Brentwood Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services by failing to ensure that a registered nurse evaluated the care of each patient for 1 (Patient #2) out 5 patients. This deficient practice was evidenced by: 1) Failing to notify a physician of a patient’s critical lab results; 2) Failing to obtain a STAT lab test ; 3) Failing to document vital signs for a patient who had decreased responsiveness and 4) Failing to immediately transfer a patient to the emergency room after being found “barely responsive” (See findings in A-0395).”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to meet the requirements of Condition of Participation for Laboratory Services as evidenced by the failure to have a written description of critical/abnormal lab results that were to be reported to the physician. As a result, 1 (Patient #2) out of 5 sampled patients’ critical labs were not reported to the physician as her condition deteriorated. {see findings at A-0584}”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to implement opportunities for improvement and initiate changes by failing to ensure that timelines for family contact were being monitored and followed per hospital policy after 1 of 5 patient’s family failed to be contacted during their hospital stay (Patient #1). Findings: Review of the hospital policy titled, Family Involvement in Treatment (dated 03/2026), revealed in part that the patient’s family members will be contacted promptly after admission and after the patient has signed the proper releases. The patient’s treatment plan will be reviewed with the family either in a family session or in telephone contact with the Social Worker/Counselor. Review of the medical record for Patient #1 revealed an admit date of 02/14/2026 and a discharge date of 02/25/2026. Further review of the record revealed the only communication with the patient’s family was dated 02/24/2026, when the counselor called the patient’s mother regarding an incident that occurred with the patient. There was no evidence of 24 hour contact with the family after admission or any family sessions with the counselor. Review of the hospital grievance log revealed on 02/25/2026, the patient’s mother complained of several issues, including having no communication from the patient’s counselor during the entire admission. Under steps taken to resolve grievance, it was documented that S5Counselor was counseled and re-educated. Review of a counseling form dated 03/05/2026 revealed that S5Counselor was counseled due to the failure to adequately communicate treatment information to the family. The counseling form further stated that S5Counselor will maintain a patient tracking sheet to ensure that requirements for patient care are upheld. The tracking sheet is designed to be able to be handed off to incoming staff should the counselor be out of office. On 03/24/2026 at 9:15 AM, interview with S6Director of Clinical Services revealed that contact should be made with the patient’s family within 24 hours of admission and a family session should be planned after that point. S6Director of Clinical Services confirmed that this family contact did not occur during Patient #1’s admission. She further stated that S5Counselor was counseled regarding this and was now using a patient tracking sheet to ensure all timelines are followed. When asked if anyone had been monitoring S5Counselor’s tracking sheet to ensure current patient timelines were being followed, S6Director of Clinical Services stated no. At that time, the surveyor requested to review S5Counselor’s patient tracking sheets. On 03/24/2026 at 9:25 AM, S6Director of Clinical Services provided S5Counselor’s patient tracking sheet. Review of the sheet revealed it had only six patient names on it with lines indicating psychosocial assessment, treatment plan and discharge dates only. There were no trackers on the form for 24 hour contact or family sessions. When asked if S5Counselor had more than six patients on her caseload, S6Director of Clinical Services stated yes. She further stated that S5Counselor was not using the assigned tracking sheet that she was supposed to be using. S6Director of Clinical Services further stated that she was not aware of this until now and this was an issue needed to be revisited.”

