St Veronica

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51768 Based on policy review, record review, document review, observation, interview, and video review, the hospital failed to ensure and promote the patients’ right to informed consent and a safe physical environment. The effect of these failures has the potential to result in a breach of patient privacy, patient harm and other adverse outcomes. Findings include: 1. The hospital failed to obtain informed consent for audio and visual recording for 29 of 29 reviewed patient medical records. (Refer to tag A-0143) 2. The hospital failed to provide an environment free from objects that could be utilized to inflict harm and ensure that 1 of 11 reviewed staff were trained in techniques to provide care to patients. (Refer to tag A-0144) 3. The hospital failed to protect 1 of 29 reviewed patients from all forms of abuse and harassment. (Refer to tag A-0145)”

“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: 51768 Based on policy review, record review, document review, and interview, the hospital failed to provide evidence of 24-hour nursing services furnished that were supervised by a registered nurse (RN) and adhered to hospital policy and procedure. These deficient practices place patients receiving care at this hospital at risk for potential injury or harm. Findings include: 1. The hospital failed to ensure that a registered nurse (RN) was present to provide 24-hour nursing services. (Refer to tag A-0393) 2. The hospital failed to ensure nursing staff adhered to hospital policy and procedure regarding mental health assessments for 14 of 29 reviewed patient records and fall interventions for 7 of 8 reviewed patient records (Refer to tag A-0398)”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 51768 Based on policy review, record review, document review, observation, and interview, the hospital failed to obtain informed consent for audio and visual recording for 29 of 29 (Pt 1-29) reviewed patient medical records. These failures have the potential to result in a breach of patient privacy. Findings include: Review of a hospital document titled “Videotaping, Photographing and Other Imaging of Residents,” last revised 09/03/24, showed, “ ...Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect or emergencies ...” Review of a hospital document titled, “PATIENT HANDBOOK,” revised 10/06/25, showed, “ ...You the Patient have the right to: ...19. Personal dignity and privacy. 10. Be examined, use the toilet, bathe, dress, receive treatments and be interviewed in surroundings that assure reasonable visual and auditory privacy .... 20. Require consent prior to recording or filming made for purpose other than the identification, diagnosis or treatment of your condition ...” Review of Quality Assurance and Performance Improvement (QAPI) meeting minutes on 09/10/25 showed “ ...Absolute Protection Services inspected camera system and enabled remote viewing for leadership ...” Review an audio and video recording of Patient 17’s room from 9:55 PM to 10:55 PM on 12/25/25, showed that the facility has the capability to retain audio and visual recordings. Review of Pt 1-29 patient medical records identified no consent documentation for audio and visual recording. An observation on 01/05/26 at 12:30 PM showed 20 of 20 patient rooms, and all patient care areas had live video monitoring streamed to two monitors in the rooms. During an interview on 01/05/26 at 2:05 PM, Staff E, Director of Plant Operations, stated that video and audio recordings are digital and will be maintained for approximately a month. If an incident occurs, these recordings can be downloaded and stored on a thumb drive. During an interview on 01/06/26 at 3:36 PM Staff D, Director of Nursing, stated that video recordings can be accessed and downloaded through an online system.”

