Eastern La Mental Health System

“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: 48050 Based on record review and interview, the hospital failed to ensure each patient or patient representative consented to treatment and was informed of his or her patient rights. This deficient practice is evidenced by failure to obtain signed consent for telemedicine 3 (#1, #2, #3) of 3 (#1-#3) records reviewed. Findings: Review of the hospital’s Client Handbook last revised on 06/2024 revealed in part: Admission: Upon admission * You will be given information on informed consent for treatment. ARTICLE XIII: TELEMEDICINE: Telemedicine involves the use of electronic video communication to provide professional clinical services from a remote information. The Chief of Staff with Governing Body approval may recommend the clinical services be provided by telemedicine. These clinical services shall be consistent with hospital accepted quality standards. Review of Patient #1’s medical record revealed Patient #1 was admitted on 04/26/2023 for Schizophrenia. Further review revealed an Informed Consent For Telemedicine Evaluation by ELMHS Physician not filled out or signed by the admitting physician, but signed by Patient #1. Further review of the record revealed this patient was receiving telehealth visits. Review of Patient #2’s medical record revealed Patient #2 was admitted on 07/10/2025 for Schizophrenia. Further review revealed an Informed Consent For Telemedicine Evaluation by ELMHS Physician signed by the admitting physician, but not by Patient #2. Further review of the record revealed this patient was receiving telehealth visits. Review of Patient #3’s medical record revealed Patient #3 was admitted on 06/23/2025 for Schizophrenia. Further review revealed an Informed Consent For Telemedicine Evaluation by ELMHS Physician signed by the admitting physician, but not by Patient #3. Further review of the record revealed this patient was receiving telehealth visits. In an interview on 02/10/2026 at 1:50 PM, S7SW verified S6MD was the admitting provider who performs face to face assessments and telemedicine assessments. In an interview on 02/10/2026 at 1:45 PM, S1TQMPC the above information mentioned above.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to the physician’s orders. The deficient practice is evidenced by failure of the nursing staff to administer Patient #1’s medications per physician order. Findings: Review of Patient #1’s medical record revealed a provider order dated 10/17/2025 at 9:09 AM for Abilify 10mg 1 tablet PO BID if refused give Zyprexa 10mg IM for each dose refused. Further review of Patient #1’s MAR dated 10/16/2025 to 12/11/2025 revealed refusal of Abilify on 11/03/2025 of the 8:00 PM dose, 11/26/2025 of the 8:00 PM dose, and 11/30/2025 of the 8:00 PM dose. Patient #1 did not receive the Zyprexa 10mg IM due to the refusal Albilify. There was no documentation in the record of medical provider notification of the refusals. In an interview on 02/010/2026 at 2:30 PM, S1TQMPC confirmed Patient #1 refused Abilify on 11/03/2025 of the 8:00 PM dose, 11/26/2025 of the 8:00 PM dose, and 11/30/2025 of the 8:00 PM dose and Zyprexa IM was not given when Patient #1 refused the Abilify.”

“PHARMACIST SUPERVISION OF SERVICES CFR(s): 482.25(b)(1) §482.25(b)(1) - All compounding, packaging, and dispensing of drugs and biologicals must be under the supervision of a pharmacist and performed consistent with State and Federal laws. This Standard is not met as evidenced by: 48050 Based on record review and interview the hospital failed to ensure all ordered medications were transcribed correctly on the medication record to ensure correct administration. Findings: Review of Patient #1’s provider orders revealed the following ordered dated 10/17/2025 at 9:09 AM: Abilify (Aripiprazole) 10mg 1 tablet PO BID if refused give Zyprexia (Olanzapine) 10mg IM for each dose refused. Further review of Patient #1’s MAR revealed the following entries Aripiprazole 10mg 1 tablet PO BID to be administered at 8:00 AM and 8:00 PM and another entry Olanzapine 10mg IM PRN BID- 10mg recommended dose with maximum 30mg in 24 hours. Review of Patient #1’s MAR revealed the following: MAR dated 10/14/2025 to 10/21/2025 has handwritten entry: Abilify 10mg 1 tablet PO BID and another handwritten entry * If Abilify is refused give Zprexia 10mg IM for each dose refused MAR dated 10/16/2025 to 10/23/2025 has typed entry: Aripiprazole 10mg 1 tablet PO BID to be administered 8:00 AM and 8:00 PM; handwritten on same entry: * if refused, give Zyprexa 10mg IM. Typed entry on separate page with Olanzapine 10mg IM BID PRN. MAR dated 10/23/2025 to 10/30/2025 has a typed entry: Aripiprazole 10mg 1 tablet PO BID to be administered at 8:00 AM and 8:00 PM with handwritten direction added: if refused give Zyprexa 10mg IM. Second page has typed entry: Olanzapine 10mg IM BID PRN recommended dose *maximum 30mg in 24 hours MAR dated 10/30/2025 to 11/06/2025 has a typed entry: Aripiprazole 10mg 1 tablet PO BID to be administered at 8:00 AM and 8:00 PM with handwritten direction added: if refused give Zyprexa 10mg IM See P2. Second page has typed entry: Olanzapine 10mg IM BID PRN recommended dose *maximum 30mg in 24 hours MAR dated 11/06/2025 to 11/13/2025 has a typed entry: Aripiprazole 10mg 1 tablet PO BID to be administered at 8:00 AM and 8:00 PM with handwritten direction added: if refused give Zyprexa 10mg IM See Pg 2. Second page has typed entry: Olanzapine 10mg IM BID PRN recommended dose *maximum 30mg in 24 hours MAR dated 11/13/2025 to 11/20/2025 has a typed entry: Aripiprazole 10mg 1 tablet PO BID to be administered at 8:00 AM and 8:00 PM with handwritten direction added: See P2 *if refused. Second page has typed entry: Olanzapine 10mg IM BID PRN recommended dose *maximum 30mg in 24 hours MAR dated 11/20/2025 to 11/27/2025 has a typed entry: Aripiprazole 10mg 1 tablet PO BID to be administered at 8:00 AM and 8:00 PM. Second page has typed entry: Olanzapine 10mg IM BID PRN recommended dose *maximum 30mg in 24 hours MAR dated 11/27/2025 to 12/04/2025 has a typed entry: Aripiprazole 10mg 1 tablet PO BID to be administered at 8:00 AM and 8:00 PM. Second page has typed entry: Olanzapine 10mg IM BID PRN recommended dose *maximum 30mg in 24 hours MAR dated 12/04/2025 to 12/11/2025 has a typed entry: Aripiprazole 10mg 1 tablet PO BID to be administered at 8:00 AM and 8:00 PM. Second page has typed entry: Olanzapine 10mg IM BID PRN recommended dose *maximum 30mg in 24 hours Further review of Patient #1’s MAR dated 10/16/2025 to 12/11/2025 revealed refusal of Abilify on 11/03/2025 8:00 PM dose, 11/26/2025 8:00 PM dose, and 11/30/2025 8:00 PM dose. Patient #1 did not receive the Zyprexa 10mg IM due to the refusal Albilify. In an interview on 02/10/2026 at 10:35 AM, S4Pharm verified above information and confirmed the pharmacist should have transcribed the provider order on the MAR as follows: Abilify 10mg 1 tablet PO BID if refused give Zyprexa 10mg IM for each dose refused.”

“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 ensure each patient was informed of their right to have a family member or representative of his or her own choice and his or her own physician notified promptly of his or her admission to the hospital as evidenced by failure to include the Patient’s Right for admission status notification included in the list of patient rights provided to the patient. Findings: Review of psychiatric hospital document titled “Client Handbook” last reviewed 06/2024, revealed in part: “A summary of your rights are available in this Handbook.” Further review of section titled “Civil and Treatment Rights”, failed to reveal the right to admission status notification.” Review of psychiatric hospital document titled “Civil and Treatment Rights, Policy review” presented by S20ED as current, failed to reveal the right to admission status notification as part of the staff policy review. During an interview on 09/17/205 at 2:40 PM, S18SW stated the hospital did not have a policy in place to make the admission notification phone call; therefore the calls were not made. During an interview on 09/18/205 at 11:12 AM, S19PRS stated each patient is given a copy of the “Client Handbook” which contained their patient rights. S19PRS and S3TQM confirmed the right to admission status notification was not included.”

“PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s): 482.13(b)(4) The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric facility failed to ensure each patients’ right to have a family member or representative of his or her own choice and his or her own physician notified promptly of his or her admission to the hospital as evidenced by failure to document family notification of admission in 4 (#1 and #4) of 4 (#1-#4) patient medical records reviewed. Findings: Patient #1 Review of Patient #1’s medical record revealed an admission date 09/02/2025. Continued review failed to reveal that a family member or representative of Patient #1 was notified promptly of his psychiatric hospital admission. During an interview on 09/17/205 at 2:40 PM, S18SW and S3TQM confirmed there was no evidence of Patient #1’s family or caregiver having been notified of Patient #1’s admission. Patient #2 Review of Patient #2’s medical record revealed an admission date 07/22/2025. Continued review failed to reveal that a family member or representative of Patient #2 was notified promptly of his psychiatric hospital admission. During an interview on 09/17/205 at 12:23 PM, S3TQM confirmed there was no evidence of Patient #2’s family or caregiver having been notified of Patient #2’s admission. Patient #3 Review of Patient #3’s medical record revealed an admission date 05/28/2025. Continued review failed to reveal that a family member or representative of Patient #3 was notified promptly of his psychiatric hospital admission. During an interview on 09/17/205 at 12:45 PM, S3TQM confirmed there was no evidence of Patient #3’s family or caregiver having been notified of Patient #3’s admission. Patient #4 Review of Patient #4’s medical record revealed an admission date 07/01/2025. Continued review failed to reveal that a family member or representative of Patient #4 was notified promptly of his psychiatric hospital admission. During an interview on 09/17/205 at 2:23 PM, S3TQM confirmed there was no evidence of Patient #4’s family or caregiver having been notified of Patient #4’s admission. On 09/17/205 at 2:40 PM, S18SW stated the hospital did not have a policy in place to make the notification call, therefore the calls were not made.”

“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 record review and interview, the psychiatric hospital failed to ensure care in a safe setting as evidenced by failure to ensure 1 (S11CGT) of 10 (S6CGT, S8CGT-S15CGT) unlicensed staff personnel files reviewed contained a complete criminal background report. Findings: Pursuant to La. R.S. 40:1203.1-5, licensed health care providers shall request that a criminal history and security check be conducted on the non-licensed person, prior to any employer making an offer to employ or to contract with a non-licensed person or any licensed ambulance personnel to provide nursing care, health-related services, medic services, or supportive assistance to any individual. Pursuant to La. R.S. 40:2179 and 2179.1, in part: “Non-licensed person” means any person who provides for compensation nursing care or other health-related services directly related to patient care to patients of a hospital. The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State’s designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2 Employers may request criminal history information stored in LACCH in one of three ways: (1) use of the Bureau’s Internet Background Check (IBC) website (https://ibc.dps.louisiana.gov/), (2) via Authorized Agents, and (3) submission of applicants fingerprints. Review of S11CGT’s personnel file revealed a non-licensed person hired 01/17/2023. Continued review revealed a Background Report furnished by Screening Company ‘A’ dated 07/08/2022. Further review revealed the Sex Offender Registry as “Incomplete”, the Nationwide Criminal Registry as “Incomplete, The Statewide Criminal Registry as incomplete, and the county criminal registry as incomplete. During an interview on 09/18/2025 at 10:26 AM, S5DONHR confirmed S11CGT’’s personnel file did not reveal evidence of a completed Louisiana Office of State Police approved criminal background check.”

“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: 47397 Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to adhere to hospital policy and ensure video surveillance was available 24 hours a day, 7 days a week to protect the safety of the of the clients, staff, visitors and Eastern Louisiana Mental Health System (ELMHS) property. Findings: Review of psychiatric hospital’s document titled “Client Handbook”, revised 06/2024, revealed in part: “Video Surveillance, in part: ELMHS uses Video Surveillance 24 hours a day 7 days a week to protect the safety of the clients, staff, visitors and ELMHS Property”. Review of psychiatric hospital’s policy #LD-26 titled “Incident Reporting Policy and Procedure”, last reviewed 09/30/2024, revealed in part: “I. Definitions: 17. Incident-Generally, an incident is defined as any event, condition or situation, which impacts the systems and operation of the worksites. 18. Incident Reporting-An incident report is a tool that documents any event that may or may not have caused injuries to a person or damage to an ELMHS’ asset. It is used to capture injuries and accidents, near misses, property and equipment damage, health and safety issues, security breaches and misconduct in the worksite. (Other than abuse and neglect reporting). IV. Policy: 3. Continuous Improvement of Processes: An Incident Report provides a clear picture of what ELMHS should focus on resolving, changing, improving, or eliminating. This also helps Management implement new policies to determine the efficacy of these changes for safety and quality. V. Procedures: A. Types of Incidents: 2. Near Misses-these are situations where the people involved had no injuries but could have been potentially harmed by the risks detected. Observations on 09/16/2025 between 1:37 PM and 2:00 PM, guided by S1TQM, R2RNC, and S3TQM of Room ‘b’ and Room ‘c’ revealed each room contained a large black box attached to the wall with an electrical cord dangling from the bottom plugged into an electrical outlet located over a desk. Two electrical panels noted near the large box, no pad locks and open in Room ‘c’. Pad lock noted to one of the two electrical panels in Room’d’. Review of Patient #3’s progress notes dated 09/08/2025 at 8:10 AM, revealed patient punched the TV stand and snatched the temperature gauge off the seclusion room doors. Staff immediately intervened and escorted this patient to the seclusion room. Review of Patient #3’s medical record revealed patient was placed in restraint chair located in Room ‘a’ on 09/08/2025 from 10:05 AM until 2:00 PM. Review of Patient #3’s Progress Notes dated 09/08/2025 at 10:15 AM, revealed patient was in restraint chair in seclusion room, uncooperative, shaking chair, forcing it backwards. No obvious injuries noted. Review of video surveillance on 09/16/2025 at 2:22 PM navigated by S16PM of Room ‘a’ on 09/08/2025 failed to reveal video images between the times of 6:33:31 AM and 2:49 PM. Review of video surveillance on 09/17/2025 at 10:22 AM navigated by S16PM and S17IT of Room ‘b’ revealed at 5:38 AM the breaker was flipped per staff, the battery took over power for approximately one hour and the video was no longer functioning from 6:33:31 AM until 2:49 PM when IT was on the scene. During an interview on 09/16/2025 at 1:51 PM, S20IT confirmed the large box contained Video System ‘B’ that was plugged into the wall above the security officers’ desk. If the system became unplugged, video surveillance would run on battery for approximately 1 hour then video would no longer be available unless the system was attached to the generator power. During an interview on 09/16/2025 at 2:35 PM, S16PM stated he was investigating an incident that occurred on 09/05/2025 and noticed the video of the seclusion room was not available. S16PM reported he sent an email to S17IT and discovered that on 09/08/2025 at 2:49 PM the video was turned back on per S17IT. During an interview on 09/17/2025 at 11:05 AM, S17IT reported he installed new cameras approximately 2 weeks ago and noticed the breaker was off on the 09/08/2025 around 2:30 PM. The cameras in Rooms ‘a’ and ‘b’, and the sleep area did not have power and were not functioning. S17IT turned the breaker back on at 2:49 PM. Since then he has installed light switches so staff will not need to use the breakers for turning of the lights. He also padlocked the electrical panels. He stated he had plans to place a conduit around the plug so that it cannot be unplugged. During an interview on 09/18/2025 at 3:07 PM, S1TQM and S3TQM stated they were not sure if staff had been educated on the proper procedure to turn lights off so as not to accidentally turn of the camera system. S3TQM reported she had a sign placed above the light switches and padlocks placed on the electrical panels with hopes to have all units with the new camera system updated with the light fixtures and conduits by the following Friday. During an interview on 09/18/2025 at 3:40 PM, S3TQM verified the psychiatric hospital did not submit an incident report or a self-report related to the cameras having been shut off by staff that provided a clear picture of what the hospital should resolve, change, improve, or eliminate.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to ensure 2 (#2 and #3) of 4 (#1-#4) client medical records reviewed had an updated, individualized treatment plan. Findings: Review of psychiatric hospital’s document titled “Client Handbook”, revised 06/2024, revealed in part: “Civil and Treatment Rights”, in part: S. The right to an individualized treatment plan. Review of psychiatric hospital’s policy titled “Components and Guidelines for Treatment Planning Process”, last revised on 07/08/2025, revealed in part: “I. Definitions: E. Planning of Care: Individualized planning and provision of care, treatment and services that addresses the needs, safety and well-being of the client. Policy: It is the policy of ELMHS that each client shall have an integrated plan of care that is specific, individualized, comprehensive, dynamic, unique and appropriate to the client’s identified needs for treatment.” Patient #2 Review of Patient #2’s medical record revealed an admission date 07/22/2025 with diagnoses psychiatric diagnosis of psychosis, substance use disorder, incompetency to stand trial, involuntary hospitalization. Medical diagnosis of tobacco use disorder, tinea pedis, and overweight. Review of Patient #2’s “Master Problem List” dated 08/01/2025 revealed the following problems related to: Psychosis, Substance Use Disorder, Incompetency, Involuntary Hospitalization, Overweight, and Tobacco Use Disorder. Review of Patient #2’s “Master Problem List” dated 08/31/2025 revealed the following problems related to: Psychosis, Substance Use Disorder, Incompetency, Involuntary Hospitalization, Overweight, Chronic Hepatitis C, and Tobacco Use Disorder. Review of Patient #2’s Progressive Behavior Evaluation and Management Form dated 08/27/2025 revealed patient was attempting to hit staff and was administered Vistaril 50 mg by mouth for anxiety at 11:30 AM which was ineffective. Thorazine 100 mg intramuscularly was administered at 11:37 AM. Further review revealed Patient #2 was administered another injection of Thorazine 100 mg intramuscularly at 11:37 AM. At 11:52 AM patient was in open seclusion crying and asking for his mother, stating he was bitten by a black widow spider. No bite marks noted. Patient was unable to be redirected and became physically and verbally aggressive towards staff. Client was in restraint chair with muscle tension still present. 1:32 PM patient was released from restraint chair. Review of Patient #2’s treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incidents on 08/27/2025. Review of Patient #2’s Progressive Behavior Evaluation and Management Form dated 08/31/2025 revealed patient was eating food out of the trash and yelling at staff for attempting to re-direct him. He was administered Thorazine 50 mg intramuscularly at 9:35 AM. Review of Patient #2’s treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incident on 08/31/2025. Review of Patient #2’s Progress notes dated 09/06/2025 revealed that during rounds the patient exposed himself to multiple staff members. He reports issues with his private area. Staff notified medical. Nursing noted no obvious injuries to private area when patient exposed himself in the hallway. Review of Patient #2’s treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incident on 09/06/2025. Review of Patient #2’s Progress notes dated 09/12/2025 at 3:55 PM revealed that during rounds Patient #2 walked out of the same bathroom stall with another patient. Staff immediately intervened and escorted both patients away from each other. Patient #2 was placed on 1:1 for protection of others at 4:40 PM. Review of Patient #2’s treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incident on 09/12/2025. Patient #3 Review of Patient #3’s Progress note dated 09/07/2025 at 8:05 PM revealed Patient #3 received two shots for breakthrough psychosis. 8:12 PM patient #3 was placed on time out for twenty-nine (29) minutes in seclusion room. While in seclusion room patient picked up the mattress off bed and threw it on the floor. Patient started screaming toward staff making verbal threats saying he will break their jaw and mess them up. Review of Patient #3’s treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incidents on 09/07/2025. Review of Patient #3’s Progress note dated 09/13/2025 at 8:20 AM revealed Patient #3 was on administrative review and escorted from the dayroom area to seclusion room to receive a shot for refusing his morning medications. Patient was placed in a manual hold to receive the shot. Review of Patient #3’s treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incidents on 09/13/2025. Review of incident report dated 09/14/2025 at 8:21 AM revealed Patient #3 wason administrative review and escorted from dayroom to seclusion room for refusing morning medications. Patient was placed into manual hold to receive his shot. Review of Patient #3’s treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incidents on 09/14/2025. Review of Patient #3’s Progress note dated 09/17/2025 at 8:10 PM revealed Patient #3 wa placed in a manual hold from 8:10 PM to 8:11 PM due to becoming aggressive when attempting to administer his scheduled medication injection. Once Patient #3 was released from the hold, client continued to be aggressive and began kicking the cubical wall, staff redirected. During an interview on 09/18/2025 at 3:24 PM, S3TQM confirmed the above findings.”

