record indicated that patient was psychologically stable for discharge on 02/14/2024 and medical record lacked documentation of ongoing communication between social services and family regarding patient’s placement after discharge after care conference on 02/06/2024. 5. Interview with P1 (Nurse Practitioner) on 03/21/24 at approximately 1:00 p.m. confirmed recommendation for hospice care due to patient’s declining medical condition and the medical record lacked documentation of communication with patient’s family prior to 02/21/24.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to document daily hygiene care in 9 of 10 (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9) medical records reviewed; failed to document weekly weights per policy in 9 of 10 (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9) medical records reviewed; failed to document patient signature upon admission and discharge of personal belongings in 7 of 10 (Patients 2, 3, 4, 5, 6, 7, and 10) medical records reviewed, and failed to document removal of intravenous catheter prior to discharge in 1 of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled, “Patient Personal Care”, PolicyStat ID 12197137, last approved 08/2022, indicated all patients shall be encouraged or assisted daily in grooming daily or more often as needed and patients who are incontinent shall be assisted with cleaning or bathing and in a manner that respects privacy. 2. Facility policy titled, “Vital Signs and Weights”, PolicyStat ID 12386461, last approved 09/2022, indicated weights will be taken a minimum of once a week, unless diagnosis deems need for increased frequency weighing and the provider orders a more frequent schedule. Record vital signs and weekly weights in the patient’s medical record. 3. Facility policy titled, “Management of Patient Belongings” PolicyStat ID 13950524, last approved 07/2023, indicated upon admission staff will inventory all patient belongings and sign Personal Belongings Inventory Form and patient will sign form. 4. Review of Patient 1’s medical record lacked documentation of hygiene on 01/10/24, 01/11/24, 01/12/24, 01/13/24, 01/14/24, 01/15/24, 01/16/24, 01/17/24, 01/18/24, 01/19/24, 01/20/24, 01/21/24, 01/22/24, and 01/23/24 and documentation of weekly weights per policy on 01/10/24 and 01/17/24. 5. Review of Patient 2’s medical record lacked documentation of hygiene on 01/16/24, 01/17/24, 01/18/24, 01/19/24, 01/20/24, 01/21/24, 01/22/24, 01/23/24, and 01/24/24; lacked documentation of weekly weights per policy on 01/17/24 and 01/24/24; and lacked documentation of patient’s signature on Patient Personal Effects Inventory and documentation patient received personal items upon discharge. 6. Review of Patient 3’s medical record lacked documentation of hygiene on 01/27/24, 01/28/24, 01/29/24, 01/30/24, 02/01/24; lacked documentation of weekly weights per policy on 01/31/24; and lacked documentation patient received personal items upon discharge. 7. Review of Patient 4’s medical record lacked documentation of hygiene on 02/02/24, 02/03/2024, 02/04/24, 02/05/24, 02/06/24, 02/07/24, 02/10/24, 02/11/24, 02/12/24, 02/13/24, 02/14/24, 02/15/24, 02/16/24, 02/17/24, 02/19/24, 02/20/24 and 02/22/24; lacked documentation of weekly weights per policy on 02/07/24, 02/14/24, and 02/21/24; lacked documentation patient received personal items upon discharge and was discharged without their hearing aids and upper dentures; lacked documentation that intravenous catheter was removed prior to discharge. 8. Review of Patient 5’s medical record lacked documentation of hygiene on 02/07/24, 02/10/24, 02/11/24, 02/12/24, 02/14/24; lacked documentation of weekly weights per policy on 02/07/24 and 02/14/24; and lacked documentation of patient’s signature on Patient Personal Effects Inventory and documentation patient received personal items upon discharge. 9. Review of Patient 6’s medical record lacked documentation of hygiene on 02/11/24, 02/13/24, 02/14/24, 02/15/24, 02/16/24, 02/17/24, 02/20/24, and 02/21/24; lacked documentation of weekly weights per policy on 02/14/24 and 02/21/24; and lacked documentation of patient’s signature on Patient Personal Effects Inventory and documentation patient received personal items upon discharge. 