Northlake Behavioral Health System

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 52121 Based on record review and interviews, the hospital failed to identify and track all adverse patient events. The deficient practice is evidenced by failure of hospital staff to initiate an incident report for quality review after a patient was dropped off at the wrong address by hospital-arranged third-party transportation for 1 (#1) of 3 patients reviewed. This deficient practice had the potential to impact all patients requiring hospital-arranged third-party transportation. Findings: Review of the hospital’s policy titled, “Quality Assurance and Performance Improvement,” with a reviewed date of 02/10/2026, revealed, in part: Policy: It is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, patient quality of life and patients’ rights and is based on the scope and complexity of services defined by the Facility Risk Assessment. Purpose: The purpose of this requirement is the completion and implementation of the QAPI plan to identify the high risk, problem prone and high volume areas to evaluate for improvement and identify, collect and use data relevant to the unique characteristic and needs of the patient’s needs. Definitions: “Adverse Events”: An adverse event is defined as an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof, which includes near misses. “Near Miss”: A potential harm event that did not reach a patient. Procedure: 1. The facility will develop, implement and maintain a QAPI program that is effective, data driven, comprehensive and will focus on indicators of the outcomes of care and quality of life. 2. The plan describes the process for identifying and correcting quality deficiencies and contains the necessary components such as: a. Tracking and measure performance; c. Identifying and prioritizing quality deficiencies. Review of Patient #1’s clinical record revealed he was admitted to the hospital on 07/31/2026 with diagnoses including Unspecified mood disorder with psychotic features and mild intellectual disability. Review of Patient #1’s therapist notes, dated 08/13/2026, revealed, in part: Patient and therapist reviewed and completed the crisis safety plan and discharge plan. Patient reported understanding to the best of his ability ... However, at approximately 3:20 p.m., the group home care manager called asking what time the patient left. When the therapist informed the care manager that the patient left around 1:30 p.m., there was concern about the patient’s location because the trip should not have taken that long. The therapist consulted with the discharge planner to contact Medicaid transportation, who had scheduled the transport to pick up the patient. The driver received the address incorrectly. The therapist contacted both the Medicaid driver and asked someone from the group home to go to the incorrect destination address to look for the patient. After approximately 30 minutes, the group home care manager contacted the therapist and reported that the patient was located at a flea market approximately one mile away. Signed, S5SW. Review of Patient #1’s discharge summary, with a discharge date of 08/13/2026, revealed, in part: The patient was discharged to a group home, and transportation was provided by Medicaid. Review of the hospital’s incident log, dated 06/01/2026 to 08/18/2026, revealed no incidents logged for Patient #1. An interview was conducted on 08/18/2026 at 1:30 p.m. with S5SW. S5SW recalled the events documented in her therapist note. She stated she did not enter an incident report related to the discharge event but notified her supervisor. An interview was conducted on 08/18/2026 at 2:02 p.m. with S4CD. S4CD stated she supervised the discharge planners and social workers/therapists, was aware of the discharge-related event, and confirmed she did not enter an incident report. An interview was conducted on 08/18/2026 at 1:46 p.m. with S2QD. S2QD confirmed there was no hospital incident report or quality assurance investigation related to the discharge event and stated she was unaware of the event.”

“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: 48050 Based on record review and interview, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. The deficient practice is evidenced by: 1)failure of the physician/practitioner to document daily progress notes on 1(#3) of 3 (#1, #2, #3) reviewed medical records of patients with acute status; and 2) failure of the physician/practitioner to assess 1(#3) of 3 (#1, #2, #4) patients post-fall. Findings: 1)Failure of the physician/practitioner to document daily progress notes on 1 (#3) of 3(#1, #2, #3) reviewed medical records of patients with acute status. Review of the hospital’s policy # TX 1-200 titled “Treatment Planning”, last reviewed on 01/06/2026, revealed in part: Purpose: To assure that the patient/family/guardian, and all members of the treatment team have the opportunity to provide input into treatment planning and to assure development of a comprehensive and complete plan of care that serves as a guide for providing individualized treatment. Comparative Timelines: Progress Note Summary for MD for Adults every 24 hours. Review of Patient #3’s medical record revealed Patient #3 was admitted on 11/19/2025 and discharged on 11/26/2025. Further review of Patient #3’s medical record revealed provider progress notes documented on 11/20/2025, 11/21/2025, 11/23/2025, and 11/25/2025. In an interview on 01/28/2025 at 3:15 PM, S3RM confirmed that providers should assess acute patients daily and document a progress note in the medical record. 2)Failure of the physician/practitioner to assess 1(#3) of 3 (#1, #2, #4) patients post-fall. Review of hospital policy # PE-1200 titled, “ Fall Assessment/Fall Precautions” last reviewed on 04/10/2025 revealed in part: “PURPOSE: the purpose of this policy is to provide procedures for the assessment and management of patients at risk for falls in order to reduce the risk of harm resulting from falls. PROCEDURES: C. Post-Fall Assessment: 3. A LIP must review the post-fall assessment, determine if the patient will be placed on or continued on Fall Precautions, and identify and order appropriate interventions.” Review of Patient #3’s medical record revealed Patient #3 had a fall on 11/25/2025 at 8:25 PM. Further review of Patient #3’s medical record revealed a Post Fall Assessment Tool (PFTAT)/RN which was completed and the Post Fall Assessment MD/LIP portion not completed. In an interview on 01/28/2025 at 3:15 PM S3RM verified the post fall assessment MD/LIP should be completed by the physician/practitioner after all patient falls per facility policy.”

“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: 48050 Based on observation, record review, and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by failure to ensure employees were trained in crisis intervention in 2 (S7MHT, S10MHT) of 14 (S5RN, S6RN, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S12MHT, S13MHT, S14MHT, S15MHT, S16MHT, S17MHT, S18MHT) personnel files reviewed. Findings: A review of employee personnel records for S7MHT and S10MHT failed to reveal current documented crisis intervention training. Further review revealed S7MHT’s crisis intervention training expired 08/28/2025 and S10MHT’s crisis intervention training expired 08/05/2025. In an interview on 01/28/2026 at 1:30 PM, S19HR confirmed S7MHT and S10MHT did not have documented current crisis intervention training in their employee file. In an interview on 01/28/2026 at 2:30 PM, S4COO confirmed that all nurses and MHT’s should have current education in crisis intervention to provide a safe patient environment.”

“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: 48050 Based on record review and interview, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficient practice is evidenced by failure to self-report incidents involving allegations of abuse/neglect within 24 hours to the Department of Health and Hospitals in 1 (#2) of 3 medical records reviewed. Findings: Review of hospital policy number, RI-0800 titled “Abuse/Neglect of Patients/Reporting Allegations,” last revised 02/22/2025, revealed in part: “PURPOSE: To ensure all patients are free from all forms of abuse and neglects. DEFINITIONS: 1. ADULT PATIENTS: “Neglect” means a negligent act or omission by an individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk of injury or death, and includes, but is not limited to, acts or omissions such as failure to: establish or carry out an appropriated individual program or treatment plan; provide adequate nutrition, clothing, or healthcare; and the failure to provide a safe environment. PROCEDURE: A. Timeline for notifications: ADULTS. RN Supervisor: 7. Complete the Alleged Abuse and Neglect form to provide an electronic tracking document to ensure that all Authorities are notified within the specified time frames. This document is utilized as electronic notification to the CEO, DON, Risk, and attending physician. 8. Notify LDH/Health Standards section of all allegations, no matter how irrational the allegation may be, within 24 hours.” Review of Patient #2’s medical record revealed an admit date of 10/01/2025 for Mood Disorder and Suicidal Ideations. Further review of Patient #2’s medical record revealed a history of self-harm. Review of Patient #2’s Nursing Notes revealed in part the following incidents: 11/08/2025 at 4:30 PM: Precautions: Suicidal Precautions and Other: Visual Contact with no pencils or utensils (sharp objects). Patient #2 asked for clothes then went to the shower room to shower. Patient #2 used a comb to open a wound on her left forearm. 11/14/2025 9:15 PM: Observation: Visual Contact with no combs or zippers (sharp objects). Patient #2 found with piece of paper clip and reopened wound to left forearm. In an interview on 01/28/2026 at 2:00 PM, S3RM confirmed there were no Self-Reports for the above-mentioned incidents. S3MR also confirmed that they were unable to find incident reports for the above-mentioned incidents on 11/08/2025, or 11/14/2025.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 48050 Based on record review and staff interview, the hospital failed to develop, implement, measure and track corrective action plans aimed at performance improvement to ensure that improvements are sustained. This deficiency is evidenced by the hospital failing to use data collected to implement an action plan to prevent abuse/neglect and promote patient safety. Findings: Review of Self-Report log for November 2025, December 2025, and January 2026 which identified self-reports for Patient #1 and Patient #2. Further review revealed Patient #1’s incident of physical abuse was not substantiated and Patient #2’s self-harm was substantiated. Patient #1’s incident report of alleged physical abuse occurred on 12/21/2025 at 10:50 AM when Patient #1 was engaging in self-harm behavior and aggression toward staff. MHT placed Patient #1 in a manual hold so a PRN medication could be administered. While Patient #1 was in a manual hold Patient #1 complained of left arm pain and was sent to the ED for evaluation. The ED diagnosed Patient #1 with a distal left humerus fracture. Further review of the self-report documented that the allegations of physical abuse could not be substantiated due to the facility not being able to see the actual manual hold on video camera to determine improper use of CPI. As a result of this incident the facility would have mandatory training for the staff on CPI techniques. On 01/28/2026 at 9:00 AM a request was made to S3MR and S4COO for the MHT’s performance improvement plan and mandatory staff education on CPI techniques that were documented in the Patient #1’s self-report listed above. In an interview on 01/28/2026 at 11:58 PM, S4COO reported that the education compliance related to Patient #1’s incident was 56.66% completion. S4COO further reported she was unaware that the education was not completed. In an interview on 01/28/2026 at 2:00 AM, S3MR verified MHT involved in Patient #1’s incident of alleged physical abuse had been terminated for other reasons. S3MR was not aware the staff education on CPI techniques was not completed. Patient #2’s incident of self-harm occurred on 11/06/2025 at 8:10 PM in which the MHT failed to monitor Patient #2 per MD orders of visual contact allowing Patient #2 to cause self-harm via comb. The facility substantiated allegations of neglect and reported all staff would be trained on contraband, what qualifies as contraband and Level of Observations. Further review of the incident self-report confirmed the MHT involved in the incident would be placed on a 90-day performance improvement plan which would be monitored by the direct supervisor. In an interview on 01/28/2026 at 2:20 PM S3MR confirmed that mandatory education as a result of the incident for Patient #2 listed above was never sent out to staff. S3MR further reported she was unaware that staff did not receive the mandatory education.”