“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: 17450 Based on record review and interview, the hospital failed to ensure that a registered nurse evaluated the care of each patient for 1 (Patient #2) out of 5 sample patients. This was evidenced by: 1) failing to notify a physician of a patient’s critical lab results; 2) failing to obtain a STAT lab test; 3) failing to document vital signs for a patient who had decreased responsiveness and 4) failing to immediately transfer a patient to the emergency room after being found “barely responsive”. Findings: Review of the medical record for Patient #2 revealed an admission date of 02/22/2026 with diagnoses including bipolar disorder, rule out neurocognitive disorder. The history and physical indicated that the patient had a history of kidney disease and hypertension. Review of the medical record for Patient #2 revealed the psychiatrist wrote an order on 03/10/2026 at 8:00 PM for a medical consult due to multiple bruises on patient’s legs, arms, torso, buttocks and two wounds on knees from crawling around. Review of the medical record for Patient #2 revealed S3NP (medical consultant) assessed the patient on 03/11/2026 and ordered CBC, CMP labs and increase fluids. Review of lab results for Patient #2 dated 03/12/206 revealed the following abnormal results: Creatinine 3.05 (normal 0.52 - 1.04). [High creatinine indicates low kidney function.] GFR 17.5 (normal is greater than 60). [Low GFR indicates severe reduction in kidney function.] WBC 20.6 (normal 3.7 - 10.6). [High WBC indicates infection in the body.] There was no documented evidence in the record that the above critical lab results were reported to the physician. Review of the medical record for Patient #2 revealed S4MD saw the patient on 03/13/2026 at 8:10 AM and ordered a STAT CMP. There was no evidence in the record that this STAT lab was performed. Review of nurses notes dated 03/13/2026 at 9:30 PM revealed the patient’s “mental status continues to decline”. “Tonight she is worse than ever.” The note further revealed patient was “lethargic, unable to get up from the floor, sickly looking, barely responsive and pupils not reactive to light.” The note further documented the nurse was calling the house supervisor. There were no vitals documented as being assessed at this time. Nurses notes dated 03/13/2026 at 10:00 PM (30 minutes after finding patient barely responsive) revealed the house supervisor was notified to take a look at the patient because the patient “didn’t look right”. Vital signs documented at this time included a heart rate of 118-130 beats per minute. Nurses notes dated 03/13/2026 at 10:10 PM revealed the house supervisor came to see patient and called a rapid response. Review of the rapid response team assessment form dated 03/13/2026 at 10:10 PM revealed that EMS was called at 10:29 PM (one hour after initially finding the patient barely responsive). On 03/25/2026 at 10:00 AM, interview with S4MD revealed that he ordered a STAT CMP for the patient on 03/13/2026 because there had been no further labs ordered since admit on 02/22/2026. When asked if he was aware of the critical lab results from the labs that were ordered by S3NP on 03/12/2026, he stated no. When asked what he would have done if he had been aware of the abnormal lab results dated 03/12/2026 (GFR and Creatinine), S4MD stated he would have immediately transferred the patient to the ER. S4MD further stated that nursing staff never notified him of the critical labs from 03/12/2026. When asked if Patient #2’s symptoms/unresponsiveness could have been related to these abnormal lab results, S4MD stated yes. On 03/25/2026 at 11:35 AM, interview with S2CNO confirmed that the nursing staff should have notified the physician of the abnormal lab values dated 03/12/2026 (GFR, Creatinine, WBC), but there was no documented evidence this occurred. S2CNO confirmed that STAT order for CMP lab written by S4MD on the morning of 03/13/2026 was not obtained. S2CNO further confirmed the lack of assessment of vital signs upon finding the patient barely responsive on 03/13/2026 and the failure of the nurse to immediately send the patient out to the ER when found in that state of health.”