“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: 47397 Based on record review and interview, the hospital failed to ensure all licensed nurses adhered to the policies and procedure of the hospital. This deficient practice is evidenced by failure of licensed nurse to document rounds and vital signs per policy on 1 (#2) of 4 (#1-#4) patient medical records reviewed. Findings: Review of psychiatric hospital policy titled “Nursing-2005-604, PC-NUR-00” last reviewed 05/19/2025, revealed in part: “V. Procedure: D. Documentation: ii. The RN shall assess the client and document the client’s status every two hours on the Restrictive Management Seclusion & Restraint Sheet. iii. Documentation may include, but is not limited to the following: b. Vital signs every fifteen minutes with the RN taking vital signs every thirty minutes.” Patient #2 Review of Patient #2’s medical record revealed Restrictive Management, Seclusion & Restraint Sheet dated 09/02/2025 and ordered at 8:35 AM due to patient attempting to attack staff while being redirected. He was placed in manual hold and escorted to seclusion room. Behaviors continued to elevate and patient was placed in restraint chair at 8:40 AM. Patient was released from restraint chair at 11:55 PM. Review of the observation portion of the Restrictive Management, Seclusion & Restraint Sheet dated 09/02/2025 and ordered at 8:35 AM failed to reveal the registered nurse documented a patient assessment and status between 8:40 AM and 11:45 AM as required per hospital policy. Continued review failed to reveal the nurse documented vital signs between the hours of 10:55 AM and 11:55 AM. During an interview on 09/18/2025 at 12:30 PM, S3TQM confirmed the above findings.”

“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: 47397 Based on observation, record review and interview, the psychiatric hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice is evidenced by the failure to fully investigate and identify the manner in which Patient #1 obtained the weapon used to attack Patient #2. Review of psychiatric hospital document titled “Hospital/Licensed Provider Abuse/Neglect Initial Report” revealed in part: Patient-to-Patient Physical Assault involving client on 2:1 observation physically assaulted another client on 08/15/2025 at 7:12 PM. The incident occurred in Building ‘A’ on ward ‘Ad’ hallway. Description of the alleged incident: Incident Report: While Patient #1 was being monitored, Patient #1 walked up the hallway and hit Patient #2 in the face with a piece of metal. Staff quickly intervened and redirected Patient #1 back to his room. Patient #2 was sent to the hospital. Patient #1 was on 2:1 Direct Observation and was able to pull out an older shower holder object from the wall near the showers and conceal it in his pants as Patient #1 described to S4RN about his intentions. Description of injuries and treatment provided: Patient #2 with Acute right mandibular ramus fracture sent to Hospital ‘B’. No injuries noted for Patient #1. Patient observation status: Patient #1 was on 2:1 Direct Observation. Patient #2 was not on restrictive management. Initial actions taken: Patient #1 remains on 2:1 Direct Observation. The 2 guards were moved to another unit. Patient #2 was sent to Hospital ‘B’. The investigation was concluded with the following video review: Video footage (Camera: Camera View: W4 Hall Frnt EH-135): 19:08:48: Patient #1 turns in the direction of Patient #2 places his left hand inside the front of his pants and pulls something out of his pants. Patient #1 then runs in Patient #2’s direction and begins hitting Patient #2 with the object. The CGT standing approximately 6-8 feet from Patient #1 begins to run in the direction of Patient #1 and Patient #2. 19:09:04: The CGT’s successfully separate Patient #1 and Patient #2 at this time. 19:09:06: Something shiny (possibly metal) can be seen in Patient #1’s hand at this time as two CGT’s are holding client. 19:09:15: The shiny object is removed from Patient #1’s hand at this time. Final comments: DVD available upon request. Note: Due to technical issues over the weekend, it was not clear if this report was received by HSS, therefore, Program Monitor S16PM resubmitted this report. Further review of “Hospital/Licensed Provider Abuse/Neglect Initial Report” failed to reveal further video review and interviews in order to identify the manner in which Patient #1 obtained the weapon used to attack Patient #2. Observation on 08/26/2025 between 9:30 AM- 11:45 AM of recorded video from camera EH W4 Hall Mid F on 08/15/2025 from 5:29 PM to 7:09 PM, with S16PM navigating the video monitor revealed the following: 7:02 PM: Patient #1 was in the hallway outside of his room talking with a group of approximately 3 other patients when one of the group, Patient #R1, turned and walked down hallway into bathroom followed by Patient #1 who did not walk into the bathroom but turned and went back into his room. 7:03 PM: Patient #1 walked out of his room and walked into bathroom with guard behind him who stayed in hallway by door. 7:04 PM: Patient #1 in bathroom with a guard stationed on both sides of the bathroom doorway. 7:04:25 PM: Patient #1 walked out of the bathroom and then to his room at 7:04:31 PM. 7:04:53 PM: Patient #1 left his room and went back into bathroom doorway, then down hall, then turned back around and went in his room at 7:05:25 PM. 7:05:30 PM: Patient #R1 came out of bathroom and went into Room ‘a’. 7:05:56 PM: Patient #1 walked out of his room and walked into Room ‘a’. 7:06:08 PM: Guard in hallway when Patient #1 walked out of Room ‘a’ and into his room hand in pocket on left. 7:07:19 PM: Patient #1 walked out of his room and walked down hall towards nurses’ station/dayroom then walked back to his room then walked back out into hallway with guards behind him. 7:08:08 PM: Patient #1 walked back to his room then back out into hall, leaned against the wall then walked back into his room with guards by his doorway and in hallway. 7:08:40 PM: Patient #1 walked out of his room into the hallway towards the nurses’ station/dayroom with two guards following. 7:08:48 PM: Patient #1 reached into the left side of his pants pulled out a rectangular shaped, hand-sized shiny object and proceeded to hit Patient #2 who was leaning against the wall in the hallway near the dayroom with the object. Guards intervened and separated Patient #1 from Patient #2. During an interview on 08/20/2025 at 3:25 PM, S2LT stated he believed another patient who was not on 1:1 or 2:1 observations pulled the piece of metal used by Patient #1 out of the bathroom wall and gave it to Patient #1 on the night of the incident. He reported he was almost certain of this because Patient #1 was on 2:1 observations since June 2025 and the guards had been closely sticking with him. During an interview on 08/26/2025 at 11:45 AM, S16PM agreed with the above findings and stated, the guard did not have visual on Patient #1 for only a few seconds while he was in Room ‘a’. During an interview on 08/26/2025 at 1:00 PM, S17SEC stated the guards should have been inside the room with the client, they should always be in close proximity to client. There should be no barrier between client and guard, they cannot see past a room wall. It was against hospital policy and protocol when the guards did not walk into the room with patient and lost sight of him.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to ensure 1 (#2) of 4 (#1-#4) client medical records contained a plan of care addressing all of the patient’s medical conditions as identified problems. Findings: Review of psychiatric hospital’s policy titled “Components and Guidelines for Treatment Planning Process”, last revised on 07/08/2025, revealed in part: “I. Definitions: E. Planning of Care: Individualized planning and provision of care, treatment and services that addresses the needs, safety and will-being of the client. Policy: It is the policy of ELMHS that each client shall have an integrated plan of care that is specific, individualized, comprehensive, dynamic, unique and appropriate to the client’s identified needs for treatment. Procedure: 3. The treatment plan shall include: a. A substantiated diagnosis, psychiatric or medical, that is identified by the attending physician or licensed independent practitioner, and used by the treatment team as the primary focus upon which the treatment planning will be based.” Review of Patient #2’s medical record revealed a 35 year-old male admitted on 07/30/2025. Review of Patient #2’s Psychiatric Evaluation dated 07/31/2025 revealed diagnoses included Schizophrenia, Intellectual Disability, mild, Substance abuse, Hypertension, Dyslipidemia, Tenia Pedis, Chronic Constipation, Diabetes Mellitus and GAF 35. Review of Patient #2’s Psychiatry Provider Progress Note, dated 08/08/2025, revealed the following provider documentation: Treatment Plan: Problem 3. Intellectual Disability-“We will take it into consideration when developing treatment plan and we will assist him in achieving higher level of functioning.” Review of Patient #2’s Treatment plan dated 08/09/2025, failed to reveal Intellectual Disability addressed as a problem with interventions and goals to assist him in achieving higher level of functioning. During an interview on 08/25/2025 at 12:05 PM, S3TQM confirmed Patient #2’s Treatment Plan failed to include Intellectual Disability addressed as a problem with interventions and goals to assist him in achieving higher level of functioning.”

“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 interview, the psychiatric hospital failed to ensure the Registered Nurse (RN) completed staff assignment sheets as evidenced by failure to include all patients and their room numbers on staff assignment sheets when assigning staff to patients on 2 of 2 Building/Unit Assignment sheets reviewed. Findings: Review of Building/Unit Assignment sheets dated 08/14/2025 and 08/15/2025 for Building ‘A’ revealed the following: -The forms were divided into sections, 1 section for each of the 4 wards: Units Aa, Ab, Ac, and Ad. -Each section contained a list of the names of clients that were on precautions other than routine observation. -Each section was signed by an RN under the list of staff assigned to each ward. -The form failed to reveal the names of the clients who were on routine observation. -The form failed to reveal the room numbers associated with each patient listed. During an interview on 08/25/2025 at 12:05 PM, S1TQM confirmed the patients on routine observation were not included on the staff assignment sheets and stated that the nurses usually use the shift report to identify the room numbers of each patient. Review of psychiatric hospital document titled Building ‘Aa’ “Shift Report” dated August 14, 2025 Revealed 24 patients listed. The section titled “RM” (Room) was blank for all 24 patients listed. Review of psychiatric hospital document titled Building ‘Ab’ “Shift Report” dated August 14, 2025 Revealed 31 patients listed. The section titled “Hall/Room” revealed only the hallway location of each of the 31 patients listed. Review of psychiatric hospital document titled Building ‘Ac’ “Shift Report” dated August 14, 2025 Revealed 32 patients listed. The section titled “Hall/Room” was blank for all 32 patients listed. Review of psychiatric hospital document titled Building ‘Ad’ “Shift Report” dated August 14, 2025 Revealed 22 patients listed with 3 patients in the sick bay. The section titled “Hall/Room” listed room numbers for only 10 of the 22 patients. Review of psychiatric hospital document titled Building ‘Aa’ “Shift Report” dated August 15, 2025 Revealed 24 patients listed. The section titled “RM” (Room) was blank for all 24 patients listed. Review of psychiatric hospital document titled Building ‘Ab’ “Shift Report” dated August 15, 2025 Revealed 32 patients listed. The section titled “Hall/Room” revealed only the hallway location of each of the 32 patients listed. Review of psychiatric hospital document titled Building ‘Ac’ “Shift Report” dated August 15, 2025 Revealed 32 patients listed. The section titled “Hall/Room” was blank for all 32 patients listed. Review of psychiatric hospital document titled Building ‘Ad’ “Shift Report” dated August 15, 2025 Revealed 22 patients listed with 3 patients in the sick bay. The section titled “Hall/Room” listed room numbers for only 10 of the 22 patients. During an interview on 08/25/2025 at 12:15 PM, S3TQM confirmed the patients did not have their room numbers identified on the assignment sheets and that only a few patients had a room number listed on the shift report. S3TQM stated nursing staff have been concerned about this and are trying to address it. During an interview on 08/26/2025 at 1:20 PM, S18RN stated the hospital used identification bands on the patients to confirm each patient’s identity therefore there was no need for room numbers on the staffing assignment sheets or shift reports.”