“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: 48050 Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. The deficient practice is evidenced by failure of the Registered Nurse to document patient observations every 2 hours per hospital policy in 3 (#1, #2, #3) of 3 (#1-#3) medical records reviewed. Findings: Review of hospital policy number TX 7-1001, titled “Level of Observation and Precaution,” last revised 12/05/2025, revealed in part: “PURPOSE: To reduce the risk of patient harm to self or others as needed for patient condition, using active supervision. 2. The RN Charge Nurse is directly responsible for monitoring observation levels and precautions, and for assigning staff to carry out the ordered observations and precautions. 3. The Unit RN Charge Nurse will physically round to make direct observation of each patient on the unit every two (2) hours and will initial each patient’s individual observation sheet at the time this direct observation is conducted. 4. The RNs will monitor compliance with the observation and precaution status by staff during rounds.” Patient #1 Review of Patient #1’s medical record revealed Patient #1’s observation level was every 15 minutes rounding by the Mental Health Technician (MHT) and every 2 hours by the RN. The Rounding Forms dated with following times the RN missed rounding on the patient every 2 hours: 12/03/2025 at 5:15 PM; 12/04/2025 at 1:15 AM; 12/17/2025 at 7:15 AM, 9:15 AM, 11:15 AM, 1:15 PM, 3:15 PM, and 5:15 PM; 12/21/2025 at 11:30 AM, 1:30 PM, 3:30 PM, and 5:30 PM; 12/31/2025 at 7:15 AM, 9:15 AM, 11:15 AM, 1:15 PM, 3:15 PM, and 5:15 PM; 01/05/2026 at 7:15 PM; 01/08/2026 7:15 AM, 9:15 AM, 11:15 AM, 1:15 PM, 3:15 PM, and 5:15 PM; 01/10/2026 1:15 AM; 01/14/2026 7:15 AM, 9:15 AM, 11:15 AM, 1:15 PM, 3:15 PM, and 5:15 PM; 01/17/2026 9:30 AM, 11:30 AM, 1:30 PM, 3:30 PM, and 5:30 PM;01/18/2026 7:15 AM, 9:15 AM, 11:15 AM, 1:15 PM, 3:15 PM, 5:15 PM, and 7:15 PM; 01/22/2026 1:30 PM, 3:30 PM, and 5:30 PM, and 9:15 PM; AND 01/20/2026 at 9:30 PM and 11:30 PM. In an interview on 01/27/2026 at 3:30 PM, S3RM verified the RN missed rounding every 2 hours on Patient #1 as mentioned above. Patient #2 Review of Patient #2’s medical record revealed Patient #2’s observation level was every 15 minutes rounding by the Mental Health Technician (MHT) and every 2 hours by the RN. The Rounding Forms dated with the following times the RN missed rounding on the patient every 2 hours: 11/08/2025 at 6:15 PM; 11/09/2025 9:15 AM, 11:15 AM, 1:15 PM, 3:15 PM, and 5:15 PM; 11/12/2025 11:30 AM, 1:30 PM, 3:30 PM, and 5:30 PM; and 11/13/2025 7:15 AM, 9:15 AM, 11:15 AM, 1:15 PM and 5:15 PM. In an interview on 01/28/2026 at 2:00 PM, S3RM verified the RN missed rounding every 2 hours on Patient #2 as mentioned above. Patient #3 Review of Patient #3’s medical record revealed Patient #3’s observation level was every 15 minutes rounding by the Mental Health Technician (MHT) and every 2 hours by the RN. The Rounding Forms dated with the following times the RN missed rounding on the patient every 2 hours: 10/02/2025 5:15 PM; 10/06/2025 9:15 AM, 11:15 AM, and 1:15 PM; 10/10/2025 5:15 PM; 10/22/2025 5:15 PM; 10/25/2025 7:15 AM, 9:15 AM, 11:15 AM, and 1:15 PM; 10/27/2025 5:15 PM; 10/30/2025 7:15 AM, 9:15 AM, 11:15 AM, 1:15 PM, 3:15 PM, and 5:15 PM; 10/31/2025 7:15 AM, 9:15 AM, 11:15 AM, 1:15 PM, 3:15 PM, and 5:15 PM; AND 11/05/2025 7:15 AM, 9:15 AM, 11:15 AM, 1:15 PM, 3:15 PM, and 5:15 PM. In an interview on 01/28/2026 at 3:15 PM, S3RM verified the RN missed rounding every 2 hours on Patient #3 as mentioned above.”

“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: 48050 Based on record reviews and interviews, the hospital failed to ensure all orders, including verbal orders, were dated, timed, and authenticated promptly by the ordering practitioner for 3 (#1, #2, #3) of 3 patient records reviewed. Findings: Review of the hospital’s policy # MS-0101 titled “Medical Staff Rules and Regulations”, reviewed 08/09/2025, revealed in part: “C. Physician Orders: 2. Verbal Orders- Verbal Orders can be recorded only by a registered nurse or licensed practical nurse. Verbal orders should be signed as soon as possible, but not later than 10 days. Verbal Orders given by On-Call Physicians can be signed by attending MD or providers making rounds. “ Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 11/25/2025. Review of the physician orders revealed the following orders were verbal orders and not signed by the ordering practitioner/physician: 01/03/2026 8:43 PM Norco 5/325 mg PO Q 12 hours PRN pain- maximum dosing 12 tablets 01/03/2026 12:03 AM D/C Oxycodone 01/05/2026 8:15 PM Transfer to ER 01/27/2026 8:25 PM Medical Consult related to complaints of discomfort to right arm In an interview on 01/27/2026 at 3:30 PM, S3RM confirmed the verbal orders above were not signed by the practitioner/physician. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 10/1/2025. Review of the physician orders revealed the following orders were not signed by the ordering practitioner/physician: 10/08/2025 4:48 PM Discontinue 1:1 at 7:00 PM, patient to have visual contact observation 11/08/2025 5:45 PM Apply triple antibiotic ointment to left forearm wound, apply non-latex band aid daily times 5 days 11/10/2025 5:25 PM Unit restriction, no point store In an interview on 01/28/2026 at 2:15 PM, S3RM confirmed the above stated physician orders were not signed by the physician/practitioner. Patients #3 Review of Patient #2’s medical record revealed Patient #2 was admitted on 10/1/2025. Review of the physician orders revealed the following orders were not signed by the ordering practitioner/physician: 11/25/2025 8:43 PM Please send patient to Lakeview Hospital for evaluation status post fainting, low blood pressure 11/25/2025 8:44 PM Place patient on fall precautions In an interview on 01/28/2026 at 3:15 PM, S3RM confirmed the above stated physician orders were not signed by the physician/practitioner.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 48050 Based on record reviews and interviews, the hospital failed to include a discharge summary in the medical record within 30 days of discharge according to hospital policy for 2 (#2, #3) of 3 patient records reviewed. Findings: Review of the hospital’s policy # IM-1401 titled “HIM-04: Discharge Record Review”, reviewed 02/12/2024, revealed in part: “Purpose: To ensure a completed medical record. Procedure: 4. Physician Discharge Summaries are due within 30 days of discharge.” Review of the hospital policy #MS-0101 titled, “Medical Staff Rules and Regulations” last reviewed on 08/09/2025 revealed in part: “J. Discharges: 4. Discharge Summaries are to be completed within 30 days of discharge.” Patient #2 Review of Patient #2 medical record revealed Patient #2 was admitted on 10/01/2025 and discharged on 11/18/2025. Further review of Patient #2’s medical record revealed the discharge summary was not completed until 12/22/2025. In an interview on 01/28/2026 at 2:20 PM, S3RM confirmed the discharge summary was not completed within 30 days of Patient #2’s discharge date. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 11/19/2025 and discharged on 11/26/2025. Further review of Patient #3’s medical record failed to reveal a discharge summary. In an interview on 01/28/2026 at 3:17 PM, S3RM confirmed there was no documentation of a discharge summary included in Patient #3’s medical record. S3RM further confirmed the physician has 30 days from discharge to complete the discharge summary.”