“WRITTEN DESCRIPTION OF SERVICES CFR(s): 482.27(a)(2) A written description of services provided must be available to the medical staff. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to have a written description of critical/abnormal lab results that were to be reported to the physician. As a result, 1 (Patient #2) out of 5 sampled patients’ critical labs were not reported to the physician as her condition deteriorated. Findings: Review of the hospital’s contracted services revealed that Hospital Lab A performed all laboratory services for the hospital. Review of the hospital policy titled, Laboratory Services (last revised 02/2019) revealed in part that critical laboratory tests and critical laboratory values have been defined by the medical staff in coordination with Hospital Lab A. When abnormal or critical lab values are generated, the laboratory will verify the value and immediately notify the nursing staff by phone and by hard copy, printed or faxed. The nurse will document their initials and the date and time on the lab report or in the progress notes. The nurse will immediately notify the attending physician of the critical lab value report (no later than 20 minutes). On 03/25/2026 at 10:15 AM, interview with S2CNO revealed that Hospital Lab A notifies nursing staff of any critical lab results and then the nurses notify the physicians of these results. When asked if the nursing staff notifies the physician of any other abnormal results, S2CNO stated only if Hospital Lab A calls do we notify the physician. On 03/25/2026 at 10:55 AM, S2CNO was asked to provide the documents regarding medical staff defining critical laboratory tests and critical values. At that time, S2CNO revealed that she was unable to locate any evidence of critical laboratory values being defined by the medical staff. She further stated that the medical director told her to follow Hospital Lab A’s critical value reporting procedures. Review of Hospital Lab A’s policy titled, Laboratory Critical Value Notification, revealed it included a list of hematology critical values. The policy stated that personnel performing testing are responsible for critical value notification and documentation of that notification. Further review of this list of critical values revealed it did not include all lab tests that were performed at the hospital, including creatinine and GFR. Review of the medical record for Patient #2 revealed the psychiatrist wrote an order on 03/10/2026 at 8:00 PM for a medical consult due to multiple bruises on patient’s legs, arms, torso, buttocks and two wounds on knees from crawling around. Review of the medical record for Patient #2 revealed S3NP (medical consultant) assessed the patient on 03/11/2026 and ordered CBC, CMP labs and increase fluids. Review of the lab results for Patient #2 dated 03/12/206 revealed the following: Creatinine 3.05 (normal 0.52 - 1.04). [High creatinine indicates low kidney function]. GFR 17.5 (normal is greater than 60). [Low GFR indicates severe reduction in kidney function.] WBC 20.6 (normal 3.7 - 10.6). [High WBC indicates infection in the body.] There was no documented evidence in the record that the above critical lab results were reported to the physician. Review of nurses notes dated 03/13/2026 at 9:30 PM revealed the patient’s “mental status continues to decline”. “Tonight she is worse than ever.” The note further revealed patient was “lethargic, unable to get up from the floor, sickly looking, barely responsive and pupils not reactive to light.” The note further documented the nurse was calling the house supervisor. EMS was contacted on 03/13/2026 at 10:29 PM to transfer the patient to the hospital. On 03/25/2026 at 10:00 AM, interview with S4MD was conducted. When asked if he was aware of the critical lab results from the labs that were ordered by S3NP on 03/12/2026, he stated no. When asked what he would have done if he had been aware of the abnormal lab results dated 03/12/2026 (GFR and Creatinine), S4MD stated he would have immediately transferred the patient to the ER. S4MD further stated that nursing staff never notified him of the critical labs from 03/12/2026. When asked if the patient’s symptoms/unresponsiveness could have been related to these abnormal lab results, S4MD stated yes. On 03/25/2026 at 11:35 AM, interview with S2CNO confirmed that the nursing staff did not notify Patient #2’s physician of the creatinine, GFR and WBC results (dated 03/12/2026) because the Hospital Lab A never contacted them regarding a critical lab result. Review of Hospital Lab A’s policy with S2CNO, which listed all critical lab values to be reported, revealed it did not include creatinine or GFR values to be reported. Further review revealed that Patient #2 had a WBC of 20.6 on 03/12/2026, however the reporting values on Hospital Lab A’s policy revealed critical results as <2,000/mm or >40,000/mm. S2CNO stated she was unsure how those values compared to the resulted WBC values for the patient. S2CNO further stated that she was not aware that all labs collected at the hospital were not on Hospital Lab A’s critical value reporting policy. S2CNO further confirmed that Patient #2’s physician should have been notified of the abnormal lab values dated 03/12/2026 (GFR, Creatinine, WBC). Further interview with S2CNO revealed that the hospital’s current process regarding the reporting of critical lab results failed to identify all labs collected in the hospital and needed to be reevaluated.