“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: 48051 Based on observation, record review and interview, the hospital failed to ensure the patient right to be free from all forms of abuse/neglect. This deficient practice is evidenced by the failure to ensure Continuous Visual Observation (CVO) at 15 feet distance was being appropriately performed on 1 (#2) of 3 (#1 - #3) patients reviewed. Findings: A review of hospital policy, “Observation and Precautions,” Policy Number: Nursing-2005-504, PC-NUR-12, effective 03/3005, last revised 05/19/2025 and approved 05/20/2025, revealed in part: “I. DEFINITIONS C. Continuous Visual Observation (CVO) at Fifteen (15) Feet: the client is continuously visually observed from a distance of not more that fifteen (15) feet from the assigned staff member. A physician’s order is required for CVO at fifteen (15) feet in distance. The registered nurse (RN) shall confer with the physician to determine the exact type of observation required for the client (1:1, 2:1). A staff member may observe no more than (3) clients on CVO. E. Precaution Observation: level of observation for clients with risk factors that present as potential for or as danger to self. Risk factors requiring elevated observation may include, but are not limited to, suicidal ideations, gestures, elopement and falls. Precautionary observation requires a physician’s order. IV. POLICY It is the policy of ELMHS to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. PROCEDURE B. Nursing Care for Clients on Precautions: ii. Continuous Visual Observation (CVO) at Fifteen (15) Feet in Distance a. PAs or Nursing-Security staff shall be assigned to clients on continuous visual observation at fifteen (15) feet. b. Staff assigned to a client on continuous visual observation shall remain within fifteen (15) feet of the client and the client must remain in sight at all times.” A review of hospital policy, “Client Abuse and Neglect Policy and Procedure,” Policy Number: LD-25, effective 05/16/2024 and approved 05/28/2024, revealed in part: I. POLICY: Eastern Louisiana Mental Health System (ELMHS) is committed to preserving the right of each person receiving services to be free of abuse and neglect. All forms of abuse/neglect of client by employees of ELMHS and its affiliates are prohibited. V. STATUTORY DEFINITIONS AND EXAMPLES B. Louisiana R.S. 15:1503. i. Abuse: the infliction of physical or mental injury, or action which may reasonably be expected to inflict physical injury, on an adult by other patties including, but not limited to, such means as sexual abuse, abandonment, isolation, exploitation, or extortion of funds or other things of value. Neglect: failure, by a caregiver responsible for an adult’s care, or by other parties, to provide the proper or necessary support or medical, surgical, or any other care necessary for the adult’s well-being. No adult who is being provided treatment in accordance with a recognized religious method of healing in lieu of medical treatment shall for that reason alone be considered to be neglected or abused. C. Louisiana R.S. 40:2009.20. These definitions apply to any person residing in a facility or receiving services from a provider licensed by HSS of the LDH Office of the Secretary. This includes, but is not limited to, clients residing in a licensed hospital and other licensed health facilities as defined by this statute. i. Abuse: the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including, but no limited to, sexual abuse or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. ii. Neglect: the failure to provide the proper or necessary medical care, nutrition, or other care necessary for the consumer’s well-being. D. 42 CFR 482.13(c)(3). These definitions contained in the Code of Federal Regulations (CFR) apply to hospitals participating in the Medicaid and /or Medicare programs. i. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. ii. Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. H. Listed below are examples of the types of conduct that constitute abuse and neglect. vi. Neglect: a. Acts or omissions by a person responsible for providing care or treatment which caused harm to, or placed a client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment, or basic care. b. Failure to provide or withhold appropriate services, nutrition, clothing, treatment, or care by gross errors in judgement, inattentions, or ignoring may also be considered a form of neglect. c. Failure to establish and carry out an appropriate program or treatment plane. d. Failure to provide a safe environment. e. Failure to provide and obtain needed medical treatment. f. Failure to supervise a client such that the client is placed in danger.” A review of the form, “State of Louisiana Department of Health & Hospitals - Office of Mental Health Client Incident, Injury, and Data Reporting Form,” revealed in part, an incident involving Patient #2 taking place on 06/29/2025 at 7:30 AM. The S16RN’s description of the incident in Section B of the report: “Pt acquired a piece of bacon from the floor, shoved it in his mouth and began choking. Pt fell from sitting position in chair to floor. While choking, code blue was called by S17CGT. Pt was able to cough up the bacon. Pt didn’t lose consciousness or stop breathing. S18MD notified.” A review of the “APS Facility Investigation Report,” Investigation ID: 12859, investigation by S19APSI, revealed an interview with Patient #2 on 07/01/2025 at 3:25 PM, conducted by S19APSI. Patient #2 revealed in part, “He was eating bacon and eggs and oatmeal. Client stated, The food got caught in his throat and wouldn’t come out.” This report revealed an interview with S12CGT on 07/02/2025 at 1:35 PM conducted by S19APSI. S12CGT revealed in part, “I was assigned to two CVO’s. During breakfast feeding (730) I was assisting one of the CVO’s while the other was eating his breakfast tray. In the process, The CVO that was eating [Patient #2], began to choke ...at no time did I leave either patient unattended. I [S12CGT] feel one CGT shouldn’t be assigned to two patient at the same time, because no two patients are alike and I as a CGT can’t be in two places at one time.” A second interview with S12CGT on 07/03/2025 at 12:25 PM and conducted by S19APSI revealed in part, S20CGT’s location during the before mentioned choking incident on 06/29/2025. S12CGT replied, “I was present at the time and never left the unit. I was currently assisting the other CVO [Random #1] ...the nurse did the report and it stated patient [Patient #2] had picked a piece of bacon off the floor, which in my defense is incorrect [Patient #2] tray had chopped bacon on it and his tray had been verified by the nurse. Also in my defense, the lineup of that day is incorrect. I was on two CVO’s both [Patient #2] and [Random #1].” This report revealed an interview with S13CGT on 07/08/2025 at 10:31 AM conducted by S19APSI. S13CGT revealed in part, “[Patient #2] was a CVO and assigned to S12CGT. However S12CGT was also assigned [Random #1]. S12CGT was in the sleeping area with [Random #1] at the time of the incident.” A request was initiated on 07/29/2025 at 11:30 AM with S3TQMPC to interview S12CGT. However, S12CGT was not on duty on this day and was unavailable via telephone. Observations during a walk-through of the hospital on 07/28/2025 from 9:10 AM to 9:55 AM revealed Patient #2 ambulating the unit of Building A. Patient #2 was hunched over at the waist at an approximate 80 - 90 degree angle with his head/face towards the ground. His upper body, from waist up was almost parallel with the floor. He was hastily ambulating unassisted. His general body appearance or posture did not afford a physically easy way to swallow food or allow food to easily pass down his esophagus. His upper body, from waist up was almost parallel with the floor. In an interview on 07/28/2025 and present on the walk-through of Building A, S21RNBM and S22CGT confirmed the identity of Patient #2. They further confirmed Patient #2 body configuration and indicated that was his normal appearance. S22CGT confirmed if a patient was on CVO at 15 Feet, then the CGT assigned to the patient would remain in the dining day room with the patient as he was eating. Observations on 07/28/2025 of recorded video from camera W4DayRm SW EH-135 on 06/29/2025 from 7:25 AM to 7:25 AM, with S20PM navigating the computer and S3TQMPC present, revealed Patient #2 during this time frame ambulating between the main day room and the dining day room. The recorded video failed to reveal S12CGT, the assigned CGT within 15 feet of Patient #2 until the patient had been assisted up from the floor. In an interview on 07/28/2025 and present during the observation of recorded video, S20PM confirmed the above mention findings on the recorded video. A review of Patient #2’s medical record revealed a provider order on 04/28/2025 at 2:10 PM for CVO at not more than 15 feet for medical observation/choke precautions and a diet order on 04/16/2025 for Dysphagia Level 2 Mechanical Altered Supervision order: Close Visual Observation (CVO): At all times, including meals. A review of the form, “Restrictive Management Observation & Precaution Sheet (0600 - 1800) dated 06/29/2025 revealed in part, S12CGT’s initials as the performer of observations checks from 6:30 AM to 11:00 AM. A review of Random Patient #1’s medical record and the form, “Restrictive Management Observation & Precaution Sheet (0600 - 1800) dated 06/29/2025 revealed in part, S12CGT’s initials as the performer of observations checks from 6:30 AM to 11:00 AM. After review of the above mentioned findings, S12CGT was unable to be in 2 locations at one time and maintain CVO at fifteen (15) feet in distance on 2 patients while these patients were in different locations at one time. In an interview on 07/29/2025 at 1:30 PM, S3TQMPC confirmed the above mentioned findings.”

“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: 48051 Based on observation, record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice is evidenced by the failure to fully investigate and identify the source and the potential cause of Patient #2’s choking event and the observation of Patient #2 while eating. Findings: A review of hospital policy, “Observation and Precautions,” Policy Number: Nursing-2005-504, PC-NUR-12, effective 03/3005, last revised 05/19/2025 and approved 05/20/2025, revealed in part: “I. DEFINITIONS C. Continuous Visual Observation (CVO) at Fifteen (15) Feet: the client is continuously visually observed from a distance of not more that fifteen (15) feet from the assigned staff member. A physician’s order is required for CVO at fifteen (15) feet in distance. The registered nurse (RN) shall confer with the physician to determine the exact type of observation required for the client (1:1, 2:1). A staff member may observe no more than (3) clients on CVO. E. Precaution Observation: level of observation for clients with risk factors that present as potential for or as danger to self. Risk factors requiring elevated observation may include, but are not limited to, suicidal ideations, gestures, elopement and falls. Precautionary observation requires a physician’s order. IV. POLICY It is the policy of ELMHS to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. PROCEDURE B. Nursing Care for Clients on Precautions: ii. Continuous Visual Observation (CVO) at Fifteen (15) Feet in Distance a. PAs or Nursing-Security staff shall be assigned to clients on continuous visual observation at fifteen (15) feet. b. Staff assigned to a client on continuous visual observation shall remain within fifteen (15) feet of the client and the client must remain in sight at all times.” A review of the, “Diet Manuel Nutritional Services Department Easter Louisiana Mental Health System 2022,” approved 10/10/2022, revealed in part: “Texture Modified Diets and Thickened Liquids: ELMHS Dysphagia Level 2-Ground: Minced, soft and moist foods, can be scooped and shaped; easily by fork. No mixed consistency. Foods that are minced, soft and moist and can be scooped and shaped (e.g., into a ball shape) should have a particle size four millimeters by 4 millimeters for adults. ELMHS Order: Dysphagia Level 2: Food Group: Protein Foods; Foods Recommended: Prepared, Moistened, tender fresh or frozen red meat, including beef, pork, or lamb finely mashed into pieces no larger than 4 mm lump size.” A review of hospital policy, “Prevention of Choking,” Policy Number: MS-13, approved and effective 08/15/2017, revealed in part: “DEFINITIONS 1. Choking: identified as a blockage, obstruction or compression in the larynx or trachea causing occlusion of the airway, resulting in the failure of air exchange. 2. Choking precautions: Observations and interventions by staff utilized to provide a safe environment for clients that are at risk of for choking. 3. Modified Texture Diet: Blending, chopping, grinding, or mashing foods easier to chew or swallow. In some cases only meats are altered in texture. In other cases, all foods must be altered. 4. Dysphagia: difficulty swallowing which can cause medical and/or feeding issues. IV. POLICY It is the policy of Eastern Louisiana Mental Health System that clients will be provided with a sage and therapeutic environment. This will include ongoing assessment of the individual client’s ability to chew and swallow safely, provisions of treatment such as environmental modifications, behavioral interventions, and dietary modifications that are based on individual needs of each client. V. CHOKING RISK FACTORS A. Clients with cognitive and/or behavioral problems may have an increased risk for choking. Listed below are several barriers staff should be aware of that can increase a client’s risk of choking: 1. Eating too fast 2. Not chewing food well 3. Overfilling mouth 4. Eating too large portions 5. Talking while eating 6. Having a poor posture while eating 7. Hoarding/Stealing Food. VI. PORCEDURES B. Placement of Clients on Special Diets and Supervision 3. For clients at risk for choking, the initial Choking Precautions Order Protocol shall be: b. Ward Mealtime Supervision: ii. Clients shall sit at the same table as other clients at risk for choking. iii. Close Visual Observation (CVO) during meal time.” A review of the form, “State of Louisiana Department of Health & Hospitals - Office of Mental Health Client Incident, Injury, and Data Reporting Form,” revealed in part, an incident involving Patient #2 taking place on 06/29/2025 at 7:30 AM. The S16RN’s description of the incident in Section B of the report: “Pt acquired a piece of bacon from the floor, shoved it in his mouth and began choking. Pt fell from sitting position in chair to floor. While choking code blue was called by S17CGT. Pt was able to cough up the bacon. Pt didn’t lose consciousness or stop breathing. S18MD notified.” A review of the “APS Facility Investigation Report,” Investigation ID: 12859, investigation by S19APSI, revealed an interview with Patient #2 on 07/01/2025 at 3:25 PM, conducted by S19APSI. Patient #2 revealed in part, “He was eating bacon and eggs and oatmeal. Client stated, The food got caught in his throat and wouldn’t come out.” This report revealed an interview with S12CGT on 07/02/2025 at 1:35 PM conducted by S19APSI. S12CGT revealed in part, “I was assigned to two CVO’s. During breakfast feeding (730) I was assisting one of the CVO’s while the other was eating his breakfast tray. In the process, The CVO that was eating [Patient #2], began to choke ...at no time did I leave either patient unattended. I S12CGT feel one CGT shouldn’t be assigned to two patient at the same time, because no two patients are alike and I as a CGT can’t be in two places at one time.” A second interview with S12CGT on 07/03/2025 at 12:25 PM and conducted by S19APSI revealed in part, S20CGT’s location during the before mentioned choking incident on 06/29/2025. S12CGT replied, “I was present at the time and never left the unit. I was currently assisting the other CVO [Random #1] ...the nurse did the report and it stated patient [Patient #2] had picked a piece of bacon off the floor, which in my defense is incorrect [Patient #2] tray had chopped bacon on it and his tray had been verified by the nurse. Also in my defense, the lineup of that day is incorrect. I was on two CVO’s both [Patient #2] and [Random #1].” This report revealed an interview with S13CGT on 07/08/2025 at 10:31 AM conducted by S19APSI. S13CGT revealed in part, “[Patient #2] was a CVO and assigned to S12CGT. However S12CGT was also assigned [Random #1]. S12CGT was in the sleeping area with [Random #1] at the time of the incident.” A request was initiated on 07/29/2025 at 11:30 AM with S3TQMPC to interview S12CGT. However, S12CGT was not on duty on this day and was unavailable via telephone. Observations on 07/28/2025 of recorded video from camera W4DayRm SW EH-135 on 06/29/2025 from 7:25 AM to 7:25 AM, with S20PM navigating the computer and S3TQMPC present, revealed Patient #2 eating his breakfast tray in the main day room. Patient #2’s food tray was sat on a chair in the middle of the main day room. Patient #2 was in his standing position, which placed him leaned over his food tray. Patient #2’s upper body was bent over at the waist and at times, his head was lower than his waist. Patient #2 appeared to be chewing, however, Patient #2 was also ambulating between the main day room and the dining day room. At no point was a CGT following him as he was walking between these rooms. The dining day room was not visible to camera video. While Patient #2 was in the dining day room, it appeared another patient summoned Patient #2 to return to the main day room. During this process, Patient #2 appeared to be chewing and hastily ambulating to get to his tray. As he approaches the chair with his tray, a substance appears to come from his mouth. After reaching his chair, he grabs the chair with both hands and as he leans forward over the chair, more substance appeared to fall from his mouth and he appeared to be coughing at that point. He then stands and motions towards a CGT (which was not assigned to him) who assists him and them assists him to floor. During the review of video, when Patient #2 was in view of the camera, it was never observed that he retrieved anything from the floor. In an interview on 07/28/2025 and present during the observation of recorded video, S20PM confirmed the above mention findings on the recorded video. A review of the document, “Jackson and Forensic Campuses House Managers’ Report,” dated 06/29/2025 with an entry under the heading: Incidents/PRNs: “[Patient #2]-CVO at 15ft. for patient safety/choking/fall precautions being watched by S12CGT was sitting in the dayroom eating Breakfast when he fell onto the floor coughing from choking on a small piece of beacon.” After the review of the above mentioned finding, a full investigation of this incident did not take into account all aspects related to observations of the client, limited activity while eating, a review of the food tray for findings of bacon being on this tray and not retrieved from the floor, and initiatives to limit Patient #2’s activity while eating. Per video review, Patient #2 was not siting while he was eating, he was not being appropriately observed and monitored and it was reported he had chopped bacon on his food tray. In an interview on 07/29/2025 at 1:30 PM S3TQMPC confirmed the above mentioned findings.”