“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: 14442 Based on record review and interview, the hospital failed to ensure the patient right to personal privacy as evidenced by failing to ensure patients received a copy of the hospital video and audio surveillance protocol for 3 (#1, #2, #3) of 3 sampled patients. Findings: Review of the hospital Video Surveillance Policy #: EC-0002, Revised: 03/08/2024 revealed, in part: Policy: It is the policy of Northlake Behavioral Health System (NBHS) to ensure that the facility balances the security and safety derived from the use of video surveillance with the privacy rights of the individual. The video surveillance policy provides detailed direction concerning the context, procedures and protocols within which the facility installs and operates surveillance cameras. Notice of Use of Video Systems: The use of video/audio monitoring is noted on NBHS Consent for Treatment forms. Review of Northlake Behavioral Health System patient admit packet revealed, in part: This packet contains the following documents: Patient Rights and Responsibilities, NBHS Health Insurance Portability & Accountability Act (HIPAA) Including Video Surveillance Guidelines and NBHS Grievance Procedure. Further review of this packet revealed no evidence it contained video surveillance guidelines. Review of Patient #1, Patient #2, and Patient #3’s medical records revealed acknowledgment forms that read, in part: Acknowledgment of Receipt of Video & Audio Surveillance Protocol. I acknowledge that I have received a copy of the Notice of Privacy Practices, Patient Rights and Responsibilities including Video Surveillance Protocol, and Grievance Procedures of NBHS this date. Further review of Patient #1, Patient #2, and Patient #3’s medical record revealed no evidence the patients received a copy of the Video & Audio Surveillance Protocol. In an interview on 06/10/2024 at 1:13 p.m., S3Risk Manager (RM) confirmed the admit packet provided to patients did not contain a copy of the hospital video and audio surveillance protocol. S3RM confirmed this information needed to be added to the patient admit packet. S3RM confirmed there was no evidence Patient #1, Patient #2, and Patient #3 received a copy of the hospital video and audio surveillance protocol.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44495 Based on observation, record review, and interview the facility failed to meet the requirements for the Condition of Participation (CoP) for Patients’ Rights. The deficient practice is evidenced by: 1) failure to provide the ordered level of observation and restrictions for patients with aggressive behavior based on 4 (IR6, IR7, IR8, IR9) of 6 (IR1, IR3, IR6, IR7, IR8, IR9) reviewed patient to patient abuse incident reports and of 5 (S18MHT, S21MHT, S22MHT, S23MHT, and S24MHT) of 5 interviewed mental health technicians who were not of aware of restrictions for the patients under their care (see findings under Tag A0144) ; and 2) failure to screen staff for convictions that bar employment in healthcare facilities in the State of Louisiana for 5 (S7MHT,S8MHT,S9MHT,S13MHT,S32MHT)of 21 (S6MHT- S13MHT, S15MHT- S20MHT, S25RN S26RN, S30MHT-S35MHT) personnel files reviewed (see findings under Tag A0144); and 3) failure to ensure each patient is assigned to the care of a mental health technician (see findings under Tag A0144); and 4) failure to protect patients from abuse by appropriately screening staff through review of a criminal background check in 2 (IR4, IR5) of 3 (IR2, IR4, IR5) reviewed incident reports of staff to patient abuse from a total of 9 reviewed incident reports (see findings under Tag A0145). An Immediate Jeopardy (IJ) was identified on 01/22/2024 at 11:20 a.m. and reported to S1CEO, S4RN, and S5RM. The Immediate Jeopardy (IJ) situation was the result of the hospital’s failure to ensure patient safety. The hospital’s failure to maintain the ordered level of observation and distance precautions for patients with aggressive behavior endangered all patients in the hospital and created the potential for serious injury. On 01/22/2024 at 3:25 p.m., S5RM presented the plan for lifting the immediacy of the IJ. The plan included revisions to the current policy including the documentation of restrictions, provisions to ensure MHTs are not assigned 2 patients with restrictions from each other, and re-education of the nursing staff and medical providers on the policy changes. On 01/23/2024 at 12:15 p.m. after direct observation, record review and interview, the IJ was removed for the failure to maintain the ordered level of observation and restrictions; however, there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared. Therefore, noncompliance remains at the Condition Level.”

“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: 44495 Based on record review and interview, the facility failed to ensure each patient was allowed to actively participate in his/her plan of care. The deficient practice is evidenced by failure to document patient participation or refusal of participation in care planning for 3(#3, #5, #9) of 10 (#1-#10) reviewed patient records. Findings: Patient #3 Review of the medical record for Patient #3 revealed the patient was admitted on 07/25/2023 with diagnosis of paranoid schizophrenia and was discharged on 01/02/2023. Review of the multidisciplinary plan of care for Patient #3 revealed the treatment plans for 11/25/2023 and 11/30/2023 were not signed by the patient and there is no indication the patient refused to participate. In interview on 01/18/2024 at 2:16 p.m., S4RN verified the care plans for Patient #3 were not signed and there was no indication the patietn refused to participate. Patient #5 Review of the medical record for Patient #5 revealed admission on 07/29/2023 with a diagnosis of schizophrenia and dementia, and was currently still admitted to the facility. Review of the multidisciplinary plan of care for Patient #5 revealed the treatment plans for 09/28/2023, 10/30/2023, 11/30/2023 and 01/03/2024 were not signed and there was no indication the patient refused to participate. In interview on 01/22/2023 between 9:40 a.m. and 9:45 a.m., S4RN verified the treatment plans were not signed and there was no indication the patient refused to participate. Patient #9 Review of the medical record for Patient #9 revealed admission on 10/06/2023 with a diagnosis of unspecified mood disorder and, and was currently still admitted to the facility. Review of the multidisciplinary plan of care for Patient #9 revealed the treatment plan for 11/13/2023 was not signed and there was no indication the patient refused to participate. In interview on 01/22/2023 at 4:00 p.m., S4RN verified the treatment plan was not signed and there was no indication the patient refused to participate.”

“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: 44495 Based on record review and interview, the facility failed to ensure each patient’s right to informed consent. The deficient practice is evidenced by failure to document the patient’s refusal to sign admission consents for 1 (#5) of 10 (#1-#10) reviewed medical records. Findings: Review of the medical record for Patient #5 revealed admission on 07/29/2023 with a diagnosis of schizophrenia and dementia. Review of the admission consents for Patient #5 revealed a sticky note with “Refused to Sign,” on the assignment of benefits sheet. The form for acknowledgement of the restraint and seclusion policy, the form for acknowledgement of the privacy practices, patient rights and responsibilities, receipt of video surveillance protocol and receipt of the grievance procedures, and the form for advanced directives/ organ donor information was not signed by patient #5 and there was no indication he refused to sign. In interview on 01/22/2024 between 9:40 a.m. and 9:45 a.m., S4RN verified the forms were to be signed by the patient or documented the patient refused to sign. S4RN also verified if the patient refuses to cooperate at the time of admission, the staff are supposed to retry at a later time.”