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 40957 Based on record review and interviews, the hospital failed to ensure a patient complaint of alleged sexual abuse was recognized as a grievance. This deficient practice was evidenced by failing to correctly identify a patient grievance for 1 (#1) of 3 (#1-#3) patients reviewed for complaints/grievances. Findings: Review of hospital policy titled “Patient Grievance Procedures, RI.012”, last revised on 09/2024, revealed in part: Policy Grievances that endanger the patient, such as neglect and abuse, will be reviewed immediately upon receipt by the Patient Advocate, Chief Nursing Officer, or Nursing Supervisor. On “off shifts” or weekends, the weekend Patient Advocate will communicate with the Administrator on call to resolve any immediate potential for harm ...All complaints of abuse or neglect will be considered a grievance. When a report of sexual or physical abuse or neglect, whether directly by referral is received, the Department of Health and Hospitals will be notified within 24 hours from the time the facility was notified of the complaint and the Administer on call is also notified of any occurrences on nights and weekends. At all times, the local law enforcement agency will be notified to assist in this process of investigating abuse violations ... Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: “11. Facility Investigation (Administrative Review) and Final Investigative Report: In accordance with regulations, facilities are directed to process an allegation of abuse or neglect as a grievance in accordance with facility Grievance Processes and Abuse/Neglect policies. In accordance with §482.13, an allegation of abuse/neglect is to be treated as a grievance even if the complainant recants or indicates that the issue is resolved. A written response must be issued to the reporting patient or patient’s representative. In many cases, the presentation of an abuse investigation handled in this manner will satisfy surveyor reviews related to the manner in which a facility processes grievances.” Review of Patient #1’s medical record revealed Patient #1 was admitted to the hospital on 06/10/2025 and was discharged from the hospital on 06/19/2025. Patient #1’s admitting diagnosis was disruptive mood dysregulation. Secondary diagnosis was attention deficit hyperactive disorder. Review of Patient #2’s medical record revealed Patient #2 was admitted to the facility on 01/30/2025 and was still at the hospital as of 07/02/2025. Admitting diagnosis was major depressive disorder, recurrent, severe without psych features. Review of the facility’s incident log for Patient #2 read as follows- Sexual misconduct patient to patient 06/18/2025 11:20 PM, inpatient psych adolescents. On 06/19/2025 at 12:03 PM, it was reported to the Medical Doctor that a peer (Patient #2) came into peer’s (Patient #1) room, took his (Patient #2) pants off and humped him (Patient #1) in his face. During an interview on 07/01/2025 at 2:55 PM S1Performance Improvement reported a grievance was not completed for the incident between Patient #1 and Patient #2.”

“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: 40957 Based on record review and interview the hospital failed to ensure compliance with reporting abuse and neglect. The deficient practice is evidenced by failure of the facility to report an accusation of sexual assault to the Louisiana Department of Health. Findings: Review of the instructions provided in the document “Louisiana Department of Health Health Standards Section, Self-Reporting Process for Hospitals - Abuse/Neglect, Revised 12/01/2021, revealed in part: “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 Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable).” And “Patient-to-patient assaults should be categorized as “Neglect” in relation to “Patient-to-Patient Physical Assault” or “Patient-to-Patient Sexual Assault.” From a LDH standpoint, the issue under review is to determine whether the facility failed to take prudent action to prevent, and/or respond to, the (alleged) occurrence. These incidents should be assessed as alleged “Neglect” (i.e. the hospital’s failure to act with due diligence). Also indicate what the allegation of neglect involves (i.e. sexual assault, physical assault, elopement, death, or other).” Review of the facility’s incident log revealed the following incident: Sexual misconduct patient to patient 06/18/2025 11:20 PM, inpatient psych adolescents. On 06/19/2025 at 12:03 PM, it was reported to the Medical Doctor that a peer (Patient #2) came into peer’s (Patient #1) room, took his (Patient #2) pants off and humped him (Patient #1) in his face. Review of the medical record for Patient #2 revealed the patient was on one to one observation form 06/13/2025 until 06/30/2025 while awake. Review of the video footage revealed Patient #2 was not under one to one observation at the time of the incident on 06/18/2025. Patient #2 was seen on video footage going up and down hallway and going into other patients rooms. There was no visible evidence of a staff member within arms length of Patient #2. Review of the provided documentation revealed the incident was reported to Louisiana Department of Child and Family Services but not to Louisiana Department of Health. Further review revealed disciplinary action was received by the MHT for failure to perform hall presence. The nurse and house supervisor also received disciplinary action for documentation and education on the one to one policy was provided to the staff. During an interview on 07/01/2025 at 2:55 PM S1Performance Improvement verified Patient #2 did not receive one to one observation while awake on the date of the incident of 06/18/2025. S1Performance Improvement also verified Louisiana Department of Health was not notified after the patient to patient sexual misconduct allegations were noted on 06/19/2025.”