10. Review of Patient 7’s medical record lacked documentation of hygiene on 02/24/24, 02/25/24, 02/26/24, 02/27/24, 02/28/24, 02/29/24, 03/01/24, 03/02/24, 03/03/24, 03/04/24, 03/05/24, 03/06/24, 03/07/24, 03/09/24, 03/10/24, and 03/13/24; lacked documentation of weekly weights per policy on 02/28/24, 03/06/24, and 03/13/24; and lacked documentation patient received personal items upon discharge. 11. Review of Patient 8’s medical record lacked documentation of hygiene on 02/24/24, 02/25/24, 02/26/24, 02/27/24, 02/28/24, 02/29/24, 03/01/24, 03/03/24, and 03/04/24; and lacked documentation of weekly weights per policy on 02/28/24. 12. Review of Patient 9’s medical record lacked documentation of hygiene on 03/08/24, 03/09/24, 03/10/24, 03/11/24, 03/14/24, 03/15/24, 03/16/24, and 03/17/24; and lacked documentation of weekly weights per policy on 03/13/24. 13. Review of Patient 10’s medical record lacked documentation patient received personal items upon discharge. 14. Interview with A2 (Director of Quality and Risk) on 03/20/24 at approximately 4:00 p.m. confirmed the following: a. Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9 lacked documentation of daily hygiene care as mentioned on the above dates and staff should document daily on the Patient Observation Form. b. Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9 lacked documentation of weekly weights as mentioned on the above dates. Staff should document weekly weights on Wednesdays and document the weight on the Patient Observation Form. c. Patients 2, 3, 4, 5, 6, 7, and 10 lacked documentation of confirmation of personal belongings upon admission and receipt of personal belongings upon discharge.”

“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: 41134 Based on document review and interview, the nursing staff failed to follow the hospital policy and notify a patient’s (P1) power of attorney or authorized family member after a reported fall, for 1 of 10 patient’s medical records reviewed. Findings Include: 1. Facility policy “Fall Prevention Program”, PolicyStat: 13554604, last approved 04/2023, indicated that a fall notification will be made to provider, administration, and family immediately upon discovery of a fall event. 2. Medical record review indicated P1 had an unobserrved fall on 01/04/2024. The medical record, lacked documentation that staff had notified P1’s power of attorney, or authorized family member of the reported fall on 01/04/2024. 3. The facility incident reporting log lacked documentation that staff had notified P1’s power of attorney, or authorized family member of P1’s reported fall on 01/04/2024. 4. At 1542 hours on 03/13/2024, per interview with S2, Quality/Risk, confirmed that P1’s medical record and incident reporting log did not indicate any documentation that the patient’s power of attorney (POA) or authorized family members were notified of P1’s fall in accordance with facility policy.”

“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: 38371 Based on document review and interview, facility failed to protect 1 of 10 (patient 6) from abuse. Findings Include: 1. Review of policy titled: Patient Rights and Responsibilities (PolicyStat ID: 13517670) last approved 04/2023, indicated patient’s are entitled to humane care and protection from harm. 2. Review of medical record indicated Daily Nursing Narrative dated 01/05/24, nurse found patient 6 in bed with edema and small amount of blood present below right eye and orbit swollen shut. Incident Report completed and Registered Nurse notified. 3. Interview on 01/29/24 with P56 (Behavioral Health Aide) at 4:15 pm, confirmed found patient 6 in bed with bruising on both cheeks,, black eye and bruised neck. 4. Interview on 01/29/24 with P50 (Chief Executive Officer) at confirmed above scenario and that an Incident Report was completed, but there was no investigation.”

“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: 38371 Based on document review and interview, nursing failed to follow policies regarding skin care in 1 of 10 (patient 6) medical records reviewed. Findings Include: 1. Review of policy titled: Skin Assessment (PolicyStat ID: 12385990) last approved 09/2022, indicated a weekly skin assessment to be completed and documented in the medical record. 2. Review of patient 6’s medical record lacked documentation of weekly skin assessments (admitted 01/02/24 and discharged 01/18/24). 3. Interview on 01/29/24 with P50 (Chief Executive Officer) at 4:50 pm confirmed lack of documentation of weekly skin assessments.”