“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: 44495 Based on observation, record review, and interview, the hospital failed to ensure care in a safe setting. The deficient practice is evidenced by: 1) failure to provide the ordered level of observation and restrictions for patients with aggressive behavior based on 4 (IR6, IR7, IR8, IR9) of 6 (IR1, IR3, IR6, IR7, IR8, RI9) reviewed patient to patient abuse incident reports and of 5 (S18MHT, S21MHT, S22MHT, S23MHT, and S24MHT) of 5 interviewed mental health technicians who were not of aware of restrictions for the patients under their care; ; and 2) failure to screen staff for convictions that bar employment in healthcare facilities in the State of Louisiana for 5 (S7MHT,S8MHT,S9MHT,S13MHT,S32MHT)of 21 (S6MHT- S13MHT, S15MHT- S20MHT, S25RN S26RN, S30MHT-S35MHT) personnel files reviewed; and 3) failure to ensure each patient is assigned to the care of a mental health technician. Findings: Review of hospital policy titled “Level of Observation and Precaution”, dated 05/09/2022, revealed, in part, “Types of Observations: . . 4) One to One (1:1)- this level of observation requires that an individual is supervised in close proximity. The 1:1 level of observation differs from VC in that the individual is maintained within three to six feet, while all other elements of the VC level of observation are maintained. . . . Types of Precautions: . . . 7) Distance Precaution (Distance)-to minimize risk of physical contact between two (2) or more patients. A distance between them of a minimum of eight (8) feet shall be maintained at all times, as is physically reasonable. The goal is always re-adjust physical space/location to maintain the eight (8) foot distance.” 1)Failure to provide the ordered level of observation and precautions for patients with aggressive behavior A review of self-reported incidents of patient to patient abuse was performed. The review revealed 4 (IR6, IR7, IR8, IR9) of 6 (IR1, IR3, IR6, IR7, IR8, RI9) critical incidents involved failure to provide the level of observation and restrictions ordered by the licensed practitioners. Incident Report 6 (IR6) Review of IR6 revealed on 12/19/2023 at 8:35 a.m., Patient #6 and Patient #7 were in the dining room eating when Patient #6 walked up behind Patient #7 and began hitting Patient #7 in the head. Further review of the report revealed the facility found the allegation of neglect was unsubstantiated and stated, “Both of the patients were being properly monitored per their MD orders.” Review of the orders for Patient #7 revealed an order from 11/14/2023 at 6:00 a.m. placing Patient #6 on distance precautions from Patient #7. In interview on 01/22/2024 at 10:33 a.m., S5RM verified the nursing staff neglected to monitor the patients per the physician’s orders. Incident Report 7 (IR7) Review of IR7 revealed on 01/11/2023 at 3:10 p.m., “Patient #1 enters the foyer area from the dayroom to get in line for a snack. Patient #5 is yelling and Patient #1 tells him to shut up as he standing in line. Patient #5 responds “I will not be quiet I have rights.” It is unclear who hit whom first but both patients put their hands up and contact was made. The incident happened in a blind spot. Staff immediately intervened and separated the patients,” and “Patients were separated for safety reasons and distance precautions orders were continued.” Further review of the incident report revealed, “The allegation of neglect is unsubstantiated due to the staff intervening and separating the patients. Both of the patients were being properly monitored per their MD orders.” In interview on 01/22/2024 at 10:33 a.m. S5RM was questioned about the statement, “distance precautions were continued,” S5RM verified that Patient #1 and Patient #5 had an earlier physical altercation and were placed on distance precautions at that time which were still in effect. S5RM verified the nursing staff neglected to monitor the patients as ordered. Incident Report 8 (IR8) Review of the provided incident reports revealed IR8 occurred on 12/03/2023 at 12:30 p.m. Review of IR8 revealed in part, “Patient #9 and Patient #10 were trying to attack Patient #8.” Review of the assignment sheet for the unit on 12/03/2023 revealed S27MHT was assigned one to one observation of Patient #9. Review of the observation sheet for Patient #9 on 12/03/2023 revealed S27MHT signed the observation sheet from 11:45 a.m. until 7:00 p.m. with no double signature to indicate someone else had briefly monitored the patient. Review of the statement by S27MHT on 12/03/2023 revealed in part, “I was by the lock seclusion room, when I was asked to come back to the unit. When I got on the unit, Patient #10 and Patient #9 was trying to fight Patient #8.” In interview on 01/22/2024 at 2:10 p.m., S4RN verified the neglect. S27MHT admitted to being off the unit and there is no documentation another staff member was watching Patient #9 who was on one to one observation. Incident Report 9 (IR9) Review of IR9 revealed it covered two critical events on Unit E for 12/03/2023 at 11:59 a.m. and 5:51 p.m., Patient #9 and Patient #10 attacked R1 in both events. The investigation report found the allegation of neglect in the care of Patient #9, Patient #10 and R1 to be unsubstantiated. Review of the assignment sheet for Unit E on 12/03/2023 revealed S14MHT was assigned to observe Patient #8 who was on one to one observation. Review of the observation sheet from the incident report for Patient #8 for 12/03/2023 revealed S14MHT had signed the observation sheet until 5:30 p.m. and the observations stop at that point. There is no time stamp on the copy to indicate what time the observation sheet was copied to be included in the incident report. Review of the final observation sheet in the medical record revealed S14MHT had been the only MHT who signed the observation sheet indicating he provided the one to one observation of Patient #8 from 1:00 p.m. until 7:00 p.m. Further review revealed at 5:51 p.m. Patient #8 was lying down in his bedroom. Review of the investigation into the incident at 5:51 p.m. revealed S14MHT stated, “I walked off the unit into the nursing station to bring in another incident report. When I walked back onto the floor, Patient R1 was sitting on the bed and Patient #10 and Patient #9 were standing in front of him trying to hit him when I went to help . . .” In interview on 01/22/2024 at 2:15 p.m., S4RN verified the neglect. S14MHT admitted he had left the unit, entered the nursing station, and participated in a critical event while he was supposed to be providing one to one observation of Patient #8 in his bedroom. S4RN verified the investigation did not include the neglect of observation of other patients on the unit during the critical event. After review of the incident reports revealed the patients were not properly monitored in the past, direct observations and interviews were performed on Unit A on 01/22/24 between 8:55 a.m. and 9:15 a.m. Direct observation on Unit A at 8:55 a.m. accompanied by S4RN revealed S18MHT leaving the unit with a box of trash on a rolling chair headed away from the unit. In an interview on 01/22/24 at 9:00 a.m., in the presence of S4RN, S21MHT verified she was unable to identify which of her assigned patients were on distance precautions. S21MHT reported she did not have a staff sheet with her to assist in identifying which patients were on distance precautions. In an interview on 01/22/2024 at 9:08 a.m., in the presence of S4RN, S18MHT stated S21MHT was watching his patients while he was taking out the trash. S18MHT reported he had one patient on distance precautions. A review of staffing sheet with S18MHT and S4RN revealed S18MHT had two patients on distance precautions. In an interview on 01/22/2025 at 9:10 a.m., S21MHT verified she did not know that S18MHT’s assigned patients were on distance precautions. In an interview on 01/22/2025 at 9:16 a.m., in the presence of S4RN, S23MHT verified she was unable to identify which of her assigned patients were on distance precautions. S23MHT verified she was not able to identify which patients should be distanced from her patients. S23MHT verified each patient to be distanced was identified by a medical record number on her assignment sheet and she was unable to identify each patient by medical record number. In an interview on 01/22/2024 at 9:24 a.m., in the presence of S4RN, S22MHT reported she had no patients on distance precautions. A review of staffing sheet with S22MHT and S4RN revealed S22MHT had three patients on distance precautions. In an interview on 01/22/2024 at 9:26 a.m., in the presence of S4RN, S24MHT reported she had one patient on distance precautions. S24MHT verified she was unable to identify which patients should be distanced from her patient. In an interview on 01/22/2024 at 9:28 a.m., S4RN verified S18MHT, S21MHT, S22MHT, S23MHT and S24MHT did not know they had patients on distance precautions and were unable to identify which patients should be distanced. S4RN verified this was a patient safety issue. An Immediate Jeopardy (IJ) was identified on 01/22/2024 at 11:20 a.m. and reported to S1CEO, S4RN, and S5RM. The Immediate Jeopardy (IJ) situation was the result of the hospital’s failure to ensure patient safety. The hospital’s failure to maintain the ordered level of observation and distance precautions for patients with aggressive behavior endangered all patients in the hospital and created the potential for serious injury. On 01/22/2024 at 3:25 p.m., S5RM presented the plan for lifting the immediacy of the IJ. The plan included: -Revision to Policy TX.7-1001 titled” Level of Observation and Precaution.” The revisions included instructions on steps to be taken by staff to maintain the distance precautions. -Re-education would begin for all direct care staff on the different precautions and how to maintain them per the revised policy. The re-education would begin immediately with the 2 shifts for 01/22/2023 and be completed once the 2 shifts on 01/13/2024 were re-educated prior to the start of each shift. -Re-education of nursing staff on patient assignments. The patient assignments will be made by a registered nurse. -Assurance that staff accepting patient assignments know each patient and the precautions ordered for that patient. Each patient’s assignment sheet will continue to have the medical record number of each patient he/she is to be distanced noted under precautions. -Each patient’s precautions will also be added to the bed list and will be reviewed daily by the charge nurse and revised as needed. -Mental Health Technicians will not be assigned two patients that are on distance precautions from each other. -Providers were to be informed of the changes to the policy via an audiovisual conference on 01/22/2023. A review and reconciliation through observation, record review, and interview of nursing staff and providers on 01/23/2023 revealed all direct care staff observed and interviewed had been re-educated. All staff were able to verbalize the revisions to the policy, demonstrate knowledge of their assigned patient’s level of observation and precautions, and explain to the surveyor which of their patients where on distance precautions and from whom they were to be distanced. Review of the provided documents revealed changes to the policy, a list of providers who acknowleded the re-education, and a list of staff who were re-educated. On 01/23/2023 at 12:15 p.m., the IJ was removed. 2) Failure to screen staff for convictions that bar employment in healthcare facilities in the State of Louisiana Review of the memo HHS 16-2-016 released 12/12/1016 regarding Criminal Convictions that Bar Employment of Unlicensed Persons or Ambulance Personnel revealed in part, “It is the responsibility of all employers that employ non-licensed persons or ambulance personnel to know which convictions bar employment. Louisiana Revised Statute 40:1203.3 covers criminal convictions that bar an employer from hiring a non-licensed person or ambulance personnel. Those criminal convictions are listed in the following table: . . . R.S.14:64 . . . R.S.40:966, R.S. 40:967, R.S.40:968, R.S.40:8969” Review of personnel files was performed between 01/11/2024 and 01/23/2024. The review 4 staff with disqualifying criminal records and one unlicensed direct care provider who did not have a criminal background check. S7MHT was hired on 10/09/2023. Review of the personnel file for S7MHT revealed a criminal background check was performed on 10/05/2023. The criminal background check revealed S7MHT had previously plead guilty to armed robbery (R.S.14:64). The facility hired S7MHT without consulting the list of convictions that bar employment in a healthcare facility. S8MHT was hired on 09/25/2023. Review of the personnel file for S8MHT revealed a background check was performed on 09/19/2023. The criminal background check revealed S8MHT had several felony convictions including possession of marijuana (R.S.40:966), possession of cocaine and distribution of schedule II narcotics (R.S.40:967). The facility hired S8MHT without consulting the list of convictions that bar employment in a healthcare facility. S9MHT was hired on 09/13/2021 and terminated on 01/02/2024. A background check was not performed. S13MHT was hired on 08/08/2023 and terminated on 01/15/2024. Review of the personnel file for S13MHT revealed a background check was performed on 08/18/2023. The criminal background check revealed convictions for possession of Schedule I, Schedule II, Schedule III and Schedule IV controlled dangerous substances (R.S.40:966, R.S. 40:967, R.S.40:968, R.S.40:8969). S32MHT was hired 1/25/2021 and terminated on 01/22/2024. Review of the personnel file for S32MHT revealed an initial background check was performed on hire and a second one was performed on 01/11/2023. The criminal background check revealed 2 convictions for possession of Schedule I controlled dangerous substances and 2 convictions for possession of Schedule II controlled dangerous substances (R.S.40:966 and R.S.40:967).S32MHT was documented on schedules and observation sheets as having worked on Unit E, which houses adolescents. In interview on 01/11/2024 at 3:40 p.m., S1CEO and S2COO verified S7MHT and S8MHT had convictions that barred employment in healthcare facilities in the State of Louisiana. In interview on 01/17/2024 at 4:13 p.m., S6HR verified a new criminal background check was required for all rehired personnel. S6HR verified S9MHT did not have a criminal background check before he was rehired. In interview on 01/18/2024 at 9:15 a.m. S6HR verified S13MHT was terminated because of the convictions that barred employment in healthcare facilities in the State of Louisiana. In interview on 01/22/2024 at 1:30 p.m. S4RN verified S32MHT was terminated because of the convictions that barred employment in healthcare facilities in the State of Louisiana. 3) Failure to ensure each patient is assigned to the care of a mental health technician. Review of hospital Policy # NS-1005, titled “Nursing Staffing Plan”, revised 02/20/2020, revealed in part, “Purpose: To provide adequate coverage to meet the patient care needs while maintaining safety for patients and staff. Definitions . . . Basic coverage-the minimum resources necessary to provide routine care.” Review of Unit C’s assignment sheet dated 01/19/2024 revealed a census of 15. Further review revealed the assignment of patient care for the unit had not been performed. Review of Unit F’s assignment sheet dated 01/19/2024 revealed a census of 10. Further review revealed Patient R18 without an assigned mental health technician. Review of Unit A’s assignment sheet dated 01/20/2024 revealed a census of 17. Further review revealed Patient R5 without an assigned mental health technician. Review of Unit B’s assignment sheet dated 01/21/2024 revealed a census of 20. Further review revealed the fields on the assignment sheet titled “Day Shift-Staff/Title,” “Patients Assigned” and “RN signature” were blank except for the name of one mental health technician assigned six patients. Review of Unit B’s assignment sheet dated 01/22/2024 revealed a census of 20. Further review revealed Patient R19 without an assigned mental health technician. Review of Unit B’s assignment sheet dated 01/23/2024 revealed a census of 20. Further review revealed Patient R20 without an assigned mental health technician. In an interview on 01/22/2024 at 2:30 p.m., S4RN confirmed the above assignment sheets dated 01/19/2024-01/22/2024 failed to reveal documented evidence that all patients were assigned a mental health technician. In an interview on 01/23/2024 at 12:30 p.m., S4RN confirmed the above assignment sheet dated 01/23/2024 failed to reveal documented evidence that all patients were assigned a mental health technician. 47397”