“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: 51768 Based on policy review, record review, document review, observation, interview, and video review, the hospital failed to: 1. Provide an environment free from objects that could be utilized to inflict harm, and 2. failed to ensure 1 of 11 (Staff G) personnel files reviewed were trained in techniques to provide care to patients. The cumulative effect of these failures has the potential to result in patient and staff harm. Findings Include: Review of a hospital document titled, “CONSENT FOR MEDICAL/PSYCHIATRIC TREATMENT,” revised 10/09/02, showed, “ ... Patient Rights: I acknowledge that I have been given information and instructions regarding my Patient Rights, which include ... to receive care in a safe setting ...” Review of a hospital document titled, “PATIENT HANDBOOK,” revised 10/06/25, showed, “ ... [Above Named Hospital] Unit maintains an environment as safe as possible for all patients and staff ... You the Patient have the right to ... 4. Considerate and respectful care, free from all forms of abuse (physical, emotional, etc.) or harassment ... Items that patients will not be allowed to keep in their possession include ... Weapons or anything that can be used as a weapon, sharp objects ...” Review of a hospital policy titled, “Restraint and Seclusion,” revised 11/20/25, showed, “ ...Staff are trained and competent to minimize the use of restraint, seclusion, and safe use ... The training plan shall include de-escalation, and non-physical techniques and alternatives to avoid use of restraint and seclusion, training on identifying early warning signs of physical and psychological stress, safe application, and release of restraints, and return demonstrations or post-training tests required by a nationally recognized course or program ...” An observation on 01/05/25 at 10:40 AM showed the following objects, in the nurses’ station, were accessible to patients: Six (6) three-ring binders Four (4) computer monitors with attached power and connectivity cables, keyboards and mice. Four (4) plastic organization trays Three (3) telephones with extended cords and cables. Two (2) unprotected electrical sockets. One (1) unidentified communication device with extension cables. One (1) laptop computer. An observation on 01/07/26 at 4:25 PM showed that Patient 5 was leaning their upper body over the desk into the nursing station. No staff were observed at that desk at the time. Patient 5 continued to lean over the desk, looking at the equipment for about 20 seconds before returning to other activities. An observation on 01/05/25 at 11:00 AM showed a metal box attached to the wall in the patient common area, with sharp edges and corners. Review of an audio and video recording of Patient 17’s room, dated 12/25/25 from 9:55 PM to 10:55, showed Staff G, mental health technician, harassing and assaulting Patient 17. Review of Staff G’s personnel record showed the hospital failed to provide evidence of Staff G’s de-escalation training or certification. During an interview on 01/06/2026 at 3:35, Staff D, Director of Nursing (DON), stated that Staff G had been offered Crisis Prevention Institute (CPI) training on 04/24/25, 04/26/25, 06/26/25, and 06/27/25. However, Staff G did not attend CPI training. Staff D confirmed that Staff G was allowed to provide continued patient care despite not completing training.”

“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: 51768 Based on policy review, document review, and video review, the hospital failed to protect 1 of 29 (Patient 17) reviewed patients from all forms of abuse and harassment. This failure has the potential to cause substantial harm to patients. Findings include: Review of a hospital document titled, “CONSENT FOR MEDICAL/PSYCHIATRIC TREATMENT,” revised 10/09/02, showed, “ ... Patient Rights: I acknowledge that I have been given information and instructions regarding my Patient Rights, which include ... to receive care in a safe setting, free from verbal or physical abuse or harassment ... Review of a hospital document titled “PATIENT HANDBOOK,” revised 10/06/25, showed, “ ... St. Veronica Behavioral Health Unit maintains an environment as safe as possible for all patients and staff ... You the Patient have the right to ... 4. Considerate and respectful care, free from all forms of abuse (physical, emotional, etc.) or harassment ...” Review of hospital document titled, “[Accrediting Organization] Incident Report,” completed by Staff P, Chief Nursing Officer (CNO) on 12/30/25, showed, “ ... On December 25, 2025 at approximately 2200 [Staff G, Mental Health Technician (MHT)] punched [Patient 17] in the face with a open fist in the face. [Patient 17] fell back on the bed and [Staff G] got on top of him, pinning him down with an arm over the chest and neck area on the bed while cursing and threatening the patient ...” Staff D, Director of Nursing (DON), provided video recording of an event that occurred on 12/25/25 involving Patient 17 and Staff G, mental health technician (MHT). Review of a video recording, dated 12/25/25 at 9:55 PM showed the following: At 9:55 PM, Patient 17 and Staff G entered Patient 17’s room. Staff G told Patient 17, “You are a thief.” Patient 17 stated, “No, I’m not a thief.” and Staff G replied, “Well, apparently you are. Give it back!” Patient 17 sat down on the side of the bed, and Staff G stood at Patient 17’s left side. At 9:56 PM the video recording showed Staff G reached into Patient 17’s shirt pocket. Staff G did not ask the patient for permission prior to placing hands into Patient 17’s shirt pocket. Patient 17 grabbed Staff G’s hand with their right hand and struck Staff G in the groin with their left hand. Staff G struck Patient 17 in the face. Staff G pinned Patient 17 to the bed and pressed both forearms into Patient 17’s face and neck. Staff G told Patient 17 “You fucking don’t ever touch me again in my private area. I’ll fucking kill you. Yeah, what are you gonna do, bitch?” Staff G continued to hold Patient 17 in bed while three (3) additional staff members came to bedside. Staff G continued intermittently yelling profanities as they held Patient 17’s face and neck down. Observation of the video showed Staff G wrapped their right hand around the patient’s neck three (3) and wrapped both hands around Patient 17’s neck once. Review of Staff G’s personnel record showed the hospital failed to provide evidence of Staff G’s de-escalation training or certification. During an interview on 01/06/2026 at 3:35, Staff D, Director of Nursing (DON), stated that Staff G had been offered training Crisis Prevention Institute (CPI) training, on 04/24/25, 04/26/25, 06/26/25, and 06/27/25. However, Staff G did not attend CPI training. Staff D confirmed that Staff G was allowed to provide continued patient care despite not completing training.”