“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 ensure documentation of patient’s weight on admission in 4 out of 10 patients (patient 3, 4, 5, and 6) and weekly weights in 2 out 10 patients (patient 6 and 8) medical records. 1. Review of policy titled, “Vital Signs and Weight”, PolicyStat ID 12386461, last approved 09/2022, indicated all patients will have their weights taken on admission, a minimum of once a week, and recorded in the patient’s medical record. 2. Review of patients 3, 4, 5, and 6’s medical record lacked documentation of admission weight. 3. Review of the the following medical records lacked documentation of weekly weights: a. Patient 6’s medical record lacked documentation of weekly weights on 05/24/2023, 06/07/2023, 06/21/2023, 06/28/2023, 07/12/2023, and 07/26/2023. b. Patient 8’s medical record lacked documentation of weekly weight on 09/06/2023. 4. Interview with A3, (Director of Nursing), on 11/29/2023, at approximately 6:00 pm, confirmed patients 3, 4, 5, 6’s medical record lacked documentation of admission weight and and patients 6 and 8’s medical records lacked documentation of weekly weights.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48061 Based on document review, observation and interview, nursing administration failed to provide adequate staffing for 4 of 4 days on units 100, 200, 300 and 400. Findings Include: 1. Facility staffing grid indicated from 7:00 am - 11:30 pm with a patient census of 9-12 there was to be 1 RN (Registered Nurse) & 2 BHAs (Behavior Health Aide), a patient census of 13-16 there was to be 2 RNs with 2 BHAs. 2. Staffing Pattern Worksheet review indicated units 100, 200, 300 and 400 were understaffed per the facility’s staffing grid. Unit numbers, dates, amount, type of staff member(s) lacked and patient census are indicated as follows: a. 11/18/23 i. Unit 200 short 1 BHA from 7:00 am - 3:30 pm with a patient census (PC) of 13. ii. Unit 300 short 1 BHA from 7:00 am - 11:30 pm with a PC of 11 b. 11/19/23 i. Unit 100 short 1 BHA from 7:00 am - 11:30 pm with a PC of 14. ii. Unit 200 short 1 RN from 7:00 am - 7:30 pm with a PC of 13. iii. Unit 300 short 1 BHA from 7:00 am - 11:30 pm with a PC of 11. iv. Unit 400 short 1 BHA from 7:00 am - 11:30 pm with a PC of 12 c. 11/20/23 i. Unit 100 short 1 BHA from 7:00 am - 3:30 pm with a PC of 16. ii. Unit 200 short 1 BHA from 7:00 am - 3:30 pm with a PC of 14. iii. Unit 400 short 2 BHAs from 7:00 am - 3:30 pm with a PC of 13 d. 11/21/23 i. Unit 100 short 1 RN from 7:00 am - 7:30 pm with a PC of 16. ii. Unit 300 short 2 BHAs from 7:00 am - 3:30 pm with a PC of 13. iii. Unit 400 short 1 RN from 7:00 am - 7:30 pm and short 1 BHA from 7:00 am-3:30 pm with a PC of 16. 3. During facility tour on 11/21/23 at 5:00 pm with A2 (Director of Nursing) it was observed the actual working staff did not match the indicated amount of staff members accounted for on the staffing pattern worksheet. Observations are as follows: a. Unit 400 had a patient census of 15, 1 RN (N5) and 1 BHA (N6) were present providing care. A second RN (N4), whom was on his/her second day of facility orientation, was also present. LPN (N2) who was on light duty, does not take a patient assignment and was not on duty at the time of tour, was listed as the second nurse on the staffing pattern worksheet. b. Unit 100 had a patient census of 16, 1 RN (N7) and 2 BHA’s were present providing care. RN (N4) was listed as the second nurse on the staffing pattern worksheet was noted to be with N6 on Unit 400 for orientation. 4. In interview on 11/21/23 at approximately 5:10 pm with staff member A2 (Director Of Nursing) indicated N2 and N4 were counted in the staffing numbers that should not have been and were short staffed on the other days also.”