“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: 44495 Based on record review and interview, the facility failed to ensure each patient was free from abuse, neglect and harassment. The deficient practice is evidenced by 1) failure to protect patients from abuse by appropriately screening staff through review of a criminal background check in 2 (IR4, IR5) of 3 (IR2, IR4, IR5) reviewed incident reports of staff to patient abuse from a total of 9 reviewed incident reports; and 2) failure to appropriately monitor a patient after administration of a prn behavioral medication to ensure resolution of the behavior in 1(IR3) of 9 (IR1-IR9) reviewed incident reports. Findings: 1) Failure to protect patients from abuse by appropriately screening staff through review of a criminal background check Review of the memo HHS 16-2-016 released 12/12/1016 regarding Criminal Convictions that Bar Employment of Unlicensed Persons or Ambulance Personnel revealed in part, “It is the responsibility of all employers that employ nonlicensed persons or ambulance personnel to know which convictions bar employment. Louisiana Revised Statute 40:1203.3 covers criminal convictions that bar an employer from hiring a nonlicensed person or ambulance personnel. Those criminal convictions are listed in the following table: . . . R.S.14:64 . . .” Incident Report 4 Review of IR4 revealed on 12/26/2023 at 1:21 a.m., S9MHT and S11MHT pulled Patient #5 on the floor to his room and locked him in without cause. S9MHT and S11MHT were terminated for physical abuse of Patient #5. The investigation results substantiated the allegations of abuse or neglect against all the staff involved but failed to find neglect of responsibility on the part of the facility because all staff involved had been properly trained and were up-to-date with yearly education related to their jobs. Review of the personnel file for S9MHT was performed on 01/17/2024. The review revealed S9MHT was initially hired in September 2019 and then re-hired 12/16/2021.Further review of the personnel file revealed the orientation and the criminal background check were not repeated when S9MHT was rehired. In interview on 01/18/2024 at 4:00 p.m., S2COO stated the repeat orientation was not required if the staff returned within a few months. In interview on 01/18/1014 at 4:03 p.m., S6HR verified S9MHT did not have a repeat background check performed before he was hired on 12/16/2021. S6HR verified a new background check should have been done. S6HR verified S9MHT was not properly screened prior to re-hire. Incident Report 5 Review of IR5 revealed on 01/09/2024 at 9:20 p.m., Patient #1 spit on S7MHT and S7MHT then hit Patient #1 in the face. S7MHT was immediately terminated. The investigation report found the allegation of abuse against S7MHT was substantiated but found the allegation of neglect on the part of the facility was not substantiated because they had properly trained S7MHT. Review of the criminal background check in the personnel file for S7MHT revealed 2009 S7MHT plead guilty to armed robbery (R.S. 14:64) and was to be on parole after incarceration until 8/1/2024. In interview on 01/11/2024 at 3:40 p.m., S1CEO and S2COO verified S7MHT had a history of violence and should not have been hired. 2) Failure to appropriately monitor a patient after administration of a prn behavioral medication to ensure resolution of the behavior Review of the medical record for Patient #4 revealed he was assigned to bedroom #1. On 12/30/2023 from 7:20 a.m. until 8:00 a.m. he was in the hallway. Further review revealed Patient #4 had a below the knee amputation and was known to pace when in pain or aggravated. There was no documentation of problems with Patient #4 on the morning of 12/30/2023 prior to the incident. Review of the medical record for Patient #3 revealed he was assigned to bedroom #2. On the morning of 12/30/2023, Patent #3 was slamming doors and screaming, “That mother fucker with one leg keeps walking in and out. At 7:30 a.m. and Patient #3 was given 10 mg of Zyprexa by mouth as ordered for agitation. Review of IR3 revealed on 12/30/2023 at 8:16 a.m., “Patient #3 was standing next to Patient #4 in the dining room waiting on medication pass when he said something that appeared to agitate Patient #4. Patient #4 became verbally aggressive towards Patient #3 and Patient #3 walked closer to Patient #4 and got in his face. Patient #4 shoved Patient #3 to the floor, during the fall Patient #3 hit his head on one of the seats to the dining table.” Patient #3 was sent to a local acute care hospital for evaluation and required surgery for a fractured femur. Further review of the incident report revealed the facility found that the allegation of neglect was unsubstantiated. In interview on 01/18/2024 at 3:25 p.m., S4RN reviewed the record and verified Patient #3 had been given a prn medication that was part of his regular regime for behavior. S4RN verified the incident occurred just before the time the nurse was required to perform a follow up for effectiveness. S4RN verified Patient #3 should have been observed after the administration of the medication and should not have been allowed near Patient #4 until it was confirmed the medication had provided the desired effect. S4RN verified this was neglect on the part of the staff.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to identify opportunities for improvement related to reported cases of alleged patient abuse/neglect. The deficient practice is evidenced by 1) failure to recognize neglect in 7 (IR3- IR9) of 9 reviewed reported incidents of alledged abuse/neglect; and 2) failure to investigate associated incidents involving patient safety documented in the investigations. Findings: 1)Failure to recognize neglect Incident Report 3 (IR3) Review of the medical record for Patient #4 revealed he was assigned to bedroom #1. On 12/30/2023 from 7:20 a.m. until 8:00 a.m. he was in the hallway. Further review revealed Patient #4 had a below the knee amputation and was known to pace when in pain or aggravated. There was no documentation of problems with Patient #4 on the morning of 12/30/2023 prior to the incident. Review of the medical record for Patient #3 revealed he was assigned to bedroom #2. On the morning of 12/30/2023, Patent #3 was slamming doors and screaming, “That mother fucker with one leg keeps walking in and out. At 7:30 a.m. and Patient #3 was given 10 mg of Zyprexa by mouth as ordered for agitation. Review of IR3 revealed on 12/30/2023 at 8:16 a.m., “Patient #3 was standing next to Patient #4 in the dining room waiting on medication pass when he said something that appeared to agitate Patient #4. Patient #4 became verbally aggressive towards Patient #3 and Patient #3 walked closer to Patient #4 and got in his face. Patient #4 shoved Patient #3 to the floor, during the fall Patient #3 hit his head on one of the seats to the dining table. Patient #3 was sent to a local acute care hospital for evaluation and required surgery for a fractured femur. Further review of the incident report revealed the facility found that the allegation of neglect was unsubstantiated. In interview on 01/18/2024 at 3:25 p.m. S4RN reviewed the record and verified Patient #3 had been given a prn medication that was part of his regular regime for behavior. S4RN verified the incident occurred just before the time the nurse was required to perform a follow up for effectiveness. S4RN verified Patient #3 should have been observed after the administration of the medication and should not have been allowed near Patient #4 until it was confirmed the medication had provided the desired effect. S4RN verified this was neglect on the part of the staff. Incident Report 4 (IR4) Review of IR4 revealed on 12/26/2023 at 1:21 a.m., S9MHT and S11MHT pulled Patient #5 on the floor to his room and locked him in without cause. S9MHT and S11MHT were terminated for physical abuse of Patient #5. The investigation results substantiated the allegations of abuse or neglect against all the staff involved but failed to find neglect of responsibility on the part of the facility because all staff involved had been properly trained and were up-to-date with yearly education related to their jobs. Review of the personnel file for S9MHT was performed on 01/18/2024. The review revealed S9MHT was initially hired in September 2019 and then re-hired 12/16/2021.Further review of the personnel file revealed the orientation and the criminal background check were not repeated when S9MHT was rehired. In interview on 01/18/2024 at 4:00 p.m., S2COO stated that the repeat orientation was not required if the staff returned within a few months. In interview on 01/18/1014 at 4:03 p.m., S6HR verified S9MHT did not have a repeat background check performed before he was hired on 12/16/2021. S6HR verified a new background check should have been done. S6HR verified the facility was negligent and did not properly screen S9MHT prior to re-hire. Incident Report 5 (IR5) Review of IR5 revealed on 01/09/2024 at 9:20 p.m. Patient #1 spit on S7MHT and S7MHT then hit Patient #1 in the face. S7MHT was immediately terminated. The investigation report found the allegation of abuse against S7MHT was substantiated by found the allegation on neglect on the part of the facility was not substantiated because they had properly trained S7MHT. Review of the criminal background check in the personnel file for S7MHT revealed 2009 S7MHT plead guilty to armed robbery (R.S. 14:64) and was to be on parole after incarceration until 8/1/2024. In interview on 01/11/2024 at 3:40 p.m., S1CEO and S2COO verified S7MHT had a history of violence and should not have been hired. Incident Report 6 (IR6) Review of IR6 revealed on 12/19/2023 at 8:35 a.m., Patient #6 and Patient #7 were in the dining room eating when Patient #6 walked up behind Patient #7 and began hitting Patient #7 in the head. Further review of the report revealed the facility found the allegation of neglect was unsubstantiated and stated, “Both of the patients were being properly monitored per their MD orders.” Review of the orders for Patient #7 revealed an order from 11/14/2023 at 6:00 a.m. placing Patient #6 on distance precautions from Patient #7. In interview on 01/22/2024 at 10:33 a.m., S5RM verified Patient #7 was not monitored per the physician’s orders and the nursing staff was negligent in its observation of the patients. Incident Report 7 (IR7) Review of IR7 revealed on 01/11/2023 at 3:10 p.m., “Patient #1 enters the foyer area from the dayroom to get in line for a snack. Patient #5 is yelling and Patient #1 tells him to shut up as he standing in line. Patient #5 responds “I will not be quiet I have rights.” It is unclear who hit whom first but both patients put their hands up and contact was made. The incident happened in a blind spot. Staff immediately intervened and separated the patients,” and “Patients were separated for safety reasons and distance precautions orders were continued.” Further review of the incident report revealed, “The allegation of neglect is unsubstantiated due to the staff intervening and separating the patients. Both of the patients were being properly monitored per their MD orders.” In interview on 01/22/2024 at 10:33 a.m. S5RM was questioned about her statement, “distance precautions were continued.” S5RM verified that Patient #1 and Patient #5 had an earlier physical incident and were placed on distance precautions at that time and the precautions were still in effect at the time of the second altercation. S5RM verified the orders for distance were not followed and the nursing staff was negligent in its observation of the patients. Incident Report 8 (IR8) Review of the provided incident reports revealed on 12/03/2023, IR9 occurred at 11:59 a.m. and 5:51 p.m. and IR8 occurred on 12/03/2023 at 12:30 p.m. on the same unit. Review of IR8 revealed in part, “Patient #9 and Patient #10 were trying to attack Patient #8.” Review of the assignment sheet for the unit on 12/03/2023 revealed S27MHT was assigned one to one observation of Patient #9. Review of the observation sheet for Patient #9 on 12/03/2023 revealed S27MHT signed the observation sheet from 11:45 a.m. until 7:00 p.m. with no double signature to indicate someone else had briefly monitored the patient. Review of the statement by S27MHT on 12/03/2023 for IR9 revealed in part, “I was by the lock seclusion room, when I was asked to come back to the unit. When I got on the unit, Patient #10 and Patient #9 was trying to fight Patient #8.” In interview on 01/22/2024 at 2:10 p.m., S4RN verified S27MHT was neglegent in his observation of Patient #9. S27MHT admitted to being off the unit and there is no documentation another staff member was watching Patient #9 who was on one to one observation. Incident Report 9 (IR9) Review of IR9 revealed on 12/03/2023 at 11:59 a.m. and 5:51 p.m., Patient #9 and Patient #10 attacked R1. The investigation report found the allegation of neglect was unsubstantiated in the care of Patient #9, Patient #10 and R1. Review of the assignment sheet for the unit on 12/03/2023 revealed S14MHT was assigned to observe Patient #8 who was on one to one observation. Review of the observation sheet from the incident report for Patient #8 for 12/03/2023 revealed S14MHT had signed the observation sheet from 1:00 p.m. until 5:30 p.m. and the observations stop at that point. There is no time stamp on the copy to indicate what time the observation sheet was copied to be included in the incident report. Review of the final observation sheet in the medical record revealed S14MHT had been the only MHT providing one to one observation of Patient #8 from 1:00 p.m. until 7:00 p.m. Further review revealed at 5:51 p.m. Patient #8 was in bedroom #4 lying down. Review of the investigation into the incident which occured at 5:51 p.m. revealed S14MHT stated, “I walked off the unit into the nursing station to bring in another incident report. When I walked back onto the floor, Patient R1 was sitting on the bed and Patient #10 and Patient #9 were standing in front of him trying to hit him when I went to help . . .” In interview on 01/22/2024 at 2:15 p.m., S4RN verified S14MHT admitted he had left the unit, entered the nursing station, and participated in a critical event while he was supposed to be providing one to one observation of Patient #8. S4RN verified the investigation did not include investigation into possible neglect of observation of other patients on the unit during the critical event. 2) Failure to investigate associated incidents involving patient safety documented in the investigations. Review of the documents included in the investigation of IR1, which occured on Unit E, revealed a MHT Progress note for Patient #10 which revealed under the section for additional comments, “Took staff members’ things out the closet and acted violent when told to give them back.” Review of the documents included in the investigation of IR9 revealed a statement from S14MHT which revealed in part, “While in the seclusion room Patient R1 got a piece of metal from inside there so we got the weapon from him.” In interview on 01/22/2024 at 11:25 a.m., S5RM was asked about the above statements found in the investigations. S5RM verified she had not read them and they were not investigated. In interview on 01/22/2024 at 1:30 p.m., S4RN verified he was not aware of an unlocked closet on Unit E that was used by the mental health technitians and stated an interview with the MHT would not be possible because he was no longer working at the facility.”