“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: 40957 Based on record review and interview the hospital failed to endure care in a safe setting. The deficient practice is evidenced by 1) failure to perform observations as ordered by the physician in 1(#3) of 3 (#1-#3) reviewed patient records; 2) failure to notify the admitting practitioner, in a timely matter, after an alleged incident involving possible physical abuse in 1(#3) of 3 (#1-#3) reviewed patient records; 3) failure to ensure a patient who complained of back pain after an allegation of abuse was evaluated by the nurse or licensed practitioner in 1(#3) of 3 (#1-#3) reviewed patient records. Findings: 1. Review of hospital policy, “Safety Rounds/Accountability, TX.064, Last Revised 05/2023”, revealed in part: I. Policy- It is the policy of the hospital to provide a safe, secure environment for our patients by ensuring accountability for their well-being. II. Guidelines for monitoring all Hospital patients as follows: Safety Rounds Procedure: Intake starts patient observation/monitoring plan upon arrival to intake area to prevent self-harm, worsening of their condition, elopement, etc. Intake conducts direct visual monitoring at a minimum of every 15 minutes. Intake documents handing off rounds sheets to unit staff. The charge nurse assigns responsibility for completion of patient observation rounds at the beginning of each shift and will document the assignments on the unit staff assignment sheet. 1. Every patient not on one to one (1:1) precaution will be monitored at least every 15 minutes ... 2. The staff assigned to each inpatient will keep an individual patient round sheet which will be documented on every 15 minutes, beginning with admissions process. Staff will physically go and visualize the patient ... 10. Any staff working with the patient will take the responsibility for the round sheet at the time they are in their care. If the patient is taken to therapist’s office or is with physician, the staff will notate that the patient is in meeting but must check on the patient every 15 minutes ... Review of the medical record for Patient #3 revealed the patient was admitted under a Physician’s Emergency Certificate on 05/15/2025 with a diagnosis of suicidal ideation. Review of the orders revealed the patient was placed on suicide precautions and observations were to be performed every 15 minutes. Patient #3 was admitted to the facility on 05/14/2025 and was discharged on 05/21/2025. Review of the Observation Sheets for Patient #3 revealed: 5/15/25 Observation at 11:04AM completed and next observation was at 11:22AM (approx. 18 minutes) Observation at 1:16PM was completed and next observation was at 1:49PM (approx. 33 minutes). The next observation was at 2:09PM (approx. 20 minutes). Observation completed was at 2:19PM and the next observation was at 2:42PM (approx. 23 minutes) Observation completed at 4:03PM and the next observation was at 4:21PM (approx. 18 minutes) 5/16/25 Observation completed at 5:53AM and the next observation was at 6:16AM (approx. 23 minutes) Observation completed at 1:39PM and the next observation was at 1:59PM (approx. 20 minutes) Observation completed at 7:00PM and the next observation was at 7:20PM (approx. 20 minutes) Observation completed at 7:45PM and the next observation was at 8:08PM (approx. 23 minutes) 5/17/25 Observation completed at 8:00AM and the next observation was at 8:40AM (approx. 40 minutes) Observation completed at 9:10AM and the next observation was at 9:29AM (approx. 18 minutes) Observation completed at 9:02PM and the next observation was at 9:20PM (approx. 18 minutes) 5/18/25 Observation completed at 5:20AM and the next observation was at 5:38AM (approx. 18 minutes) Observation completed at 10:58AM and the next observation was at 11:16AM (approx. 18 minutes) 5/19/25 Observation completed at 12:06AM and the next observation was at 12:24AM (approx. 18 minutes) Observation completed at 9:49AM and the next observation was at 10:08AM (approx. 19 minutes) Observation completed at 10:32AM and the next observation was at 10:55AM (approx. 23 minutes) Observation completed at 11:09AM and the next observation was at 11:27AM (approx. 18 minutes) and the next observation was at 11:49AM (approx. 22 minutes) Observation completed at 1:11PM and the next observation was at 1:29PM (approx. 