“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: 48051 Based on observation, record review and interview, the hospital failed to assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualification and competence of the nursing staff available. This deficient practice was evidenced by the failure to appropriately monitor 1 (#2) of 3 (#1 - #3) patients according to the provider order and precaution level. Findings: A review of hospital policy, “Observation and Precautions,” Policy Number: Nursing-2005-504, PC-NUR-12, effective 03/2005, last revised 05/19/2025 and approved 05/20/2025, revealed in part: “I. DEFINITIONS C. Continuous Visual Observation (CVO) at Fifteen (15) Feet: the client is continuously visually observed from a distance of not more that fifteen (15) feet from the assigned staff member. A physician’s order is required for CVO at fifteen (15) feet in distance. The registered nurse (RN) shall confer with the physician to determine the exact type of observation required for the client (1:1, 2:1). A staff member may observe no more than (3) clients on CVO. E. Precaution Observation: level of observation for clients with risk factors that present as potential for or as danger to self. Risk factors requiring elevated observation may include, but are not limited to, suicidal ideations, gestures, elopement and falls. Precautionary observation requires a physician’s order. IV. POLICY It is the policy of ELMHS to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. PROCEDURE B. Nursing Care for Clients on Precautions: ii. Continuous Visual Observation (CVO) at Fifteen (15) Feet in Distance a. PAs or Nursing-Security staff shall be assigned to clients on continuous visual observation at fifteen (15) feet. b. Staff assigned to a client on continuous visual observation shall remain within fifteen (15) feet of the client and the client must remain in sight at all times.” A review of the, “Diet Manuel Nutritional Services Department Easter Louisiana Mental Health System 2022,” approved 10/10/2022, revealed in part: “Texture Modified Diets and Thickened Liquids: ELMHS Dysphagia Level 2-Ground: Minced, soft and moist foods, can be scooped and shaped; easily by fork. No mixed consistency. Foods that are minced, soft and moist and can be scooped and shaped (e.g., into a ball shape) should have a particle size four millimeters by 4 millimeters for adults. ELMHS Order: Dysphagia Level 2: Food Group: Protein Foods; Foods Recommended: Prepared, Moistened, tender fresh or frozen red meat, including beef, pork, or lamb finely mashed into pieces no larger than 4 mm lump size.” A review of hospital policy, “Prevention of Choking,” Policy Number: MS-13, approved and effective 08/15/2017, revealed in part: “DEFINITIONS 1. Choking: identified as a blockage, obstruction or compression in the larynx or trachea causing occlusion of the airway, resulting in the failure of air exchange. 2. Choking precautions: Observations and interventions by staff utilized to provide a safe environment for clients that are at risk of for choking. 3. Modified Texture Diet: Blending, chopping, grinding, or mashing foods easier to chew or swallow. In some cases only meats are altered in texture. In other cases, all foods must be altered. 4. Dysphagia: difficulty swallowing which can cause medical and/or feeding issues. IV. POLICY It is the policy of Eastern Louisiana Mental Health System that clients will be provided with a sage and therapeutic environment. This will include ongoing assessment of the individual client’s ability to chew and swallow safely, provisions of treatment such as environmental modifications, behavioral interventions, and dietary modifications that are based on individual needs of each client. V. CHOKING RISK FACTORS A. Clients with cognitive and/or behavioral problems may have an increased risk for choking. Listed below are several barriers staff should be aware of that can increase a client’s risk of choking: 1. Eating too fast 2. Not chewing food well 3. Overfilling mouth 4. Eating too large portions 5. Talking while eating 6. Having a poor posture while eating 7. Hoarding/Stealing Food. VI. PORCEDURES B. Placement of Clients on Special Diets and Supervision 3. For clients at risk for choking, the initial Choking Precautions Order Protocol shall be: b. Ward Mealtime Supervision: ii. Clients shall sit at the same table as other clients at risk for choking. iii. Close Visual Observation (CVO) during meal time.” A review of the form, “State of Louisiana Department of Health & Hospitals - Office of Mental Health Client Incident, Injury, and Data Reporting Form,” revealed in part, an incident involving Patient #2 taking place on 06/29/2025 at 7:30 AM. The S16RN’s description of the incident in Section B of the report: “Pt acquired a piece of bacon from the floor, shoved it in his mouth and began choking. Pt fell from sitting position from chair to floor. While choking code blue was called by S17CGT. Pt was able to cough up the bacon. Pt didn’t lose consciousness or stop breathing. S18MD notified.” A review of the “APS Facility Investigation Report,” Investigation ID: 12859, investigation by S19APSI, revealed an interview with Patient #2 on 07/01/2025 at 3:25 PM, conducted by S19APSI. Patient #2 revealed in part, “He was eating bacon and eggs and oatmeal. Client stated, The food got caught in his throat and wouldn’t come out.” This report revealed an interview with S12CGT on 07/02/2025 at 1:35 PM conducted by S19APSI. S12CGT revealed in part, “I was assigned to two CVO’s. During breakfast feeding (730) I was assisting one of the CVO’s while the other was eating his breakfast tray. In the process, The CVO that was eating [Patient #2], began to choke ...at no time did I leave either patient unattended. I S12CGT feel one CGT shouldn’t be assigned to two patient at the same time, because no two patients are alike and I as a CGT can’t be in two places at one time.” A second interview with S12CGT on 07/03/2025 at 12:25 PM and conducted by S19APSI revealed in part, S20CGT’s location during the before mentioned choking incident on 06/29/2025. S12CGT replied, “I was present at the time and never left the unit. I was currently assisting the other CVO [Random #1] ...the nurse did the report and it stated patient [Patient #2] had picked a piece of bacon off the floor, which in my defense is incorrect [Patient #2] tray had chopped bacon on it and his tray had been verified by the nurse. Also in my defense, the lineup of that is incorrect. I was on two CVO’s both [Patient #2] and [Random #1].” This report revealed an interview with S13CGT on 07/08/2025 at 10:31 AM conducted by S19APSI. S13CGT revealed in part, “[Patient #2] was a CVO and assigned to S12CGT. However S12CGT was also assigned [Random #1]. S12CGT was in the sleeping area with [Random Patient#1] at the time of the incident.” A request was initiated on 07/29/2025 at 11:30 AM with S3TQMPC to interview S12CGT. However, S12CGT was not on duty on this day and was unavailable via telephone. Observations on 07/28/2025 of recorded video from camera W4DayRm SW EH-135 on 06/29/2025 from 7:25 AM to 7:25 AM, with S20PM navigating the computer and S3TQMPC present, revealed Patient #2 during this time frame ambulating between the main day room and the dining day room. The recorded video failed to reveal S12CGT, the assigned CGT within 15 feet of Patient #2. In an interview on 07/28/2025 and present during the observation of recorded video, S20PM confirmed the above mention findings on the recorded video. A review of Patient #2’s medical record revealed a provider order on 04/28/2025 at 2:10 PM for CVO at not more than 15 feet for medical observation/choke precautions and a diet order on 04/16/2025 for Dysphagia Level 2 Mechanical Altered Supervision order: Close Visual Observation (CVO): At all times, including meals. A review of the form, “Restrictive Management Observation & Precaution Sheet (0600 - 1800) dated 06/29/2025 revealed in part, S12CGT’s initials as the performer of observations checks from 6:30 AM to 11:00 AM. A review of Random Patient #1’s medical record and the form, “Restrictive Management Observation & Precaution Sheet (0600 - 1800) dated 06/29/2025 revealed in part, S12CGT’s initials as the performer of observations checks from 6:30 AM to 11:00 AM. After review of the above mentioned findings, S12CGT was unable to be in 2 locations at one time and keep a CVO on 2 patients at one time. In an interview on 07/29/2025 at 1:30 PM, S3TQMPC confirmed the above mentioned findings.”

“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: 48051 Based on record review and interview, the hospital failed to ensure all licensed nurses adhered to the policies and procedure of the hospital. This deficient practice is evidenced by: 1) Failure to ensure the timely notification of a provider of a fall with head injury in 1 (#3) of 3 (#1 - #3) patients reviewed; 2) Failure to ensure written documentation was performed and maintained during a code blue that accurately reflected the status of the patient, the interventions being performed, the patient response to those interventions, a timed log of the interventions and events as they occur and team member role and participation; and 3) Failure to ensure written documentation of active members of the Code Blue were included in the Code Blue Multi-Disciplinary. Findings: 1) Failure to ensure the timely notification of a provider of a fall with head injury in 1 (#3) of 3 (#1 - #3) patients reviewed A review of hospital policy, “ELMHS Post Altercation Medical Evaluation Protocol,” Policy #: MS-14, with an effective date 11/15/2020, last revised 08/2021 and approved 04/23/2021, revealed in part, “I. DEFINITIONS A. Client: a term used to refer to a client, patient or resident. C. Fall: The event in which a client loses their footing and falls to the floor or against a wall or object. D. Post-Altercation or Post Fall: The period of time immediately following an altercation or a fall. E. Head and/or Neck Trauma: any blow to the head or neck from an altercation, fall or self-inflected trauma. There is no need for any positive physical finding to be present for a head trauma to have occurred. E. Head and/or Neck Injury: physical findings on examination including but not limited to contusions edema, lacerations, or deformities of the areas of the scalp, face, jaws, neck, temporal, parietal, occipital or other areas of the anatomical areas about the head or neck. G. Blunt Trauma: shall mean a trauma with a closed fist (punching), any object, or a fall in which the head hit a surface such as a floor, wall or piece of furniture. H. Glasgow Coma Scale: shall mean the standard systematic system used to evaluate level of consciousness. I. Neuro Checks: shall mean a systematic evaluation of the client’s neurological status done by the appropriate personnel and recorded on the Neurological Assessment Flow Sheet. V. PROCEDURE A. Procedure for post-altercation nursing evaluation and medical and administrative staff notifications. 1. During the post altercation period, assigned staff, including but not limited to CGT’s, RSS’s, or PA’s are to assess the clients for any evidenced of trauma with particular attention to head and neck injuries. Assigned nurses will complete a Nursing Physical Assessment evaluation and form. If any head or neck injuries are noted the nurse is to notify the following of the altercation by telephone: =Building Medical Physician or on call physician (MOD) =The building Nurse Practitioner if the NP is on duty = Client’s Psychiatrist or on call Psychiatrist = Medical Director; AOD, APS as indicated by AOD =The division DON 2. Follow the ELMHS Incident Reporting Process. 4. Nursing/Security Staff are to ensure that the Post Altercation Protocol has been implemented and documented in the client’s medical record. 6. Staff shall utilized the Post Altercation Flow Sheet (Appendix A) to evaluate the client to determine if a head or neck trauma has occurred. B. Procedure for post-altercation medical evaluation and notifications 1. If an altercation occurs and the nurses report no trauma or if the medical provider feels that the description of the injuries constitute a minor injury then the notified PHYSICIAN or NP shall specifically ask the reporting nurse if the client was punched, fell or otherwise has had any blunt trauma on or about the head or neck, has had any loss of consciousness (LOC), nausea, vomiting. a. Neuro Checks every 2 hours times six checks shall be ordered on all clients who have had a head trauma. The Neurological Assessment Flow Sheet shall be utilized to do and document Neuro Checks. Unless otherwise ordered by the examining medical care provider the neuro checks shall be discontinued after the above 12 hour period. APPENDIX A: HEAD INJURY DECISION CHART (attached) **Medical Services Director or Designee must be notified of all head injuries.” A review of the form, “State of Louisiana Department of Health & Hospitals - Office of Mental Health Client Incident, Injury, and Data Reporting Form,” revealed in part, an incident involving Patient #3 taking place on 07/16/2025 with an unknown time and being discovered on 07/16/2025 at 9:00 PM. The S7RN’s description of the incident in Section B of the report: “PT. OBSERVED WITH A RED MARK ON THE LEFT SIDE OF FACE. WHEN INITIALLY QUERIED AS TO THE ORIGIN HE REFUSED TO RESPOND. EVENTUALLY ON AROUND 2100 ON 7/16/25 HE STATED THAT HE SLIPPED AND HIT HIS FACE O HIS LOCKER AS HE WAS TRYING TO GET HIS SHOES. NURSE MANAGER NOTIFIED. NP NOTIFIED AT 0743.” Signed by S7RN on 07/17/2025. Supervisors review revealed: “Informed of incident 7/17/25. Pt. assess by RN on unit. Referred to FNP for evaluation. Pt. placed on neuro checks. Referred to S14RNS supervisor for further information regarding the incident.” A review of the form, “Injury Review Form,” revealed the section: “DESCRIBE WHAT YOU DID TO ADDRESS THE INJURY: PT ASSESSED, WAITED FOR THE DAYSHIFT AND REFERRED TO NP.” Signed by S7RN on 07/17/2025. The section, “TO BE COMPLETED BY PHYSICIAN ONLY” revealed the physician being notified on 07/17/2025 at 7:43 AM and the time of first treatment by the physician on 07/17/2025 at 7:45 AM. S15FNP reported no suspicion of abuse or neglect and further documented: “No Client hit left side of face/cheek bone/head on door frame - he report he was walking out of his room and caught walker on door frame, he fell and hit face on frame. No LOC, No problem getting up and walking to dayroom. Abrasion to left cheek ~0.5 x 0.1 cm, no bleeding at this time. Keep open to air. Neuro checks.” Signed by S15FNP on 07/17/2025. A review of the form, “Nursing Physical Assessment,” dated 07/16/2025 at 9:00 PM and signed by S7RN revealed, “P - WILL REPORT TO ON COMING SHIFT FOR FOLLOW-UP WITH NURSE PRACTIONER.” A review of a progress note by S15FNP on 07/17/2025 at 7:45 AM revealed in part, “Staff reported to me at 743 am that [Patient #3] fell on 07/16/2025 around 3pm and it wasn’t reported until night nurse reported it this morning.” The above mentioned policy and procedure was not followed upon the discovery of Patient #3’s fall and resulting head injury. This delay in the notification of the provider could have had negative implications in the timely delivery of medical treatment and care. In an interview on 07/29/2025 at 11:30 AM, S3TQMPC confirmed the above mentioned findings. 2) Failure to ensure written documentation was performed and maintained during a code blue that accurately reflected the status of the patient, the interventions being performed, the patient response to those interventions, a timed log of the interventions and events as they occur and team member role and participation A review of hospital policy, “Code Blue Policy and Procedures,” Policy Number: MS-03, effective 08/29/2006, last revised 04/24/2019 and approved 09/04/2019, revealed in part: “I. DEFINTIONS B. Code Blue: A medical condition that requires Advance Cardia Life Support (ACLS), Basic Life Support (BLS), use of the Heimlich Maneuver, or any other medical emergency which requires the restoration of respiration and/or circulation. Additional medical emergencies may be designated by the Medical Doctor as needed. D. Code Blue Documentation Packet: Documents must be completed in the event of a Code Blue. 1. CODE BLUE RECORD - completed during the code event. G. Code Blue Record: The official medical emergency record of the response, interventions and patient condition during the code event. V. PROCEDURE C. Code Team Roles/Responsibilities 1. Code Leader: a. The most qualified medical personnel to arrive first at the scene (e.g.: RN Manager, RN Supervisor, MOD-Physician) shall be the Code Leader and will assign a designated staff person to be the code recorder. 2. Code Recorder: a. The code recorder shall be responsible for documenting the detail of the action taken as they occur during the code. b. He/she documents on the official CODE BLUE RECORD form throughout the complete code event. If the patient is being transferred by ambulance, documentation shall continue until the patient is transferred to the ambulance’s stretcher ready for loading. c. Appropriate RN handoff shall be recorded. Documented Hand-off shall include date, time , accepting facility name, accepting facility department name, and name of the RN that hand-off is provided to (e.g.: 11/12/08 1435 Report [hand-off] provide to Jane Smith, RN, BRGMC-ER). d. The Code Recorder should ideally be an RN/LPN. e. The Code Recorder ensures that staff participating are identified utilizing first and last name, job title, and if applicable, his/her code assignment (e.g.: recorder, compressions, rescue breathing). A review of Patient #1’s medical record revealed a CODE BLUE Record dated 06/19/2025, revealed in part the following team members with their role: S23MD-MD, S15FNP-NP, S10RNA-RN, S24RN-RNSA, and S25RN-RN. The section for vital signs revealed no documentation of time and for each: “BP - unable to obtain; HR - unable to obtain; RESP. - unable to obtain; TEMP. - unable to obtain; SAT. - unable to obtain.” The record of events section revealed in part: “6/19/2025, 1214 Code blue called. S15FNP came in CPR started; 1216 Ambulance called by S26[illegible], unable to obtain vital signs; 1217 Vital signs, suction and AED placed, nasopharyngeal airway placed per S15NP, bag and mask with oxygen started; 1217 S23MD arrived; 1228, ambulance called 2nd time; 1238 Ambulance called, CPR continuously don, no pulse CPR, bag and mask, suction are continuously provided. Blood sugar - 230 mg/dil; and 1254 Provider A on DD, took over, CPR continued, IO place per Provider A. Provider A pushed code drugs and CPR continued. No pulse at all during this time. Provider A continue code measures and still no pulse, they called time of death at 1335 (Provider A gave [illegible] doses of Epi and 2 doses of Amiodarone).” The Code Blue form failed to reveal a time logged of the events taken place, the code team including the role of each, staff performing chest compressions, staff performing ventilations, attempted interventions and at what time (e.g.: attempts at IV, AED placement, AED instructions, suctioning, airway management, chest compressions, medications administered), and patient response to any interventions. The Code Blue form failed to reveal the staff performing the recording of events or a signature after each entry as to whom was recording. The Code Blue form’s record of events was also found in the nursing progress notes as a typed entry by S10RNA. It did not appear the Code Blue form was completed as the sequence of events occurred during the code. In an interview on 07/29/2025 at 1:30 PM, S3TQMPC and S4TQMM confirmed the above mentioned findings. 3) Failure to ensure written documentation of active members of the Code Blue were included in the Code Blue Multi-Disciplinary. A review of hospital policy, “Code Blue Policy and Procedures,” Policy Number: MS-03, effective 08/29/2006, last revised 04/24/2019 and approved 09/04/2019, revealed in part: “I. DEFINTIONS B. Code Blue: A medical condition that requires Advance Cardia Life Support (ACLS), Basic Life Support (BLS), use of the Heimlich Maneuver, or any other medical emergency which requires the restoration of respiration and/or circulation. Additional medical emergencies may be designated by the Medical Doctor as needed. D. Code Blue Documentation Packet: Documents must be completed in the event of a Code Blue. 1. CODE BLUE RECORD - completed during the code event. F. Code Blue Multi-Disciplinary Review: The post-code analysis that includes all active members of the code event. The Code Blue Multi-Disciplinary Review Form is completed and sent to the Medical Director. G. Code Blue Record: The official medical emergency record of the response, interventions and patient condition during the code event. V. PROCEDURE E. Code Resolution/Review 1. The Medical Director and Registered Nurse shall assure: a. Completion and appropriate distribution of the documents as indicated on the Code Blue Multi-Disciplinary Review document. b. All Code Blue participants shall remain to review and analyze the Code Blue events. The Team Leader may designate those participant which need to remain for review. A review of the documents titled, “CODE BLUE Multi-Disciplinary Review,” failed to reveal documentation of all the participants and the review and analysis of the Code Blue event. This form appeared to be a post code check list of what actions and events that needed to be completed post Code Blue event. This form appeared to be completed by one team member, S10RNA, staff nurse assigned to Patient #1. This form did not reveal the review and analysis of the actual events of the CODE BLUE. In an interview on 07/29/2025 at 1:30 PM, S3TQMPC and S4TQMM confirmed the above mentioned findings.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by: 1) Failure to ensure a patient received care in a safe setting by preventing a patient to enter a toilet stall with a toothbrush unsupervised while on 2:1 direct observation (See Findings Tag A0144); and 2) Failure to ensure a patient received care in a safe setting by having a medical provider assess a patient or placed an order for diagnostic assessment for a patient following an alleged self-insertion of a toothbrush into his anus (See Findings Tag A0144).”