“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: 47397 Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. This deficiency is evidenced by failure of the Registered Nurses to supervise, observe and evaluate 3 (#R2, #R3 and #R4) patients per hospital policy. Findings: Review of hospital policy # TX.7-1001, titled “Level of Observation and Precaution”, last revised on 05/09/2022, revealed, in part: Policy, in part: to appropriately assess patients for high risk behaviors ...Purpose, in part: To reduce the risk of patient harm to self or others as needed for patient condition, using active supervision. 2. The RN Charge Nurse is directly responsible for monitoring observation levels and precautions ...3. The Unit RN Charge Nurse will physically round to make direct observation of each patient on the unit every two hours and will initial each patient’s individual observation sheet at the time this direct observation is conducted. 4. The RNS will monitor compliance with the observation and precaution status by staff during rounds. Active Supervision, in part: a. Maintaining the patient’s level of observation/precaution at all time. b. Maintaining staff and patient safety through conscious and deliberate observation, both subjective and objective. Look for evidence of changes in the physical environment ...or presence of contraband. Observe what the patient is doing. Listen to what they are saying .... Review of Unit A document titled “Census”, dated 01/19/2024 revealed a census of 17. The census revealed R2 was on the following precautions: Close Sight Staff (every 10 minutes); and Unpredictable Behavior Precautions. Review of Patient #R2’s observation sheet dated 01/19/2024 failed to reveal observations completed by a Registered Nurse between 10:10 a.m.-7:50 p.m. Review of Unit A document titled “Census”, dated 01/19/2024 revealed a census of 17. The census revealed R3 was on the following precautions: Close Sight Staff (every 10 minutes); and Unpredictable Behavior Precautions. Review of Patient #R3’s observation sheet dated 01/19/2024 failed to reveal observations completed by a Registered Nurse between 10:10 a.m.-7:50 p.m. Review of Unit B document titled “Census”, dated 01/20/2024 revealed a census of 20. The census revealed R4 was on the following precautions: Close Sight Staff (every 10 minutes) and Unpredictable Behavior Precautions. Review of Patient #R4’s observation sheet dated 01/20/2024 failed to reveal observations completed by mental health technician at 6:20 p.m., 6:30 p.m., 6:40 p.m., 6:40 p.m., and 7:00 p.m. In an interview on 01/22/2024, S4RN confirmed that the observation sheets for R2, R3, and R4 failed to reveal observations completed as per policy.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 47397 Based on record review and interviews the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient’s needs. This deficiency is evidenced by failing to ensure a Registered Nurse made all patient care assignments. Findings: Review of hospital policy # NS-1065, titled “Staff Assignments”, revised 03/05/2020, revealed, in part, “Procedure . . . B. Process . . . 3. A designated Mental Health Technician initiates the assignment sheet; however, the RN Charge Nurse must review the assignments for completeness and appropriateness and sign as approving the delegation of these functions as noted. “ Review of hospital Job Description titled “Registered Charge Nurse”, dated 09/2023, revealed, in part, “Responsibilities . . . Oversee as well as supervises direct care staff, makes assignments ....” Review of Assignment Sheet for Unit B dated 01/21/2024 failed to reveal the schedule was completed for the day shift. Further review failed to reveal evidence a Registered Nurse reviewed the assignment sheet on the day shift. Review of Assignment Sheet for Unit C dated 01/19/2024 failed to reveal the schedule was completed for the day shift. Further review failed to reveal evidence a Registered Nurse reviewed the assignment sheet on the day shift. In an interview on 01/22/2024 at 9:06 a.m. S4RN verified the Registered Nurses did not complete staffing assignments for any of the hospital units. S4RN verified the Mental Health Technicians (MHT) split up levels of observation and the nurse signs the assignment sheet once the MHTs made the assignments. S4RN reviewed the assignment sheets for 01/17/2024, 01/18/2024, 01/19/2024, 01/20/2024, 01/21/2024, and 01/22/2024. S4RN verified the MHTs had completed the daily schedules. In an interview on 01/22/2024 at 10:30 a.m., S5RM verified the hospital policy titled “Staff Assignments” failed to meet federal regulations for hospitals which requires the Registered Nurse to assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available.”