“RN/LPN STAFFING CFR(s): 482.23(b)(1) The hospital must provide 24-hour nursing services furnished or supervised by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all times, except for rural hospitals that have in effect a 24-hour nursing waiver granted under o488.54(c) of this chapter. This Standard is not met as evidenced by: 51768 Based on policy review, record review, and electronic communication, the hospital failed to provide evidence of 24-hour nursing services provided or supervised by a registered nurse (RN). Failure to provide 24-hour nursing services has the potential to result in patient harm. Findings Include: Review of hospital policy titled, “ON CALL FOR MANAGEMENT STAFF,” Initiated: 09-03- 2024; revised 8/20/25, showed, “POLICY: There is always an RN on call... If there is no RN scheduled to work on-site ...the on-call RN must remain in the facility to provide nursing coverage ...” Review of hospital staffing schedules and timecards showed the following: 1. On 08/13/25 from 4:30 PM to 6:54 PM, the hospital failed to ensure an RN was present. 2. On 08/17/25 from 7:30 AM to 6:58 PM, the hospital failed to ensure an RN was present. 3. On 08/22/25 from 4:30 PM to 6:49 PM, the hospital failed to ensure an RN was present. 4. On 08/27/25 from 4:30 PM to 6:55 PM, the hospital failed to ensure an RN was present. 5. On 08/28/25 from 7:30 PM to 11:59 PM, the hospital failed to ensure an RN was present. 6. On 08/29/25 from 12:00 AM to 7:00 AM, the hospital failed to ensure an RN was present. 7. On 08/31/25 from 7:30 AM to 8:54 AM, the hospital failed to ensure an RN was present. Review of an email dated 01/08/26, from Staff D, Chief Nursing Officer (CNO), showed, “If there was no staff RN scheduled, leadership covers that shift ....” The hospital failed to provide evidence that showed an RN was scheduled and present for the dates 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: 51768 Based on policy review, record review, and document review, the hospital failed to: 1. Nursing staff failed to document mental health assessments for 14 of 29 (Patient 2, 3, 4, 5, 7, 8, 9, 10, 12, 13, 16, 18, 20, and 22) reviewed patient records, and 2. Nursing staff failed to ensure fall interventions for 7 of 8 (Patient 4, 13, 16, 19, 20, 21, and 22) reviewed patients with documented falls. These deficient practices have the potential to affect patient safety and place patients at risk for harm. Findings Include: Review of a hospital policy titled, “Suicide Risk Assessment,” Revised 11/05/25, showed, “ ...All patients admitted to the psychiatric program will be screened for suicide risk upon admission, every shift, when clinically indicated, and prior to discharge ...” Review of a hospital policy titled “Fall Policy,” last revised 09/29/25, showed, “...All patients are considered high fall risk, and interventions are initiated, including but not limited to: reassessing and observing patients every 2 hours, placing patients on a mechanical alarm or other warning system, and assessing and implementing the need for 1:1 staff observation...” Review of patients’ medical records showed that nursing staff failed to complete a daily mental health assessment, the Columbia Suicide Severity Rating Scale (CSSRS), for each patient, every shift. Review of these medical records showed RNs not documenting this assessment, as listed below: 1. RN staff failed to document 8 of 29 CSSRS assessments for Patient 2. 2. RN staff failed to document 15 of 26 CSSRS assessments for Patient 3. 3. RN staff failed to document 23 of 32 CSSRS assessments for Patient 4. 4. RN staff failed to document 17 of 23 CSSRS assessments for Patient 5. 5. RN staff failed to document 4 of 30 CSSRS assessments for Patient 7. 6. RN staff failed to document 4 of 25 CSSRS assessments for Patient 8. 7. RN staff failed to document 5 of 27 CSSRS assessments for Patient 9. 8. RN staff failed to document 10 of 15 CSSRS assessments for Patient 10. 9. RN staff failed to document 3 of 13 CSSRS assessments for Patient 12. 10. RN staff failed to document 11 of 119 CSSRS assessments for Patient 13. 11. RN staff failed to document 10 of 42 CSSRS assessments for Patient 16. 12. RN staff failed to document 7 of 61 CSSRS assessments for Patient 18. 13. RN staff failed to document 28 of 45 CSSRS assessments for Patient 20. 