“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: 48537 Based on record review and interviews, the hospital failed to ensure it provided patient care in a safe setting. This deficient practice was evidenced by: 1) failure to prevent Patient #1 from entering the toilet stall with a toothbrush unsupervised while on 2:1 direct observation; and 2) failure of the medical provider to assess Patient #1 or place an order for diagnostic assessment of Patient #1 following an alleged self-insertion of a toothbrush into his anus. Findings: Review of the hospital policy number Nursing-2004-504, PC-NUR-12 titled “Observations and precautions” last revised on 09/27/2024 revealed in part: “I. Definitions: B. Two-To-One (2:1) Direct Observation: two staff members shall observe and monitor a client at not more than eight (8) feet in distance with a physicians’ order. The client must be visualized at all times. II. Purpose: The purpose of this policy is to ensure behavior management techniques that provide the least restrictive management possible, uphold ethical standards of care, and protect the client’s rights. Precautions are instituted for situations where a client’s condition and/or behavior presents as a clear and present risk to himself, others or the environment. The client’s needs are such that vigilant observation is necessary to provide a safe and protective level of care. IV. Policy: It is the policy of the Hospital to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. V. Procedure: B. Nursing Care for Clients on Precautions - i. One-to-One (1:1) Direct of Two-to-One (2:1) Direct Observation - b. Staff assigned to a client on a one-to-one or two-to-one direct observation shall remain within eight (8) feet of the client and the client must remain in sight at all times. c. Reasonable privacy may be given for a patient who is on one-to-one or two-to-one direct observation. While the client is toileting, a Staff Member may stand just outside of the toilet stall door. However, staff must remain vigilant for any signs/behaviors that would indicate possible harm to the client. x. Employees assigned to any client on one-to-one or two-to-one direct shall ensure that the client receives assistance and supervision to provide for the client’s: a. Personal safety and safety of others; b. Hygiene needs; c. Nutrition, hydrations and elimination needs.” Review of the hospital’s Medical Staff Rules and Regulations, Section XVII titled “Rules Regarding Documentation and the Clinical Record”, last reviewed January 2020, revealed in part: “B. Progress Notes: The progress notes will be written with sufficient frequency to cover all major events, complications, and responses to treatments. While anecdotal information is desirable, of greater importance is the inclusion on information containing the following elements: 1. The condition of the patient from his own perspective; 2. The condition of the patient in descriptive terms; 3. The physician’s interpretation or assessment of the patient’s status; and 4. The plan for further intervention to aid the patient’s care and treatment. It is expected that progress notes will be tied into the documented treatment plan so that the hospital course of the patient can be clearly identified. A progress note, in any case, must be written when there is a material change in the patient’s progress.” 1) Failure to prevent Patient #1 from entering the toilet stall with a toothbrush unsupervised while on 2:1 direct observation. Review of medical record for Patient #1 revealed he was admitted to the hospital on 02/25/2025 with diagnoses which included Unspecified Mood Disorder, Generalized Anxiety Disorder, PICA, Antisocial Trait Disorder, Impulse Control Disorder and Mild Intellectual Disability. Review of Patient #1’s Provider Orders revealed in part the following: 1:1 Direct Observation at not more than 8FT for self-injurious behavior; must be observed on toilet as well, need male RPM. TORB S6MD / S11RN on 02/25/2025 at 12:11 PM (This order was discontinued on 03/22/2025 at 5:20 PM). 2:1 Direct Observation at no more than 8 feet - Males only for Danger to others. TORB S7MD / S10RN on 03/22/2025 at 5:20 PM. Place Patient #1 in waist-wrist restraints. If in 72 hours there have been no violent acts against self or others or verbal threats/gestures against self or others, one wrist may be released at time. If another 72 hours passes without violent acts or threats/gestures against self or others, his other wrist may be released. If he makes violent threats/gestures/acts towards himself or others the waist wrist restraint is to be reapplied and restarted. Signed by S6MD on 03/24/2025 at 3:10 PM. A helmet with bite guard should be used while in waist-wrist restraints related to attempts to continue to bite self. Signed by S6MD on 03/24/2025 at 3:54 PM. Waist-wrist restraints are being applied primarily for reduction of severe self-injury. Vital signs to be obtained on patient Q6H. TORB S6MD / S12RN on 03/24/2025 at 4:39 PM. May remove 1 arm from restraint for 15 minutes for grooming and hygiene. Remove other arm after hygiene and grooming and clean arm where restraints are with soap and water. Ensure that where restraints are reapplied CMS checks are done. If at any time during the 15 minutes Patient attempts any type of self-injurious behavior, place restraint back to arm ASAP. TORB S6MD / S12RN on 03/28/2025 at 1:45 PM. Place in wrist-waist restraints x72 hours. S6MD on 04/07/2025 at 7:39 PM. Right hand to be free from restraints and remain free unless patient is verbally/physically aggressive. T.O. S6MD / RBTO S13RN on 04/17/2025 at 5:30 PM. 1. Client is 2:1 Direct Observation at 8 ft. self-injury, danger to others; 2. Client to be observed at all times, including when using the restroom; and 3. Not eligible to have arm out of restraint until 04/25/2025 at 6:00 AM (Release the arm without the bandage first - Right arm). T.O. S6MD / RBTO S14LPN on 04/24/2025 at 12:00 PM. Review of the facility Incident Report for 04/19/2025 for Patient #1 revealed the following: Date/Time of Incident: 04/19/2025 at 3:00 PM Location of Incident: Hallway Description of Incident: While standing on B Hall, Patient #1 was told by CGT that he could not be on that hall. When told he had to be on A Hall, Patient #1 got aggressive and banged the Plexiglass on monitor room. He then asked the nurse for a toothbrush because his mouth hurt and he wanted to brush his teeth. He later alleged that he stuck the toothbrush up his anus. Treating Psychiatrist: S8MD / S9MD RN: S10RN Assigned Staff: S15CGT & S16CGT Witnesses: S17CGT Signed: S10RN on 04/19/2025 Supervisor’s Review: Patient #1 remains on 2:1 Direct Observation at 8 ft. S15CGT and S16CGT were reassigned away from Patient #1. What Was Client’s Role? Aggressor Was Client Under Restrictive Patient Management? Yes, 8ft. direct with waist to wrist restraint Was Client Referred for Injury Review? No When Did You First Observe the Client For Injury? Date: 04/19/2025 Time: 3:00 PM Describe the Injury: No visible injury What Was the Probable Cause of the Injury: No Injury Describe What You Did to Address the Injury: N/A What Action Did You Take: Return to Program Seriousness and Level of Injury: How Serious Was the Injury - No Apparent Injury, Alleged that he stuck a toothbrush up his rectum. Signed: S10RN on 04/19/2025 Review of Patient #1’s Nursing Security Notes revealed in part the following: On 04/19/2025 at 3:00 PM - Patient #1 was standing on B Hall and was told by staff he needed to come to his hall on the ward, A Hall. Patient #1 went to his room upset. Patient #1 then came back to the monitor station and requested a toothbrush and toothpaste to brush his teeth. When he came banging on the Plexiglass and stated he shoved the toothbrush up his a**. Restraint will be replaced to right arm. Signed by: S10RN On 04/19/2025 at 3:00 PM - Patient #1 requested a toothbrush and toothpaste from the nurse, went into restroom and brushed his teeth in the toilet stall, flushed the toilet, and returned to room, then told myself and the other CGT that “I am going to get y’all under investigation. I just shoved a toothbrush up my a**.” This CGT did not see the patient insert anything. He then went to the nurses’ station and started to hit his head and first against the glass. Patient #1 was escorted back to his room. The Lt. on duty and medical notified. Signed by: S15CGT Review of the Restrictive Management Observation & Precaution Sheet (0600-1800), ELMHS #99-107a dated 04/19/2025 from 12:00 PM to 6:00 PM revealed Patient #1 was on 2:1 Direct Observation. During the time period of 1:23 PM to 3:46 PM, S16CGT and S15CGT were assigned to Patient #1. From 3:15 PM to 3:45 PM, it was documented Patient #1’s behaviors to be awake, aggressive, verbally and physically threatening. Review of Patient #1’s Psychiatric Progress Note dated 04/24/2025 at 10:53 AM revealed in part the following: Patient #1 was seen for his routine weekly staffing. Apparently on Sunday, he reported to staff that he had taken a toothbrush and inserted it into his anus. In speaking with him today about it, he stated “I lied. I didn’t do nothing with it.” When asked where the toothbrush went he stated “I flushed it down the toilet.” Treatment Plan: Problem 1. Impulsive and Inappropriate Behaviors - Patient #1 had an episode where he reported inserting a toothbrush into his anus. In speaking with him today, he stated that he lied about it. No medication adjustments will be made this week. Signed by: S6MD On 04/24/2025 at 11:40 AM, during an interview with S6MD he confirmed on 04/19/2025 prior to the incident taking place, Patient #1 no longer had an order for direct supervision while on the toilet, however he did have an order for 2:1 direct observation of 8 feet. S6MD also confirmed Patient #1 did have a history of ingesting and inserting items into his body which was one of the reasons he was on 2:1 direct observation due to his self-injurious behaviors. 2) Failure of the medical provider to assess Patient #1 or place an order for diagnostic assessment of Patient #1 following an alleged self-insertion of a toothbrush into his anus. Review of the Progressive Behavior Evaluation and Management, ELMHS #99-105 completed on 04/19/2025 for Patient #1 revealed the following: A. Indications of Emergent Behaviors: Approximate Time: 3:00 PM Behavior Cues: Muscle tension, Raised voice, Loss of personal boundaries. Staff Interventions: Referred to nursing staff. Comments: Patient #1 became difficult to redirect. Patient #1 alleges that he shoved a toothbrush up his rectum. B. Indications of Increasing Anxiety, Irritability or Psychotic Behaviors Approximate Time: 3:15 PM Behavior Cues: Refusing to listen (“No” to both verbal and nonverbal communication), Becoming verbally aggressive (Belligerent, sarcastic, starts yelling), and Intimidating staff (Shakes fist, verbal threats). Staff Interventions: Used a directive approach, Set limits (clear, concise, enforceable limits, i.e. “Please go to your room”). Comments: S8MD notified. New orders noted for Thorazine 100mg IM. S9MD notified. S9MD states no need for action to be taken for toothbrush in the rectum at this time as patient will defecate. C. Indications of Imminent Danger to Self or Others Approximate Time: 3:21 PM Behavior Cues: Hitting, Yelling. Staff Interventions: Medication given. Comments: Patient #1 received Thorazine bilaterally in buttocks. Tolerated well. Staff Impression of Triggering Incident: Patient #1 became difficult to redirect. Client alleged he shoved a toothbrush into his rectum. S8MD notified. New orders for Thorazine noted. S9MD notified. S9MD stated no action needed at the time for toothbrush as client will defecate. Signed by: S10RN at 3:00 PM. Reassessment of Patient Approximate Time: 4:21 PM Behavior Cues: Decreased muscle tone Staff Interventions: Patient Reassessment Comments: Lying in bed resting. No signs or symptoms of distress. Signed by: S10RN at 4:21 PM. Review of Medical Provider Progress Notes for Patient #1 from 04/19/2025 to 04/24/2025 revealed no documented visits and/or assessments related to the incident involving the toothbrush on 04/19/2025. Review of the Psychiatric Provider Progress Notes for Patient #1 on 04/24/2025 revealed Patient #1 was seen by S6MD at 10:53 AM for his weekly staffing meeting and was asked about the incident on 04/19/2025. On 04/24/2025 at 11:40 AM, during an interview with S6MD, he stated because of the size of the toothbrushes (approximately 3-4” in length) the hospital was supplied with for patient use which would have been what Patient #1 was given by the nurse on 04/19/2025, the concern for Patient #1 to have done damage to his rectum and/or even his sigmoid colon if he were to have inserted the toothbrush that far was minimal. S6MD stated the patient had a tendency of attention-seeking behavior that would result in him being transported off hospital grounds to received diagnostic testing and/or treatment at another facility, also resulting in him getting to eat at off-site fast food places. S6MD did not want to “reward” bad behavior by allowing him a trip off the grounds for a diagnostic assessment. S6MD stated to his knowledge he was unaware if medical had come to physical assess Patient #1 after the incident. S6MD confirmed the first time he had seen Patient #1 since the incident on 04/19/2025 was on 04/24/2025 when he made rounds and saw the patient during the weekly staffing meeting.”

“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: 48537 Based on record review and interview the facility failed to thoroughly analyze all adverse patient events and implement preventive actions. The deficient practice was evident by the hospital’s failure to ensure the safety of Patient #1 by implementing preventative measures to protect him from future self-injurious behaviors. Findings: Review of medical record for Patient #1 revealed he was admitted to the hospital on 02/25/2025 with diagnoses which included Unspecified Mood Disorder, Generalized Anxiety Disorder, PICA, Antisocial Trait Disorder, Impulse Control Disorder and Mild Intellectual Disability. Review of Patient #1’s Provider Orders revealed in part the following: 1:1 Direct Observation at not more than 8FT for self-injurious behavior; must be observed on toilet as well, need male RPM. TORB S6MD / S11RN on 02/25/2025 at 12:11 PM (This order was discontinued on 03/22/2025 at 5:20 PM). 2:1 Direct Observation at no more than 8 feet - Males only for Danger to others. TORB S7MD / S10RN on 03/22/2025 at 5:20 PM. 1. Client is 2:1 Direct Observation at 8 ft. self-injury, danger to others; 2. Client to be observed at all times, including when using the restroom; T.O. S6MD / RBTO S14LPN on 04/24/2025 at 12:00 PM. Review of the facility Incident Report for 04/19/2025 for Patient #1 revealed the following: Date/Time of Incident: 04/19/2025 at 3:00 PM Location of Incident: Hallway Description of Incident: While standing on B Hall, Patient #1 was told by CGT that he could not be on that hall. When told he had to be on A Hall, Patient #1 got aggressive and banged the Plexiglass on monitor room. He then asked the nurse for a toothbrush because his mouth hurt and he wanted to brush his teeth. He later alleged that he stuck the toothbrush up his anus. Treating Psychiatrist: S8MD / S9MD RN: S10RN Assigned Staff: S15CGT & S16CGT Witnesses: S17CGT Signed: S10RN on 04/19/2025 Supervisor’s Review: Patient #1 remains on 2:1 Direct Observation at 8 ft. S15CGT and S16CGT were reassigned away from Patient #1. What Was Client’s Role? Aggressor Was Client Under Restrictive Patient Management? Yes, 8ft. direct with waist to wrist restraint Review of the Restrictive Management Observation & Precaution Sheet (0600-1800), ELMHS #99-107a dated 04/19/2025 from 12:00 PM to 6:00 PM revealed Patient #1 was on 2:1 Direct Observation. During the time period of 1:23 PM to 3:46 PM, S16CGT and S15CGT were assigned to Patient #1. From 3:15 PM to 3:45 PM, it was documented Patient #1’s behaviors to be awake, aggressive, verbally and physically threatening. Review of Patient #1’s Psychiatric Progress Note dated 04/24/2025 at 10:53 AM revealed in part the following: Patient #1 was seen for his routine weekly staffing. Apparently on Sunday, he reported to staff that he had taken a toothbrush and inserted it into his anus. In speaking with him today about it, he stated “I lied. I didn’t do nothing with it.” When asked where the toothbrush went he stated “I flushed it down the toilet.” Treatment Plan: Problem 1. Impulsive and Inappropriate Behaviors - Patient #1 had an episode where he reported inserting a toothbrush into his anus. In speaking with him today, he stated that he lied about it. No medication adjustments will be made this week. Signed by: S6MD On 04/24/2025 at 8:35 AM, during morning conference for the day with S2EDON, S4ADON and S5TQM, they confirmed there was not open QAPI review for the 04/19/2025 incident that had taken place with Patient #1 inserting a toothbrush into in anus in the toilet stall. On 04/24/2025 at 11:40 AM, during an interview with S6MD, he confirmed on 04/19/2025 prior to the incident taking place, Patient #1 no longer had an order for direct supervision while on the toilet, however he did have an order for 2:1 direct observation of 8 feet. He stated he had tried to give Patient #1 some freedom and privacy because of his other protective measures in place. S6MD confirmed Patient #1 did have a history of ingesting and inserting items into his body which was one of the reasons he was on 2:1 direct observation due to his self-injurious behaviors. S6MD confirmed Patient #1 did not have orders at the time of the interview in place for direct observation while on the toilet, but would order them as soon as the interview was over.”