“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: 44495 47397 Based on record review and interview, the director of nursing services failed to ensure nursing care was provided according to hospital policy. This deficient practice is evidenced by the Charge Nurse initialing observation sheets before direct observations were conducted on 16 (#1, #5, #8, #9, #10, #R1, #R3, #R6, #R7, #R9, #R10, #R11, #R14, #R15, #R16 #R17) of 23 (#1,#3, #4, #5, #8, #9, #10, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R14, #R16, and #R17) patient observation sheets reviewed. Findings: Review of hospital policy # TX.7-1001, titled “Level of Observation and Precaution”, last revised on 05/09/2022, revealed, in part, “Policy . . . to appropriately assess patients for high risk behaviors ...3. The Unit RN Charge Nurse will physically round to make direct observation of each patient on the unit every two hours and will initial each patient’s individual observation sheet at the time this direct observation is conducted.” Review of Unit A’s patient observations sheets dated 01/22/2024 was conducted on 01/22/2024 at 9:00 a.m. The review revealed S29RN initialed the observation sheets of patients #1, #5, #R3, #R6, #R7, #R9, #R10, #R11, #R14, #R15, #R16 #R17 at the following times: 9:00 a.m., 10:50 a.m., 12:50 p.m., 2:50 p.m., 5:00 p.m., and 7:00 p.m. In an interview on 01/22/2024 at 1:00 p.m., S4RN verified S29RN had initialed the observation sheets for patients #1, #5, #R3, #R6, #R7, #R9, #R10, #R11, #R14, #R15, #R16 and #R17 at 9:00 a.m., 10:50 a.m., 12:50 p.m., 2:50 p.m., 5:00 p.m., and 7:00 p.m. S4RN confirmed S29RN had initialed the observation sheets before direct observation was conducted. Review of the patient observation sheets for the patients #8, #9, #10, and #R1 for 12/03/2023 provided in the documents for IR8 and IR9 revealed the nurse had initialed the observation sheets prior to each MHT’s documentation of the observations.The observation sheets appear to have been individually collected near the end of the shift for inclusion in the critical event investigations. In interview on 01/22/2024 at 1:30 p.m., S4RN compared the observation sheets collected before the end of the shift to the completed observation sheets found in the medical record of the patients #8, #9, #10, and #R1. S4RN verified either the observation sheets were signed earlier in the shift by the registered nurse or the registered nurse signed incomplete sheets at the end of the shift.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure each patient had an individualized and comprehensive treatment plan for 1 (#2) of 1 (#2) patient treatment plans reviewed. This deficiency is evidenced by failure to include all medical diagnoses as part of an individualized and comprehensive treatment plan. Findings: Review of hospital policy #TX.1-0200, titled “Treatment Planning”, revised 06/30/2021, revealed, in part, “Definitions: Plan of Care (POC): the individualized treatment plan, developed for each active problem/goal area that includes objectives, and interventions specific to the stated problem...B, in part: Treatment Planning Process:...treatment planning goals ...Prioritizing patient needs for treatment. Review of all intercurrent Medical Diagnoses. 3., . . . The Treatment Planning forms ...a. Acute Care/Extended Care Treatment Plan . . .Intercurrent medical conditions/Medical Problems. “ Review of Patient #2’s medical record revealed a Medical History and Physical dated 05/27/2023. Further review revealed a medical history of intellectual disability. Further review revealed Intellectual Disability listed under the section “Assessment/Plan”. Review of Patient #2’s Psychiatric Evaluation dated 05/27/2023 revealed Intellectual Disability as part of the History of Present Illness. Review of Patient #2’s Psychosocial Assessment dated 05/28/2023 revealed patient with current cognitive deficits. Review of Patient #2’s Supplemental Multidisciplinary Treatment Plan/Update for Judicially Committed Patients dated 06/27/2023, failed to reveal Intellectual Disability under the section Medical Diagnoses. Review of Patient #2’s Integrated Individual Care Plan, last updated 07/20/2023, failed to reveal a diagnoses of Intellectual Disabilty. Review of Patient #2’s Multidisciplinary Treatment Plan, last updated 1/10/2024, failed to reveal a problem related to Intellectual Disability. The section titled “Medical Diagnosis” revealed “none”. In an interview on 01/18/2024 at 2:15 p.m., S4RN confirmed that Patient #2’s History and Physical and Psychiatric Evaluation included the medical diagnosis “Intellectual Disability”. S4RN also verified the Master Treatment Plan, Multidisciplinary Treatment Plan, Integrated Individual Care Plan and Supplemental Multidisciplinary Treatment Plan/Update for Judicially Committed failed to include evidence of Patient #2’s diagnosis of intellectual disability.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital failed to inform the patients or patients’ representative of the patients’ rights in advance as evidenced by failure to explain in a language or manner Patient #2 could understand. Findings: Review of psychiatric hospital policy titled “Communication with Persons of Limited English”, last reviewed on 06/17/2023, revealed, in part: Policy: It is the policy of the hospital to provide for communication with persons with Limited English Proficiency (LEP), including current and prospective patients and families/significant others. Purpose, in part: ...the policy also provides for communication of information contained in vital documents, including but not limited to waivers of rights, consent to treatment forms, financial and insurance benefit forms, etc. All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients and their families will be informed of the availability of such assistance free of charge. Language assistance will be provided through use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, or technology/assistive and telephonic interpretation services. Applicability: All staff will be provided notice of this policy and procedure, and staff that may have direct contact with LEP individuals will be trained in effective communication techniques, including the effective use of an interpreter/access to contract services the services patients with limited English proficiency. Procedures. In part: 1. Obtaining a Qualified Interpreter, in part: The treatment team leader, Nurse Supervisor, or unit charge nurse is responsible for obtaining an interpreter, with the approval of the Director of Nursing/Director of Clinical Services ....In emergency situation, the hospital may opt to utilize an unqualified interpreter in order to quickly resolve the emergency. 3. Accessing Services, in part: a. The Admissions RN Supervisor or designee will be responsible for initiating arrangements for translator services beginning with the evaluations. Admission process. The hospital contracts with Multi Language Solutions. MLS can be reached ...24 hours per day. b. The use of an interpreter must be documented on the Consent for Interpreter Services form, as well as the completion of the required HIPAA documentation. e. for day-to-day communication between direct care staff and the patient, an electronic translator program can be accessed via computer. Review of psychiatric hospital policy titled “Patient Rights, Responsibilities, Advocacy, last reviewed 06/01/2023, revealed, in part: Policy: It is the policy of the hospital to protect the rights of each patient. Purpose: To assure that patients and staff are knowledgeable of patient’s rights ...Procedure, in part: G. Acknowledgement of Rights/Responsibilities. Upon receipt and review of information at admission to any program, the patient is given forms to sign acknowledging receipt and understanding of the information presented by the admission staff. Review of the psychiatric hospital document titled, “Patient Rights & Responsibilities, Patient Bill of Rights”, revealed in part: Every patient, or his/her designated representative, shall whenever possible, be informed of the patient’s rights and responsibilities in advance of furnishing or discontinuing patient care. ...The right to receive, as soon as possible, the services of a translator or interpreter to facilitated communication between the patient and the he hospitals’ health care personnel ... Review of Patient #2’s medical record revealed patient #2 was admitted on 10/26/2023 with a diagnosis of psychosis, mood disorder and THC use disorder. Further review revealed a document titled hospital “Consent for Treatment”. Continued review revealed Patient #2 acknowledged the need for an interpreter on 10/26/2023 at 10:34 a.m. Review of Patient #2’s medical record revealed Patient #2 was a self-pay patient whose preferred language was Spanish, Castilian. Continued review failed to reveal evidence of the use of an interpreter documented on the “Consent for Interpreter Services” form, as well as on the completion of the required HIPAA documentation as per hospital policy. Review of Patient #2’s medical record revealed a document dated 10/26/2023 at 10:37 a.m., acknowledging the receipt of Notice of Privacy Practices, Patient Rights and Responsibilities, Receipt of Video and Audio Surveillance Protocol and Receipt of Grievance Procedure. Further review failed to reveal the use of an interpreter documented on the acknowledgement. Continued review failed to reveal staff signature. Review of Patient #2’s medical record revealed a document titled “Acknowledgment of Receipt Advance Directive/Organ Donor Information”. Further review failed to reveal the use of an interpreter documented on the acknowledgement. Review of Patient #2’s medical record revealed a document titled “Financial Agreement” and “Release of Protected Health Care Information Via Telephone to Answering Machine or Voice Mail”. Further review failed to reveal the use of an interpreter documented on the “Financial Agreement” and “Release of Protected Health Care Information Via Telephone to Answering Machine or Voice Mail” authorization. In an interview on 12/04/2023 at 2:35 p.m., S11RM reported that the staff should have used an interpreter when communicating with Patient #2 and should have used an interpreter when completing assessments. S11RM stated she was not aware of the Interpreter Consent form as described in the Interpreter policy. S11RM confirmed that there is no evidence of Interpreter consent form documented in Patient #2’s chart. In an interview on 12/05/2023 at 10:45 a.m., S11RM and S9ADON confirmed that there was no evidence of the use of an interpreter documented on the Consent for Interpreter Services form, as well as the completion of the required HIPAA documentation, Patient Rights forms, Advance Directive, and Organ donor form, Financial Agreement forms Release of Protected Information form, as per hospital policy.”

“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: 47397 Based on record review and interview, the psychiatric hospital failed to ensure the patient /patient representative’s right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure Spanish speaking Patient #2 had a translator to assist with the development and implementation of the patient’s plan of care. Findings: Review of psychiatric hospital policy titled “Communication with Persons of Limited English”, last reviewed on 06/17/2023, revealed, in part: Purpose: To ensure persons with Limited English Proficiency have an equal opportunity to participate in the facility’s services, activities, programs and benefits. The policy of the hospital is to ensure meaningful communication with LEP patients and their authorized representatives involving their medical conditions and treatment. Procedures, in part: ...when records are kept of past interactions with patients or family members, the language used to communicate with the LEP person will be included as part of the record. Review of psychiatric hospital policy titled “Treatment Planning” last reviewed on 06/10/2023, revealed, in part: 4. The patient ...is included in treatment planning team reviews in order to: a. involve them in the decision making process; b. solicit their views/preferences; and c. develop conclusion/recommendations for care which consider their preferences. Participation must be documented ... Review of the psychiatric hospital document titled, “Patient Rights & Responsibilities, Patient Bill of Rights”, revealed in part: The right to participate in the development and implementation of his/her plan of care. Every patient...has the right to make informed decisions regarding his or her care. Review of Patient #2’s medical record revealed a document titled “Multidisciplinary Master Treatment Plan” dated 10/26/2023 at 3:37 p.m. Further review failed to reveal the language used to communicate with Patient #2. Continued review failed to reveal evidence that Patient #2 was provided a translator or interpreter during the care plan meetings in order to ensure that Patient #2 was able to fully participate in: 1) the decision making process of his treatment plan; 2) the provision of his views and preferences; and 3) the consideration of his preferences. In an interview on 12/05/2023 at 10:45 a.m. S11RM and S9ADON confirmed the treatment plan failed to reveal the language used to communicate with Patient #2 and failed to reveal evidence that Patient #2 was provided a translator or interpreter during the care plan meetings”