14. RN staff failed to document 2 of 26 CSSRS assessments for Patient 22. During an interview on 01/09/25 at 9:10 AM, Staff L, LPN, stated that a CSSRS is expected to be completed every shift. If a patient is unable or unwilling to answer a question, the staff will continue to ask them if they can respond. If the patient is unable to answer, documentation should reflect why, as evidenced by the patient’s response or condition. During an interview on 01/09/25 at 9:48 AM, Staff Q, RN, stated that a CSSRS is conducted daily. Staff Q clarified that a full mental health assessment is completed only on admission, but staff should conduct a daily assessment to evaluate whether patients have a change in condition or exhibit further mental health concerns. Patient 4 Review of Patient 4’s medical record showed Patient 4 was admitted on 12/19/25 with a diagnosis of Alzheimer’s Disease (a brain illness that damages memory and thinking). The hospital failed to implement fall interventions for Patient 4, resulting in two falls. Patient 4’s medical record showed that Patient 4 fell on 01/01/26 at 9:15 AM, and fall interventions were not in place. Patient 4’s medical record showed that Patient 4 fell on 01/06/2026 at 7:10 AM, and fall interventions were not in place. Patient 4 obtained a skin tear to the wrist and was transferred to an acute care facility for evaluation. Patient 13 Review of Patient 13’s medical record showed Patient 13 was admitted on 06/10/25 with a diagnosis of Alzheimer’s Disease (a brain illness that damages memory and thinking). The hospital failed to implement fall interventions for Patient 13, resulting in a fall. Patient 13’s medical record showed that Patient 13 fell on 01/06/26 at 12:00 AM, and fall interventions were not in place. Patient 13 obtained a skin tear to the hand and was transferred to an acute care facility for evaluation. Patient 16 Review of Patient 16’s medical record showed Patient 16 was admitted on 06/10/25 with a diagnosis of Alzheimer’s Disease (a brain illness that damages memory and thinking). The hospital failed to implement fall interventions for Patient 16, resulting in two falls. Patient 16’s medical record showed that Patient 16 fell on 06/11/25 at 4:30 AM, and fall interventions were not in place. Patient 16’s medical record showed that Patient 16 fell on 07/01/25 at 10:05 AM, and fall interventions were not in place. Patient 16 obtained an injury to the right hip and was transferred to an acute care facility for evaluation. Patient 19 Review of Patient 19’s medical record showed Patient 19 was admitted on 10/23/25 with a diagnosis of major neurocognitive disorder with behavioral disturbances (a condition that results in cognitive decline and difficulty performing tasks). The hospital failed to implement fall interventions for Patient 19, resulting in a fall. Patient 19’s medical record showed that Patient 19 fell on 10/26/25 at 8:20 PM, and fall interventions were not in place. Patient 19 obtained a facial laceration and was transferred to an acute care facility for evaluation. Patient 20 Review of Patient 20’s medical record showed Patient 20 was admitted on 09/11/25 with a diagnosis of Alzheimer’s Disease (a brain illness that damages memory and thinking). The hospital failed to implement fall interventions for Patient 20, resulting in a fall. Patient 20’s medical record showed that Patient 20 fell on 10/01/25 at 7:34 AM, and fall interventions were not in place. Patient 21 Review of Patient 21’s medical record showed Patient 21 was admitted on 12/04/25 with a diagnosis of Alzheimer’s Disease (a brain illness that damages memory and thinking) and a history of falls. The hospital failed to implement fall interventions for patient 21, resulting in a fall. Patient 21’s medical record showed that Patient 21 fell on 12/08/25 at 7:36 AM, and that fall interventions were not in place. Patient 22 Review of Patient 22’s medical record showed Patient 22 was admitted on 11/03/25 with a diagnosis of unspecified bipolar (condition that causes dramatic changes in a person’s mood). The hospital failed to implement fall interventions for Patient 22, resulting in a fall Patient 22’s medical record showed that Patient 22 fell on 11/10/25 at 4:47 PM, and fall interventions were not in place. Patient 22 was transferred to an acute care facility for evaluation. During an interview on 01/07/26 at 4:25 PM, Staff D, Chief Nursing Officer (CNO), stated that all patients who arrive on the unit should be scored at least a moderate fall risk, and interventions should be in place. Patients who fall require a reevaluation of their fall interventions.”