“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: 48537 Based on record review and interviews, the hospital failed to ensure the shift observation records were signed and dated accurately for 1 (#1) of 2 (#1 & #2) patients reviewed for shift observation records. This was evidenced by failure of the CGT to initial every 15 minutes while assigned 2:1 direct observation of Patient #1. Findings: Review of the hospital policy number Nursing-2004-504, PC-NUR-12 titled “Observations and precautions” last revised on 09/27/2024 revealed in part: “I. Definitions: B. Two-To-One (2:1) Direct Observation: two staff members shall observe and monitor a client at not more than eight (8) feet in distance with a physicians’ order. The client must be visualized at all times. II. Purpose: The purpose of this policy is to ensure behavior management techniques that provide the least restrictive management possible, uphold ethical standards of care, and protect the client’s rights. Precautions are instituted for situations where a client’s condition and/or behavior presents as a clear and present risk to himself, others or the environment. The client’s needs are such that vigilant observation is necessary to provide a safe and protective level of care. IV. Policy: It is the policy of the Hospital to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. V. Procedure: C. Documentation for Clients on Precautions - ii. The Restrictive Management Observation and Precaution Sheet (ELMHS #99-107a) shall be maintained per client, with entries noted every fifteen (15) minutes according to Nursing Charting Guidelines. Staff shall initial and sign all observational client records. iii. Staff shall document behaviors of the assigned client, nursing care provided, whether contraband was found, and other pertinent data. Documentation completion is required prior to the end of the assigned employee’s shift. F. Continuation of the Restrictive Management Observation and Precaution Sheet for Successive Shifts - iii. Nursing-Security Staff Member (CGTT, CGT, CLT) or PA Responsibilities b. Document on the RPM flow sheet at a minimum of every fifteen (15) minutes to include: 3. Initials of the person documenting every fifteen (15) minutes.” Review of Patient #1’s Provider Orders revealed in part the following: 2:1 Direct Observation at no more than 8 feet - Males only for Danger to others. TORB S7MD / S10RN on 03/22/2025 at 5:20 PM. Review of the Restrictive Management Observation & Precaution Sheet (0600-1800), ELMHS #99-107a dated 04/19/2025 from 12:00 PM to 6:00 PM revealed Patient #1 was on 2:1 Direct Observation. During the time period of 1:23 PM to 3:46 PM, S16CGT and S15CGT were assigned to Patient #1. From 2:00 PM to 3:30 PM, only one CGT’s initials were documented on the sheet. On 04/24/2025 at 2:50 PM, during an interview with S5TQM, she reviewed the Restrictive Management Observation & Precaution Sheet (0600-1800), ELMHS #99-107a dated 04/19/2025 from 12:00 PM to 6:00 PM and confirmed there was no initials from a second CGT from 2:00 PM to 3:30 PM for Patient #1 and there should have been.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47397 Based on record review and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by: 1) failure to protect patients by refraining to place S8CGT on administrative leave and to submit abuse reports in a timely manner as outlined in psychiatric hospital policy, following the accusation of physical abuse against Client #2 potentially resulting in the abuse of Client #4.(See findings in A0145). 2) failure to ensure the hospital’s contract nursing staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S11RN) of 1 (#S11RN) contract nursing staff sampled for nonphysical intervention skills training failing to have documented evidence of nonviolent behavior training within the last 3 years (See findings in A0200).”

“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 record review and interview the hospital failed to protect patients as evidenced by failure to place S8CGT on administrative leave and to submit abuse reports in a timely manner as outlined in psychiatric hospital policy, following the accusation of physical abuse against Client #2 potentially resulting in the abuse of Client #4. Findings: Review of psychiatric hospital’s policy #LD-25 titled, “Client Abuse and Neglect Policy and Procedures”, effective 05/16/24, revealed in part: “I. Policy: Eastern Louisiana Mental Health System (ELMHS) is committed to preserving the right of each person receiving services to be free of abuse and neglect. All forms of abuse/neglect of clients by employees of ELMHS and its affiliates are prohibited. IV in part: General Definitions: Substantiated: a determination based on the evidence that there is reasonable cause to believe that conduct in violation of the abuse/neglect policy occurred and, where applicable, whether such conduct is attributable to the accused. X in part: Investigation Review Process For 24-hour Facilities, in part: D. iv. A final report shall be submitted to HSS (Health Standards Section) with the findings as soon as it is concluded but within five (5) working days of submitting the initial report. If an extension is needed, a request may be submitted to HSS and must include the reason for the extension request. XIV in part: Consequences of Abuse and/or Neglect. C. The staff member confirmed to have physically or sexually abused a client will be terminated from his/her employment. Review of psychiatric hospital’s document titled “Eastern Louisiana Mental Health System Hospital Abuse/Neglect Initial Report”, dated 01/15/2025 revealed a submission date of 01/15/2025. The report described an allegation that S8CGT hit Client #2 in the face while on Unit C. Further review of the document revealed S8CGT had been removed from contact with patients and reassigned from alleged victim and monitored by supervisors. Review of Unit Assignments document provided by psychiatric hospital dated 01/15/2025 revealed S8CGT was scheduled on Unit A, day shift. S8CGT was assigned to rounds and hall monitor as senior officer from 2:00 PM-6:00 PM. Continued review revealed S8CGT was also scheduled on Unit A, day shift and assigned to rounds and hall monitor as senior officer on 01/18/2025, 01/19/2025, 01/20/2025, 01/23/2025, 01/24/2025, 01/27/2025, 01/28/2025, 01/29/2025, 02/01/2025, 02/02/2025, and 02/04/2025. Of note Unit C was closed on 01/22/2025. Review of the letter for request of protection from the Adult Protective Services (APS) investigator provided by psychiatric hospital dated 01/16/2025, revealed a direction to move S8CGT off Unit C and away from Client #2 until further notice due to an allegation of physical abuse. Review of document provided by psychiatric hospital titled “Video Footage Report,” dated and signed on 01/29/2025, revealed footage of Unit C on 01/15/2025 at 9:29:46-50 AM from 2 perspectives in hallway. The footage indicated where Client #2 was on the floor in the hallway and S8CGT was standing over Client #2 when he swung in a downward motion one time and appeared to hit Client #2 in the face. Another CGT was standing a few feet away from the incident and did not intervene. Of note, the cameras were not working on 01/15/2025 in Client #2’s room. Review of psychiatric hospital’s document titled “Case No. LA76082”, dated 02/05/2025 revealed the following video footage on 01/15/2025 at 09:29:51: S8CGT raised his right closed hand (fist) and hit Client #2 one time in his facial area while holding Client #2’s shirt with his left hand. Continued review revealed that based upon the facility review, Eastern Louisiana Mental Helath System (ELMHS) had substantiated the physical abuse allegation for S8CGT. Review of psychiatric hospital documents dated 02/06/2025, provided by S20HRS, revealed an incident occurring on 01/15/2025, involved the physical abuse of Client #2 by S8CGT and was substantiated due to evidence. Continued review revealed the recommended corrective action to be taken for substantiated abuse and or neglect was dismissal. Review of psychiatric hospital documents dated 02/25/2025, provided by S20HRS, revealed an incident occurring on 02/02/2025, involved the physical abuse of Client #4 by S8CGT and was substantiated due to evidence. Continued review revealed the recommended corrective action to be taken for substantiated abuse and or neglect was dismissal. Review of psychiatric hospital’s document titled “Eastern Louisiana Mental Health System Hospital Abuse/Neglect Initial Report”, dated 02/05/2025, revealed in part, Client #4 made an allegation to S25SW, that on 02/02/25 after being asked to brush his teeth, he and a guard cursed each other, the guard then asked him “what you want to do?” He then stated S8CGT “sucker punched me and I went down to the bed.” Review of initial actions taken revealed S8CGT was reassigned from alleged victim and was monitored by supervisors. Review of psychiatric hospital’s document titled “Eastern LA Mental Health System (Facility #330), Abuse/Neglect Review”, dated 02/21/2025, revealed in part: Date of incident: 02/02/2025. Incident Type Classification: Appointing Authority Findings: 01-Physical Abuse: is the use of physical force that may result in bodily injury, physical pain, or impairment. Substantiated due to the evidence. 03-Neglect: a failure to provide a patient care with proper food, clothing, shelter, supervision, medical care, or emotional stability. Substantiated due to the evidence. Explanation of findings, in part: The incident has been substantiated for physical abuse against S8CGT. On 02/02/2025 at approximately 6:33 AM, S8SGT can be observed making contact with Client #4 in a very aggressive manner. At this time S8CGT can be heard cursing and being very disrespectful to Client #4. At approximately 6:33 AM, S8CGT can be observed punching Client #4. He punched him approximately 6 to 8 times. Two CGTs walked into Client #4’s room and saw S8CGT hitting Client #4 while he was on the bed. The writer of the document stated, “This is a clear case of physical abuse.” Review of hospital document dated 11/11/2024-02/22/2025, provided by S19RNPC, revealed a list of separated (terminated) staff. Continued review failed to reveal S8CGT. During an interview on 2/26/25 at 9:44 AM, S20HRS reported she noticed that on 02/05/2025, TQM had entered the incident occurring on 01/15/2025 involving Client #2 into the system. S20HRS realized that after the incident on 01/15/2025, S8CGT had not been placed on administrative leave until the investigation was completed. She alerted administration and S8CGT was placed on administrative leave with pay on 02/05/2025 at 3:46 PM. She did not receive the case file from administration until 02/06/25. S20HRS stated she did not receive the 2nd case file involving Client #4 until 2/25/25 and S8CGT was on administrative leave with pay at this point. S20HRS contacted legal and was advised to hold both investigations and complete as one, in case there was an appeal and both cases could be combined into one appeal. On 02/26/2025, S8CGT was still on administrative leave with pay, which would end on 03/30/25. S20HRS stated if the process was not completed by that time, then administration will enforce annual leave. S20HRS indicated she would prepare a letter that stated recommendation for separation/termination with planned completion by 02/27/2025. S20HRS would submit the letter to the legal department who would then proceed with the process of termination/separation of S8CGT from Eastern LA Mental Health System. During an interview on 02/24/2025 at 9:45 AM, S2QD verified the initial report regarding the investigation of Client #2’s abuse allegation occurring on 01/15/2025, was submitted to HSS on 01/15/2025. The requested extension was made on 01/27/2025 13 days following the incident and the final report was submitted on 02/05/2025, 21 days following the incident and 3 days following the abuse of Client #4. During an interview on 02/24/2025 at 9:50 AM, S2QD verified the initial report regarding the investigation of Client #4’s abuse allegation occurring on 02/02/2025, was submitted to HSS on 02/05/2025. The requested extension was made on 02/18/2025 16 days following the incident and the final report was not submitted as of 03/05/2025, 31 days following the incident. During an interview on 02/27/2025 at 2:23 PM, S2QD recognized that if the investigations were completed by the psychiatric hospital within the five-day requirement per hospital policy, then the incident involving the physical abuse of Client #4 by S8CGT on 02/02/2025 may not have occurred.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(ii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (ii) The use of nonphysical intervention skills. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the hospital’s contract nursing staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S11RNC) of 1 (#S11RNC) contract nursing staff sampled for nonphysical intervention skills training failing to have documented evidence of nonviolent behavior training within the last 3 years. Findings: Review of psychiatric hospital’s policy #Nursing-2005-604, PC-Nur-00 titled, “Usage of Seclusion and Restraints”, revised 01/31/2025, revealed in part: V. Procedure, in part: A. Verbal Intervention and Redirection: i. All staff shall complete state approved mandatory training for management of aggressive/hostile behaviors. Review of psychiatric hospital’s document titled “Contract Nurses Roster, updated January 2025” revealed in part: S11RNC. Review of psychiatric hospital’s document titled “Nursing Location Sheet”, dated 01/06/2025-03/02/2025, revealed S11RNC was scheduled on Unit A for the following dates: 01/07/2025, 01/11/2025. 01/12/2025, 01/13/2025, 01/16/2025, 01/21/2025. 01/22/2025, 01/25/2025, 01/26/2025, 01/27/2025, 01/20/2025, 01/31/2025, 02/04/2025, 02/05/2025, 02/08/2025, 02/09/2025, 02/10/2025, 02/13/2025, 02/14/2025, 02/18/2025, 02/19/2025, 02/22/2025, 02/24/2025. 02/27/2025, and 02/28/2025. Review of S11RNC’s personnel file revealed “Nonviolent Crisis Intervention Training” was completed on 03/16/2021 and the training expired on 03/16/2022. In an interview on 02/26/2025 at 11:59 AM, S21HRA confirmed S11RNC’s “Nonviolent Crisis Intervention Training” expired on 03/16/2022, which was approximately 3 years ago.”