“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: 47397 Based on observation and interview the hospital failed to ensure each patient’s right to care in a safe setting. This deficient practice is evidenced by failing to ensure that enough staff were available for the safe monitoring of patients. Findings: Review of psychiatric hospital policy titled Nursing Staffing Plan, last reviewed on 03/31/2023, revealed, in part: Purpose: to provide adequate coverage to meet the patient care needs while maintaining safety for patients and staff. Procedure, in part: 2. Basic coverage provides resources for: b. Maintenance of routine observation, Q-15, SP1, Limited VC and Precautions. 3. Staffing Mix-Direct care staffing mix is comprised of RN/LPN/MHT. 4. Acuity factors that require adjusted staffing include: b. Precautions-SP (2.3), EP, Multiple VC and 1:1. Review of psychiatric hospital policy titled “Level of Observation and Precaution”, last reviewed 03/10/2023, revealed in part: Policy: It is the policy of the hospital to appropriately assess patients for high risk behaviors and to order and maintain special precautions to protect the welfare of the patient. Purpose, in part: To reduce the risk of patient harm to self or others as needed for patient condition, using active supervision. Active Supervision, in part: a. Maintaining the patient level of observation /precaution at all time. b. maintaining staff and patient safety through conscious and deliberate observation ...Types of Observations, in part: Visual Contact (VC)-This level of observation requires that the patient is kept within an area with unobstructed views such that staff has the ability to obtain and maintain eyesight readily and the patient is accessible at all times. Types of Precautions: 2) Elopement Precautions (EP)-to prevent possible runaway of a patient considered at risk of leaving the hospital. Procedures: 3. Visual Contact (VC)-Medically compromised or an suicide precaution, extremely confused or disoriented assaultive behaviors and constant elopement risk. E. Interventions, in part: 1. Visual Contact, in part: ii. Immediately assign a staff person to the level of observation. iii. Maintain therapeutic interaction and engage in activity. iv. Hand-off to next staff assignment (including breaks). G. Assignment: 3. VC can be maintained by one staff person who can still be responsible for multiple patients as long as the patient remains in line of sight. Failure to properly maintain assignment can result in harm to the patient, other patients and staff and may result in disciplinary action against the employee for neglect. Review of Unit A Census dated 10/30/2023 at 6:45 p.m. through 7:15 a.m., revealed 18 patients plus 1 incoming admission and 2 visual contact precautions and 1 elopement precautions. Review of staffing schedule of Unit A on 10/30/2023 at 6:45 p.m. through 7:15 a.m., revealed 1 Registered Nurse, and 3 Mental Health Technicians (MHT) and 1 shadowing MHT in orientation. Review of document titled “Hospital Abuse/Neglect Initial Report” dated 11/02/2023 revealed an incident involving Patient #2 on 10/31/2023 at 1:07 a.m. The report revealed all three MHTs were involved in the incident with Patient #2 while the nurse was getting an injection. In an interview on 12/04/2023 at 3:25 p.m., S9ADON confirmed the hospital failed to ensure that enough staff were available for the safe monitoring of patients. Based on the acquity level, Unit A should have had at least 4 MHTs, not including a shadowing MHT. S9ADON reported Unit A was short-staffed on the night of 10/30/2023 due to having to pull staff over to another unit.”

“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: 47397 Based on interview and record review, the hospital failed to provide an environment free from abuse/neglect and failed to implement effective interventions to prevent future occurrences of abuse/neglect. This deficient practice was evidenced by 1(#2) of 3 (#1 - #3) patient records reviewed who was the victim of physical abuse by S3MHT and verbal abuse by S1MHT and S2MHT of which the allegation was substantiated by the hospital. Findings: Review of the psychiatric hospital policy titled, “Abuse / Neglect of Patients/Reporting Allegations” revealed, in part, Statutory Definition of Abuse from 42CFR 51.2 (Protection & Advocacy for the Mentally Ill) definition of abuse: Abuse means any act (or failure to act) done knowingly, recklessly, or intentionally, including an act, which caused or could have caused major physical injury to an individual with mental illness, and includes but is not limited to acts such as: rape or sexual assault; striking; the use of excessive force when placing an individual with mental illness in bodily restrains; the use of excessive force when placing an individual with mental illness in bodily restraints; the use of bodily or chemical restraints which is not in compliance with Federal and State laws and regulations; verbal, nonverbal, mental and emotional harassment; and any other practice which is likely to cause immediate physical or psychological harm or result in long-term harm if such practices continue. Neglect means a negligent act or omission by an individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk of injury or an appropriated individual program or treatment plan ...and the failure to provide a safe environment which also includes failure to maintain adequate numbers of appropriately trained staff ...Examples of Neglect, c. Failure to provide a safe environment. IV. Duty to Report Abuse, in part: A. Timeline for notifications: Adults-Allegations will be reported to the Unit Nurse Immediately. Review of the psychiatric hospital document titled, “Patient Rights & Responsibilities, Patient Bill of Rights”, revealed in part: The right to be free from all forms of abuse and harassment. The right to receive care in a safe setting. Review of the incident report log for October 2023 revealed, in part, on 10/31/2023 at 1:07 a.m. the type of incident as “Staff to Patient”. Review of the hospital’s self-report revealed, in part, on 10/31/2023 at 1:07, Patient #2 with diagnoses psychosis and known language barrier, would not stay dressed. S1MHT, S2MHT and S3MHT began to tell the patient to go sit down when S3MHT grabbed the patient and tried to forcibly make him sit down. Patient #2 jumped up again and appeared to elbow S3MHT in the stomach area. S3MHT proceeded to put his hands around the patient’s neck and put him down on the dining room chair in a supine position. S2MHT grabbed the patient’s wrist and attempted to tell the patient he was not being compliant in Spanish. S3MHT let go of the patient’s neck and grabbed his other wrist as well. S2MHT proceeded to tell the patient “If you want drugs just say that. You are going to be here for a while chasing drugs.” And started calling the patient “El Drugo”. S1MHT then stated “If S3MHT grabs you S3MHT is tired. It takes a lot for S3MHT to put his hands on yall.” S3MHT stated, “I am not helping him anymore.” Patient #2 tried to stand up again and S3MHT forcibly placed him in the chair again while yelling at him with his finger in the patient’s face to sit down. Furthermore, the techs began having another conversation amongst themselves that the patient liked the feeling from the shots because he falls asleep while standing up, and liked being high. The patient got out of his seat and S3MHT grabbed his arm to put him back in the seat. The patient elbowed him to try to get away. S3MHT then tried to grab Patient #2 around his neck again and the patient hit him. S3MHT tried to grab Patient #2 to gain control over him but the patient fought back which caused him to rip out of his shirt and start running down the hall into his bedroom. All of the staff ran behind him into his bedroom. Witness statements state that the patient ran into the bedroom and jumped on top of his peer’s bed at the headboard. The staff tried to redirect the patient for disturbing the unit but were unsuccessful so an injection was given to the patient. The conclusion revealed the allegation of physical and verbal abuse was substantiated for S3MHT and he was immediately terminated. The allegation of verbal abuse against S1MHT and S2MHT was substantiated. Both of these employees were to attend abuse and neglect retraining before being allowed to return to the floor and placed on a 90-day Performance Improvement Plan (P.I.P) to be monitored by their direct supervisor. Review of physican orders dated 10/31/2023 at 10:00 a.m. revealed “Notify Risk Manager. Patient has scratches on neck (make incidence report). Review of S1MHTs Employee Performance Improvement Plan dated 11/03/2023 revealed S1MHT was scheduled to attend Abuse and Neglect training on 11/06/2023. Review of S2MHTs Employee Performance Improvement Plan 11/03/2023 revealed S2MHT was scheduled to attend Abuse and Neglect training on 11/06/2023. Review of S2MHTs Disciplinary Action Form dated 11/02/2023 revealed that on 10/31/2023 S2MHT violated hospital Abuse/Neglect policy by failing to report abuse/neglect when the incident occurred. Due to the abundance of infractions, S2MHT would receive a disciplinary action and a 90 day PIP due to the policy violation. Future policy violations would result in further disciplinary action and up to separation of employment. Review of staff schedule for Unit A, dated 11/02/2023 and 11/03/2023 from 6:45 p.m. through 7:15 a.m. revealed both S1MHT and S2MHT were on the schedule. In an interview on 12/05/2023 at 10:20 a.m., S9ADON and S11RM confirmed that S1MHT and S2MHT were back working on Unit A before undergoing the retraining as per the P.I.P’s. S9ADON and S11RM both stated that S1MHT and S2MHT should not have been working again until they underwent the training scheduled for 11/06/2023 in order to prevent abuse from re-occurring.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 47397 Based on record reviews and interview, the hospital failed to ensure patients in the psychiatric hospital were informed of their right to be free from physical or mental abuse, and corporal punishment and to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. This is evidenced by failing to have documented evidence that a translator was utilized to inform Spanish speaking Patient #2 of the reasons for the use of restraint/seclusion and to confirm his understanding before he was placed in seclusion. Findings: Review of the psychiatric hospital document titled, “Patient Rights & Responsibilities, Patient Bill of Rights”, revealed in part: The right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. You may not be placed in restraints or in seclusion except in an emergency to protect you or others from physical injury. Review of Patient #2’s medical record revealed hospital document titled “Philosophy and Practice for Seclusion and Restraint Use” dated 10/26/2023. Further review failed to reveal evidence of documentation that a translator or an interpreter was utilized to confirm Patient #2’s understanding of the following: 1) the hospital philosophy regarding seclusion and restraint use; 2) the definition of seclusion and restraint and when they are used; 3) the alternatives tried before using seclusion or restraint; 4) the behaviors that will result in release from restraint; and 5) how the hospital staff can help with triggered behaviors that can lead to seclusion or restraint. Review of Patient #2’s medical record revealed a Restraint/Seclusion document dated 10/29/2023 at 2:15 p.m. Further review revealed Patient #2 was placed in locked seclusion on 10/29/2023 at 2:15 p.m. for taking of clothes and banging on nurses station doors when he was told he could not go outside because of Elopement Precautions. Noted “unable to verbally direct”. Continued review failed to reveal a translator was utilized to inform Spanish speaking Patient #2 of the reasons for the use of seclusion and to confirm his understanding before he was placed in seclusion. In an interview on 12/05/2023 at 10:45 a.m., S11RM and S9ADON confirmed that Restraint/Seclusion document failed to reveal evidence that a interpreter/translator was utilized to inform Spanish speaking Patient #2 of the reasons for the use of seclusion and to confirm his understanding before he was placed in seclusion. In an interveiw on 12/04/2023 at 10:25 a.m., S12MHT stated if there is a language barrier then the MHT relies on the RN to obtain an individual translator or interperter to assist with communication. If the situation becomes volatile, the RN is responsible for determining how to overcome the language barrier.”