“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: 47397 Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by: 1) failure to fully investigate and identify physical abuse in a timely manner potentially leading to the abuse of Client #4; and 2) failure to adhere to hospital policy and ensure video surveillance was available 24 hours a day, 7 days a week to protect the safety of the of the clients, staff, visitors and Eastern Louisiana Mental Health System (ELMHS) property. Findings: 1) Failure to fully investigate and identify physical abuse in a timely manner potentially leading to abuse of Client #4. Review of psychiatric hospital’s policy #LD-25 titled, “Client Abuse and Neglect Policy and Procedures”, effective 05/16/24, revealed in part: “X in part: Investigation Review Process For 24-hour Facilities, in part: D. iv. A final report shall be submitted to HSS with the findings as soon as it is concluded but within five (5) working days of submitting the initial report. If an extension is needed, a request may be submitted to HSS and must include the reason for the extension request. Review of initial self-report regarding an incident that occured on 01/15/2025 revealed submission date of 01/15/2025. The report described an allegation that S8CGT hit Client #2 in the face. Further review revealed staff had been removed from contact with patients, reassigned from alleged victim, and monitored by supervisors. Review of final self-report to Lousiana Department of Health (LDH) revealeded ELMHS substantiated the allegation of physical abuse of Client #2 by S8CGT occurring on 01/15/2025 and submitted the report on 02/05/2025, approximately 20 days after submission of the initial report. Review of initial self-report submitted to Lousiana Department of Health (LDH0 regarding and incident occurring on 02/02/2025 revealed submission date of 02/05/2025. The incident involved allegation of the physical abuse of Client #4 by S8CGT. As of 03/05/2025, LDH had not received a final submission in regards to the incident that occurred on 02/02/2025. Review of psychiatric hospital’s document titled “Eastern LA Mental Health System (Facility #330), Abuse/Neglect Review”, dated 02/21/2025, revealed in part: Date of incident: 02/02/2025. Incident Type Classification: Appointing Authority Findings: 01-Physical Abuse: is the use of physical force that may result in bodily injury, physical pain, or impairment. Substantiated due to the evidence. 03-Neglect: a failure to provide a patient care with proper food, clothing, shelter, supervision, medical care, or emotional stability. Substantiated due to the evidence. Explanation of findings, in part: The incident has been substantiated for physical abuse against S8CGT. On 02/02/2025 at approximately 6:33 AM, S8SGT can be observed making contact with Client #4 in a very aggressive manner. At this time S8CGT can be heard cursing and being very disrespectful to Client #4. At approximately 6:33 AM, S8CGT can be observed punching Client #4. He punched him approximately 6 to 8 times. Two CGTs walked into Client #4’s room and saw S8CGT hitting Client #4 while he was on the bed. The writer of the document stated, “This is a clear case of physical abuse.” This incident was substantiated approximately 19 days after the initial incident occurred. Of note, since January 15th, 2025, the psychiatric hospital requested extensions on the following 8 initial reports related to incidents: 76690-submitted 02/19/2025-requested extension on 02/27/2025-Final report had not been submitted as of 03/05/2025, 14 days following initial submission. 76683-submitted 02/18/2025-requested extension on 02/25/2025-Final report had not been submitted as of 03/05/2025, 15 days following initial submission. 76652-submitted 02/17/2025-requested extension on 02/25/2025-Final report had not been submitted as of 03/05/2025, 16 days following initial submission. 76643-submitted 02/17/2025-requested extension on 02/25/2025-Final report had not been submitted as of 03/05/2025, 16 days following initial submission. 76537-submitted 02/12/2025-requested extension on 02/25/2025-Final report submitted on 02/26/2025, 13 days following initial submission. 76481-submitted 02/10/2025-requested extension on 02/18/2025-Final report had not been submitted as of 03/05/2025, 23 days following initial submission. 76424-submitted 02/06/2025-requested extension on 02/18/2025-Final report had not been submitted as of 03/05/2025. 27 days following initial submission. 76082-submitted 01/15/2025-requested extension on 01/27/2025-Final report submitted on 02/05/3035, 21 days following initial submission. During an interview on 02/24/2025 at 9:45 AM, S2QD stated that the psychiatric hospital was required to notify APS (Adult Protective Services) of any sexual or abuse allegations. APS had 10 days to complete their investigation. APS asked ELMHS not to investigate the incidents because it could compromise the APS investigation. 2) Failure to adhere to hospital policy and ensure video surveillance was available on Unit B 24 hours a day, 7 days a week to protect the safety of the of the clients, staff, visitors and ELMHS property. Review of psychiatric hospital’s document titled “Client Handbook”, revised 06/2024, revealed in part: “Video Surveillance, in part: ELMHS uses Video Surveillance 24 hours a day 7 days a week to protect the safety of the clients, staff, visitors and ELMHS Property”. Review of Client #R1’s complaint dated 01/11/2025 revealed his concern that one of the CGTs on Unit B was sleeping that night while on duty as another client was acting in a disturbing manner by shadow boxing and slapping himself, leaving the nurse to try to maintain peace. Further review revealed a notation by staff stating, “Client reported that he would like to withdraw this complaint. Resolved at initial level via office phone on 1/16/2025.” During an interview on 02/27/2025 at 12:32 PM, S22PM stated the cameras on Unit B were non-functioning for January and February of 2025, therefore the surveyor would be unable to view the video footage for Unit B on the night of 01/11/2025 in order to investigate R1’s complaint. Review of psychiatric hospital’s document titled “Notification Overview”, dated 02/27/2025 at 12:37 PM, revealed a notification that the cameras needed repair on Unit B. The notification stated the following: “The cameras are not showing video from January or February”.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to ensure 2 (#3 and #5) of 6 (#1-#6) client medical records reviewed had an individualized treatment plan. Findings: Review of psychiatric hospital’s document titled “Client Handbook”, revised 06/2024, revealed in part: “Civil and Treatment Rights”, in part: S. The right to an individualized treatment plan. Client #3 Review of Client #3’s medical record revealed an admission date of 04/26/2023 with diagnoses of Traumatic Brain Injury 2nd to MVA, disruptive mood dysregulation, impulse disorder, conduct disorder, mild intellect disorder, convulsions, GERD (Gastroesophageal Reflux Disease), Hyperlipidemia, and obesity. Continued review of Client #3’s medical record revealed a document titled “Modified Texture Diet Flow Sheet (Choking)”, dated 02/23/2025. The document revealed Client #3 was on a diet prescription related to dysphagia, level 3 Advanced (Chopped meat and Puree bread) Close Visual Observation (CVO) for choking while having meals/snacks. Review of Client #3’s treatment plan, last updated 02/24/2025, failed to reveal problems related to Traumatic Brain Injury or Dysphagia requiring CVO for meals and snacks. During an interview on 02/26/2025 at 2:50 PM, S19RNPC verified Client #3’s treatment plan did not contain problems related to Traumatic Brain Injury or Dysphagia requiring CVO for meals and snacks. Client #5 Review of Client #5’s medical record revealed an admission date 01/25/2017 with diagnoses of Schizophrenia, Intellectual Disability, alcohol dependence, cannabis dependence, iron deficient anemia. Review of Client #5’s treatment plan, last updated 12/24/2024, failed to reveal problems related to Intellectual Disability. During an interview on 02/26/2025 at 3:05 PM, S19RNPC verified Client #5’s treatment plan did not contain problems related to Intellectual Disability.”

“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 interview, the psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This deficient practice is evidenced by failure to ensure an RN made all patient care assignments. Findings: Review of psychiatric hospital’s policy #11 titled, “Minimum Coverage Staff Assignment”, effective 10/30/2013, revealed in part: “Policy: The Security Department will set standards to maintain adequate security coverage to meet the requirements necessary for each level of Patient Care on the Units. Procedure, in part: The shift Captains on Teams A, B, C, and D are responsible for scheduling the CGT’s daily assignments. Review of psychiatric hospital’s policy #Nursing-2005-504, PC-NUR-12 titled, “Observations and Precautions”, last revised 09/27/2024, revealed in part: I. Definitions, in part: A. One-to-One (1:1) direct observations. The client must be visualized at all times. B. Two-to one (2:1) The client must be visualized at all times. C. Continuous Visual Observation (CVO) at fifteen feet. D. Fifteen (15) Minute Check Observation. E. Precaution Observation. F. Routine Observation. G. Emergent. H. Monitor/Evaluate. IV. Policy: It is the policy of ELMHS to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. V. Procedure, in part: A. Initiation of D. Routine Observation, in part: Procedure, in part: a. the nurse shall assign clients on routine observation to staff based on the unit’s acuity level and the client’s current system level. E. Initiation of the Restrictive Management Observation and Precaution Sheet, in part: ii. RN responsibilities, in part: c. Assign a Nursing-Security staff member (CGTT, CGT, CLT) or PA to monitor the client while on restrictive management.” Review of psychiatric hospital’s documents titled “Building/Unit Assignments” dated 01/06/2025-02/24/2025 revealed the following: -The forms were divided into sections, 1 section for each of the 4 wards: Units A, B, C, and D. -Each section contained a list of the names of clients that were on precautions other than routine observation. - Each section was signed by an RN under the list of staff assigned to each ward. -The form failed to reveal the names of the clients who were on routine observation. During an interview on 02/24/2025 at 10:25 AM, S12CLT stated she made the building assignments for the CGTs for each ward and then brought the form to each ward and had the nurse approve and sign the assignment form. During an interview on 02/24/2025 at 10:30 AM, S24RNM stated the patients on routine observations were not assigned a CGT. Each ward has a CGT that rounds on the patients on routine observations. Only the patients on precautions are assigned a CGT. During an interview on 02/24/2025 at 10:52 AM, S23RN confirmed she signed the assignment sheet after S12CLT completed it.”

“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: 47397 Based on record review and interview, the psychiatric hospital and the director of the nursing service failed to ensure that each non-employee nursing care staff person’s clinical activities were evaluated. This deficient practice is evidenced by failure to ensure 31 (S11RNC, S26RNC-S56RNC) of 31 (S11RNC, S26RNC-S56RNC) contracted nurses underwent a performance evaluation. Findings: A review of psychiatric hospital’s document titled “Contract Nurses Roster, Updated January 2025” revealed S11RNC among the 31 (S11RNC, S26RNC-S56RNC) contract nurses hired for the psychiatric hospital. A review of S11RNC’s personnel file revealed date of hire 04/20/2020. Further review failed to reveal a performance evaluation completed on S11RNC since her date of hire. During an interview on 02/26/2025 at 11:54 AM, S21HRA verified the hospital did not complete performance evaluations on the contracted nurses.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by: 1. Failing to ensure the safety and protection of 1 (#4) of 4 (#1 - #4) patients from the ingestion of alcohol based hand sanitizer (See Findings Tag A0144); 2. Failing to ensure the safety and protection of 1 (#1) of 4 (#1 - #4) patients from bodily injury during two altercations with peers (See Findings Tag A0144); 3. Failing to fully investigate an incident resulting in bodily injury to 1 (#1) of 4 (#1 - #4) patients (See Findings Tag A0144); and 4. Failing to timely report allegations of abuse/neglect on 1 (#1) of 4 (#1 - #4) patients to Louisiana Department of Health - Health Standards Section (LDH-HSS) (See Findings Tag A0144).”

“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: 48051 Based on observation, record review and interview, the hospital failed to provide patient care in a safe setting. This deficient practice was evidenced: 1. Failing to ensure the safety and protection of 1 (#4) of 4 (#1 - #4) patients from the ingestion of alcohol based hand sanitizer; 2. Failing to ensure the safety and protection of 1 (#1) of 4 (#1 - #4) patients from bodily injury during two altercations with peers; 3. Failing to fully investigate an incident resulting in bodily injury to 1 (#1) of 4 (#1 - #4) patients; and 4. Failing to timely report allegations of abuse/neglect on 1 (#1) of 4 (#1 - #4) patients to Louisiana Department of Health - Health Standards Section (LDH-HSS). Findings: 1. Failing to ensure the safety and protection of 1 (#4) of 4 (#1 - #4) patients from the ingestion of alcohol based hand sanitizer A review of facility policy, “Contraband - Clients,” Policy Number LD-12, effective on 04/15/2013, last revision 04/08/2015 and approved 04/21/2025, revealed in part, I. Definitions: A. Contraband: Any item that can be considered dangerous, injurious or that might be a threat to the integrity or security of the Hospital. Categorized as Class I, II, III, or IV. II. Purpose: To identify contraband material, ensure the protection and safety of all clients, visitors, and employees, and comply with State law. Policy: The Hospital recognizes its responsibility to identify and security risks created by possession of contraband. The Hospital takes action to prevent incidents of contraband from coming into the hospital and develops processes for surveillance, conducting searches, reporting, and proper disposing of confiscated items. Clients, staff and visitors have the right to a safe and secure environment. V. Procedures: A. Contraband List: The general list consists of four classes of items: Class II - Not allowed in client’s possession at any time. Appendix C - Contraband Lists: Class II - Not allowed in client’s possession at any time: item 23. Any substance containing over 8% alcohol. Appendix A: D. Contraband as used here means: (1) ... or substance that if taken internally, whether separately or in combination with another drug or substance, produces or may produce a hypnotic effect. A review of facility policy, “Client Abuse and Neglect,” Policy Number: LD-25, with an effective date of 05/16/2024 and approved on 05/28/2024, revealed in part, I. Policy: The Hospital is committed to preserving the right of each person receiving services to be free of abuse and neglect. Purpose: The purpose of this policy is to ensure that client’s rights are protected and to establish a uniform system for timely reporting and investigating all allegations of abuse/neglect of clients. V. Statutory Definitions and Examples: D. 42 CFR 482.13(c)(3) definition in the Code of Federal Regulations (CFR) apply to hospitals participating in the Medicaid and/or Medicare programs. D-i. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. D-ii. Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. H. Examples of the types of conduct that constitute abuse and neglect. H-i. Physical Abuse: a. Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or twisting of head, arm or legs. H-vi. Neglect: a. Acts or omissions by a person responsible for providing care of treatment which caused harm to, or placed a client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment or basic care. b. Failure to provide or withhold appropriate services, nutrition, clothing, treatment, or care by gross errors in judgement, inattention, or ignoring. d. Failure to provide a safe environment. f. Failure to supervise a client such that the client is placed in danger. VI. Duty to Report: B. Any employee or affiliate of the hospital who has knowledge of possible abuse or neglect of a client or who receives a complaint of abuse from a client or any other person, shall report in accordance with the provisions of this policy and applicable law. VII. Initial Reporting Procedures: A-ii: The nurse in charge of the area/building will immediately, within 1 hour, make a verbal report to the Appointing Authority/Designee during normal business hours or the Administrator on Duty as to whether outside agencies (Health Standards Section (HSS), Adult Protective Services (APS), and/or local law enforcement) should be notified of the report. B-v: The Building/Unit RN (Registered Nurse) Manager or designee will: a. complete the online HSS Hospital Abuse/Neglect Initial Report form and submit using the “submit” button on the electronic form before the end of the shift. A review of hospital incident reports revealed an incident report on 07/11/2024 involving Patient #4. The Client Incident, Injury, and Data Reporting Form revealed in part, the incident occurred on 07/11/2024 at 10:38 a.m. The description of the incident included, “Client disoriented and acting intoxicated.” Further, the report revealed in part, other patients in Patient #4 room reported he had been drinking hand sanitizer through the night shift. Room search by correctional guard therapeutic (CGT) revealed, “ ... med cup with hand sanitizer found in room at client’s bedside.” Medical record review of Patient #4 revealed a prior incident involving the ingestion of hand sanitizer. A medical progress note dated 11/01/2023 revealed in part the patient was seen at Hospital A last night (10/31/2023) for hand sanitizer - alcohol poisoning and the patient did not remember where he picked up the hand sanitizer. A medical progress note by S10MD from 07/11/2024 at 10:58 a.m. revealed in part, called secondary to altered mental status. Per nurse’s report, patient witnessed him drinking hand sanitizer earlier. Further, the note indicated, “Pt (patient) has done this before.” A review of a urine drug screen from 07/12/2024 at 9:00 a.m. reveled Patient #4 positive for Ethyl Glucuronide - a byproduct of alcohol that can be detected after the consumption of alcohol. A review of nursing and CGT progress notes revealed Patient #4 refusing to give a urine sample from the time of the discovery of the incident until the morning of 07/12/2024. In an interview on 07/16/2024 at 3:00 p.m. S11PMI confirmed the above mentioned findings. S11PMI further confirmed the source of the hand sanitizer was not able to be identified and Patient #4 was not cooperative in providing the source. 2. Failing to ensure the safety and protection of 1 (#1) of 4 (#1 - #4) patients from bodily injury during two altercations with peers A review of facility policy, “Client Abuse and Neglect,” Policy Number: LD-25, with an effective date of 05/16/2024 and approved on 05/28/2024, revealed in part, I Policy: The Hospital is committed to preserving the right of each person receiving services to be free of abuse and neglect. Purpose: The purpose of this policy is to ensure that client’s rights are protected and to establish a uniform system for timely reporting and investigating all allegations of abuse/neglect of clients. V. Statutory Definitions and Examples: D. 42 CFR 482.13(c)(3) definition in the Code of Federal Regulations (CFR) apply to hospitals participating in the Medicaid and/or Medicare programs. D-i. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. D-ii. Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. H. Examples of the types of conduct that constitute abuse and neglect. H-i. Physical Abuse: a. Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or twisting of head, arm or legs. H-vi. Neglect: a. Acts or omissions by a person responsible for providing care of treatment which caused harm to, or placed a client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment or basic care. b. Failure to provide or withhold appropriate services, nutrition, clothing, treatment, or care by gross errors in judgement, inattention, or ignoring. d. Failure to provide a safe environment. f. Failure to supervise a client such that the client is placed in danger. VI. Duty to Report: B. Any employee or affiliate of the hospital who has knowledge of possible abuse or neglect of a client or who receives a complaint of abuse from a client or any other person, shall report in accordance with the provisions of this policy and applicable law. VII. Initial Reporting Procedures: A-ii: The nurse in charge of the area/building will immediately, within 1 hour, make a verbal report to the Appointing Authority/Designee during normal business hours or the Administrator on Duty as to whether outside agencies (Health Standards Section (HSS), Adult Protective Services (APS), and/or local law enforcement) should be notified of the report. B-v: The Building/Unit RN (Registered Nurse) Manager or designee will: a. complete the online HSS Hospital Abuse/Neglect Initial Report form and submit using the “submit” button on the electronic form before the end of the shift. A review of hospital policy, “Observations and Precautions,” Policy Number PC-NUR-12, with an effective date of 03/2005, last revised 02/2022 and approved 03/29/2022 revealed in part, I Definitions: A. One-To-One Direct: on staff member must continuously monitor a client at not more than eight (8) feet in distance with physician’s order. One staff member may be assigned to only one (1) client on One-To-One Direct at a time. Client must be visualized at all times. V. Procedure: A. One-To-One Direct. A-ii. Nursing Care: c. Reasonable privacy may be given for a client who is on one-to-one observation with the exclusion of suicide precautions. While the client is toileting, a staff member may stand just outside of the toilet stall door. However, staff must remain vigilant for any signs/behaviors that would indicate possible harm to the client. Observations 07/16/2024 at 3:25 p.m. of recorded video from House B camera view RM1 OC-157 W4 Sleep on 05/11/2024 from 8:18 p.m. to 8:22 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 lying in bed and S12CGT sitting in chair approximately 10 to 15 feet from the patient’s bed. On 05/11/2024 at 8:21:28 p.m., 3 patients (Patients #R5, #R6, and #R7 identified from incident reports) enter Patient #1’s cubicle, walk directly to his bed and immediately begin to strike Patient #1 with their hands (appear to be closed hand strikes). 2 of the aggressor patients’ hands appear to be hitting Patient #1 in the head area, while the 3rd aggressor patient’s hand are striking the torso/chest area. Each of the 3 aggressor patients appear to hit Patient #1 approximately 5 times and the altercation lasted approximately 9-10 seconds. At 8:21:34 S12CGT stands to his feet and sounds like he said, “Calvin, Calvin,” but does not walk towards Patient #1 until 8:21:39. As S12CGT walks towards Patient #1’s bed the sound revealed, “flip off, flip off, flip off,” and the 3 aggressor patients retreat from Patient #1 and exit the cubicle. S12CGT did not appear to be in a rush to physically intervene in the altercation, 10 seconds elapse before he begins to walk towards Patient #1’s bed. Further, S12CGT observation location prior to the incident appears to be greater than 8 feet from the patient. A medical record review of Patient #1 revealed in part, a nursing note from 05/11/2024 at 8:25 p.m. indicating Patient #1 was lying in bed sleeping when he was attacked by multiple peers. Patient had a quarter sized knot on the left side of his head. Patient stated he had a headache. Ice pack was applied, Tylenol was administered, assessment/neuro checks completed and the patient was being transferred to another unit for safety. Patient #1’s current observation level was 1:1 Direct, at not more than 8 feet for aggressive behaviors and this observation level was initiated on 05/02/2024 at 5:50 p.m. This observation level was continued, with the addition of being monitored by a male CGT only, on 05/11/2024 at 6:58 p.m. A restrictive management progress note from 05/11/2024 at 6:58 p.m. revealed in part, the patient smeared feces in the CGT’s (female CGT) face, became verbally aggressive with her and due to the behavior, RPM (restrictive patient management) remained in place with male CGT only. In an interview on 07/16/2024 at 3:45 p.m. S11PMI confirmed the above mentioned findings and confirmed the above incident was not reviewed by the hospital as a potential case of abuse/neglect. Observations 07/16/2024 at 2:10 p.m. of recorded video from House C camera view Hall OC-131 on 06/01/2024 from 8:07 p.m. to 8:16 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 entering the restroom at 8:07:05 p.m. The S13CGT remained outside the doorway and across the hall from the bathroom door the entire time Patient #1 is in the restroom-approximately 8 minutes. During this time frame, patients would enter and exit the restroom, but these patients were alone with Patient #1, not as a group. S13CGT was never seen opening the door or glancing through the window on the door to observe the patients. His only view in the restroom was when the door opens and closes when other patients are entering and exiting the restroom. At 8:15:03 p.m. S13CGT moved towards the door as it is seen opening, Patient #1 is seen exiting the restroom and walking towards the dormitory. Recorded video from House C camera view RM7 OC-155 W2 Sleep on 06/01/2024 at 8:20:23 p.m. revealed Patient #1’s nose area appeared to have a red substance on it. A medical record review of Patient #1’s observation level during the 06/01/2024 incident revealed 1:1 Direct at not more than 8 feet for aggressive behaviors with male CGT only. A nurse note from 06/01/2024 at 8:20 p.m. revealed in part the patient was hit in the nose and had a nose bleed. A review of the hospital final investigative report revealed Patient #1 indicated another patient hit him but he did not know who the other patient was or what they looked like. S13CGT statement indicated he remained outside the restroom door as he was trained. In an interview on 07/16/2024 at 2:45 p.m. S11PMI confirmed the above mentioned findings. In an interview on 07/17/2024 at 12:40 p.m. S9DON confirmed the observation policy indicated the CGT should be stationed outside the bathroom stall door. 3. Failing to fully investigate an incident resulting in bodily injury to 1 (#1) of 4 (#1 - #4) patients A review of facility policy, “Abuse and Neglect Policy and Procedures for LDH,” Policy Number: 76.3, with an effective date of 06/06/2016. This policy was in effect through 05/16/2024. The policy revealed in part, I Policy: LDH is committed to preserving the right of each person receiving services to be free of abuse. Purpose: To establish a policy prohibiting abuse, neglect, exploitation, or extortion (hereafter termed “abuse”) of clients and to establish a procedures for reporting, investigating reviewing, and resolving alleged incidents of abuse. VII. Examples of Abuse: A-1. Physical Abuse: Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or twisting of head, arm or legs; the use of physical force which is unnecessary or excessive; and inappropriate or unauthorized use of restraint. A-6. Neglect: Acts or omissions by a person responsible for providing care or treatment which caused harm to a client, which placed the client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment or basic care. Failure to provide appropriate services, treatment, or care by gross errors in judgement, inattention, or ignoring may also be considered a form of neglect. 6-c. Failure to provide a safe environment. 6-e. Failure to supervise a client such that the client is placed in danger. VIII. Duty to Report Abuse: B. Any employee of LDH or an affiliate who has knowledge of possible abuse of a client or who receives a complaint of abuse from a client or any other person, shall report in accordance with the provisions of this policy, applicable law, and the facility or programs office’s internal policy and procedures. IX. Procedures for Reporting: C. Reporting outside the facility/program: All incidents of possible abuse involving LDH clients as alleged victims and/or LDH or affiliate staff as the accused shall be reported immediately to Adult Protective Services (ADP). For purposes of this LDH policy, it is the responsibility of the facility/program manager to ensure that the appropriate external agencies listed below are notified in a timely manner. C-2. The Health Standards section of the LDH Bureau of Health Services Financing for allegations involving persons who are receiving care in a facility licensed by that Section. Reposts should be made immediately or as soon as possible, but in no case later than 24 hours after knowledge. XVI. Investigative Review Process for 24-Hour Facilities: E. Conducting the Investigation: 3. If the facility is required by law or regulations to report to Health Standards, the APS investigator shall gather and analyze all available facts, and submit all available statements of witnesses and evidence in a preliminary written report within 5 working days from the date the incident was reported. Once the investigation and review process is complete, Health Standards shall be notified of the final outcome. A review of hospital policy, “Observations and Precautions,” Policy Number PC-NUR-12, with an effective date of 03/2005, last revised 02/2022 and approved 03/29/2022 revealed in part, I Definitions: A. One-To-One Direct: on staff member must continuously monitor a client at not more than eight (8) feet in distance with physician’s order. One staff member may be assigned to only one (1) client on One-To-One Direct at a time Observations 07/16/2024 at 3:25 p.m. of recorded video from House B camera view RM1 OC-157 W4 Sleep on 05/11/2024 from 8:18 p.m. to 8:22 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 lying in bed and S12CGT sitting in chair approximately 10 to 15 feet from the patient’s bed. On 05/11/2024 at 8:21:28 p.m., 3 patients (Patients #R5, #R6, and #R7 identified from incident reports) enter Patient #1’s cubicle, walk directly to his bed and immediately begin to strike Patient #1 with their hands (appear to be closed hand strikes). 2 of the aggressor patients’ hands appear to be hitting Patient #1 in the head area, while the 3rd aggressor patient is striking the torso/chest area. Each of the 3 aggressor patients appear to hit Patient #1 approximately 5 times and the altercation lasted approximately 9-10 seconds. At 8:21:34 S12CGT stands to his feet and sounds like he said, “Calvin, Calvin,” but does not walk towards Patient #1 until 8:21:39. As S12CGT walks towards Patients #1’s bed the sound revealed, “flip off, flip off, flip off,” and the 3 aggressor patients retreat from Patient #1 and exit the cubicle. S12CGT did not appear to be in a rush to physically intervene in the altercation, 10 seconds elapse before he begins to walk towards Patient #1’s bed. Further, S12CGT observation location prior to the incident appears to be greater than 8 feet from the patient. A medical record review of Patient #1 revealed in part, a nursing note from 05/11/2024 at 8:25 p.m. indicating Patient #1 was lying in bed sleeping when he was attacked by multiple peers. This note is what prompted the surveyor to request more information related to this incident. The before mentioned nursing note further revealed in part, the patient had a quarter sized knot on the left side of his head. The patient stated he had a headache. Ice pack was applied, Tylenol was administered, assessment/neuro checks completed and the patient was being transferred to another unit for safety. Patient #1’s current observation level was 1:1 Direct at not more than 8 feet for aggressive behaviors and this observation level was initiated on 05/02/2024 at 5:50 p.m. This observation level was continued, with the addition of being monitored by a male CGT only, on 05/11/2024 at 6:58 p.m. A restrictive management progress note from 05/11/2024 at 6:58 p.m. revealed in part, the patient smeared feces in the CGT’s (female CGT) face, became verbally aggressive with her and due to the behavior, RPM (restrictive patient management) remained in place with male CGT only. In an interview on 07/16/2024 at 3:45 p.m. S11PMI confirmed the above mentioned findings and confirmed the above incident was not reviewed by the hospital as a potential case of abuse/neglect. 4. Failing to timely report allegations of abuse/neglect on 1 (#1) of 4 (#1 - #4) patients to Louisiana Department of Health - Health Standards Section (LDH-HSS) Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed “Department” shall mean the Department of Health and Hospitals. “Unit” means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, “Abuse” is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report. Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. A review of facility policy, “Client Abuse and Neglect,” Policy Number: LD-25, with an effective date of 05/16/2024 and approved on 05/28/2024, revealed in part, I Policy: The Hospital is committed to preserving the right of each person receiving services to be free of abuse and neglect. Purpose: The purpose of this policy is to ensure that client’s rights are protected and to establish a uniform system for timely reporting and investigating all allegations of abuse/neglect of clients. V. Statutory Definitions and Examples: D. 42 CFR 482.13(c)(3) definition in the Code of Federal Regulations (CFR) apply to hospitals participating in the Medicaid and/or Medicare programs. D-i. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. D-ii. Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. H. Examples of the types of conduct that constitute abuse and neglect. H-i. Physical Abuse: a. Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or twisting of head, arm or legs. H-vi. Neglect: a. Acts or omissions by a person responsible for providing care of treatment which caused harm to, or placed a client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment or basic care. b. Failure to provide or withhold appropriate services, nutrition, clothing, treatment, or care by gross errors in judgement, inattention, or ignoring. d. Failure to provide a safe environment. f. Failure to supervise a client such that the client is placed in danger. VI. Duty to Report: B. Any employee or affiliate of the hospital who has knowledge of possible abuse or neglect of a client or who receives a complaint of abuse from a client or any other person, shall report in accordance with the provisions of this policy and applicable law. VII. Initial Reporting Procedures: A-ii: The nurse in charge of the area/building will immediately, within 1 hour, make a verbal report to the Appointing Authority/Designee during normal business hours or the Administrator on Duty as to whether outside agencies (Health Standards Section (HSS), Adult Protective Services (APS), and/or local law enforcement) should be notified of the report. B-v: The Building/Unit RN (Registered Nurse) Manager or designee will: a. complete the online HSS Hospital Abuse/Neglect Initial Report form and submit using the “submit” button on the electronic form before the end of the shift. A review of hospital policy, “Observations and Precautions,” Policy Number PC-NUR-12, with an effective date of 03/2005, last revised 02/2022 and approved 03/29/2022 revealed in part, I Definitions: A. One-To-One Direct: on staff member must continuously monitor a client at not more than eight (8) feet in distance with physician’s order. One staff member may be assigned to only one (1) client on One-To-One Direct at a time. Client must be visualized at all times. V. Procedure: A. One-To-One Direct. A-ii. Nursing Care: c. Reasonable privacy may be given for a client who is on one-to-one observation with the exclusion of suicide precautions. While the client is toileting, a staff member may stand just outside of the toilet stall door. However, staff must remain vigilant for any signs/behaviors that would indicate possible harm to the client. Observations 07/16/2024 at 3:25 p.m. of recorded video from House B camera view RM1 OC-157 W4 Sleep on 05/11/2024 from 8:18 p.m. to 8:22 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 lying in bed and S12CGT sitting in chair approximately 10 to 15 feet from the patient’s bed. On 05/11/2024 at 8:21:28 p.m., 3 patients (Patients #R5, #R6, and #R7 identified from incident reports) enter Patient #1’s cubicle, walk directly to his bed and immediately begin to strike Patient #1 with their hands (appear to be closed hand strikes). 2 of the aggressor patients’ hands appear to be hitting Patient #1 in the head area, while the 3rd aggressor patient is striking the torso/chest area. Each of the 3 aggressor patients appear to hit Patient #1 approximately 5 times and the altercation lasted approximately 9-10 seconds. At 8:21:34 S12CGT stands to his feet and sounds like he said, “Calvin, Calvin,” but does not walk towards Patient #1 until 8:21:39. As S12CGT walks towards Patients #1’s bed the sound revealed, “flip off, flip off, flip off,” and the 3 aggressor patients retreat from Patient #1 and exit the cubicle. S12CGT did not appear to be in a rush to physically intervene in the altercation, 10 seconds elapse before he begins to walk towards Patient #1’s bed. Further, S12CGT observation location prior to the incident appears to be greater than 8 feet from the patient. A medical record review of Patient #1 revealed in part, a nursing note from 05/11/2024 at 8:25 p.m. indicating Patient #1 was lying in bed sleeping when he was attacked by multiple peers. Patient had a quarter sized knot on the left side of his head. Patient stated he had a headache. Ice pack was applied, Tylenol was administered, assessment/neuro checks completed and the patient was being transferred to another unit for safety. Patient #1’s current observation level was 1:1 Direct at not more than 8 feet for aggressive behaviors and this observation level was initiated on 05/02/2024 at 5:50 p.m. This observation level was continued, with the addition of being monitored by a male CGT only, on 05/11/2024 at 6:58 p.m. A restrictive management progress note from 05/11/2024 at 6:58 p.m. revealed in part, the patient smeared feces in the CGT’s (female CGT) face, became verbally aggressive with her and due to the behavior, RPM (restrictive patient management) remained in place with male CGT only. A review of the facility Hospital Abuse/Neglect Initial Report revealed the date of the incident was 05/11/2024, the date of discovery was 07/16/2024 and the report submit date was 07/16/2024. In an interview on 07/16/2024 at 3:45 p.m. S11PMI confirmed the above mentioned findings and confirmed the above incident was not reviewed by the hospital as a potential case of abuse/neglect. Observations 07/16/2024 at 2:10 p.m. of recorded video from House C camera view Hall OC-131 on 06/01/2024 from 8:07 p.m. to 8:16 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 entering the restroom at 8:07:05 p.m. The S13CGT remained outside the doorway and across the hall from the bathroom door the entire time Patient #1 is in the restroom-approximately 8 minutes. During this time frame, patients would enter and exit the restroom, but these patients were alone with Patient #1, not as a group. S13CGT was never seen opening the door or glancing through the window on the door to observe the patients. His only view in the restroom was when the door opens and closes when other patients are entering and exiting the restroom. At 8:15:03 p.m. S13CGT moved towards the door as it is seen opening, Patient #1 is seen exiting the restroom and walking towards the dormitory. Recorded video from House C camera view RM7 OC-155 W2 Sleep on 06/01/2024 at 8:20:23 p.m. revealed Patient #1’s nose area appeared to have a red substance on it. A medical record review of Patient #1’s observation level during the 06/01/2024 incident revealed 1:1 Direct at not more than 8 feet for aggressive behaviors with male CGT only. A nurse note from 06/01/2024 at 8:20 p.m. revealed in part the patient was hit in the nose and had a nose bleed. A review of the hospital final investigative report revealed Patient #1 indicated another patient hit him but he did not know who the other patient was or what they looked like. S13CGT statement indicated he remained outside the restroom door as he was trained. A review of the facility Hospital Abuse/Neglect Initial Report revealed the date of the incident was 06/01/2024, the date of discovery was 06/18/2024 and the report submit date was 07/16/2024 In an interview on 07/16/2024 at 2:45 p.m. S11PMI confirmed the above mentioned findings.”

“Social Service Records CFR(s): The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history. This Standard is not met as evidenced by: 40957 Based on record review and interview the facility failed to ensure an initial psychosocial assessment was completed within 30 days of admission for 1 (Patient #2) of 3 (Patients #1, #2, #3) sampled patients. Findings: Review of the hospital’s Social Services Policy and Procedures Manual revealed, in part: III. Psychosocial Assessment Psychosocial assessments have a standardized format as determined by the Uniform Medical Records Committee of OBH (Office of Behavior Health). This basic outline (or sequence of categories) is designed to serve the purpose of both initial assessment, as well as annual update. A. Social Worker Role and Expectations 1. A psychosocial assessment will be completed by the assigned Social Worker on each patient shortly after admission to obtain pertinent information needed for the development of the individualized treatment plan and subsequent discharge planning... a) East Division, Community Homes, Forensic Division, and SFF (Secure Forensic Facility) - Typed or dictated within 15 days post admission. Completed copy signed and on chart in 30 days... Review of Patient #2’s Initial Psychosocial Assessment revealed the patient’s admit date was 11/07/2023 and the date of assessment was 01/29/2024. Date received was on 02/02/2024. Date formatted was on 02/05/2024. During an interview on 07/16/2024 at 2:45 p.m., S4TQM verified Patient #2’s Initial Psychosocial Assessment was not completed within 30 days after Patient #2 was admitted to the facility.”