18 minutes) Observation completed at 1:42PM and the next observation was at 2:08PM (approx. 26 minutes) Observation completed at 6:58PM and the next observation was at 7:17PM (approx. 19 minutes) Observation completed at 8:12PM and the next observation was at 8:50PM (approx. 38 minutes) Observation completed at 9:47PM and the next observation was at 10:09PM (approx. 22 minutes) and the next observation was at 10:27PM (approx. 18 minutes) Observation completed at 10:41PM and the next observation was at 11:00PM (approx. 19 minutes) and the next observation was at 11:19PM (approx. 19 minutes) 5/20/24 Observation completed at 10:28AM and the next observation was at 10:47AM (approx. 19 minutes) Observation completed at 10:05PM and the next observation was at 10:31PM (approx. 26 minutes) In a interview on 05/29/2025 between 2:38 PM and 2:49 PM, S1 Performance Improvement (S1PI) verified that the facility had experienced problems with the electronic observation system. S1PI stated the problems were first noticed at the end of March or beginning of April of 2025 and they had been working with the corporate office to fix the issue. S1PI stated, “It took us a while to figure it out.” S1PI stated initially the techs performing the observations complained that even though the patients were within range, the system was not recognizing the patient as in range. S1PI stated the techs were instructed to log out and then log back in. When the techs did this, sometimes it would produce observations that were late due to the time it took to reset the system. S1PI stated that she was not sure but thought that 90% of the issues were corrected by the end of April, but there were still some issues. When asked about Patient #3, who had late 15 minute observations documented in May, S1PI stated “I’m not going to say all the late observations were due to connectivity problems, but sometimes they are late because there are other things happening on the unit.” S1PI stated the facility had already initiated a plan to monitor the work performed by the MHT. S1PI verified that a report is run every morning and if a certain MHT has too many observations outside of the range, the person monitoring will discuss it with the MHT. When asked if any of the MHT’s responsible for the care of Patient #3 were interviewed about the timeliness of the observations for Patient #3, S1PI stated she was not sure. S1PI was then encouraged to provide all information she could about the issues with the observation monitoring system for review by the state health standards office. 2. Record review of the hospital’s final self-report dated 05/22/2025 revealed the following, in part: Date of incident 05/15/2025, date discovered on 05/16/2025. The Physician was notified of alleged abuse on 05/20/2025. In an interview on 05/29/2025 at 3:05 PM, S1PI verified the physician was not notified about the allegations in a timely matter. 3. Record review of hospital’s final self-report dated 05/22/2025 revealed the following, in part: Date of incident was 05/15/2025 and was discovered on 05/16/2025. Time of discovery was 4:00 PM. Patient #3 made accusations that S2MHT had pushed her against the wall while in the bathroom. Patient #3 indicated she was threatened by S2MHT that she would slap her when the patient stated she was going to tell her mom. Then Patient #3 stated S2MHT picked her up and carried Patient #3 to her room, threw her on her bed and she fell on the floor and hurt her back ... Name the clinician that assessed the patient was marked as unknown at this time. Date assessed was marked as unknown at this time. Time assessed was marked unknown at this time. Description on Patient #3’s injury, Patient #3 complained of back pain. In an interview on 05/29/2025 at 3:05 PM, S1PI verified Patient #3 did not have an appropriate assessment completed after Patient #3 complained of having back pain.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 40957 Based on record review and interview, the hospital failed to protect the rights of each patient. The deficient practice is evidenced by failure to ensure two staff members were present during a nursing admission assessment, which included a body search, for 2 (Patient #1, #3) of 3 sampled patients. Findings: Review of the form titled “Nursing Admission Assessment” revealed it contained an area for patient body search. Further review of the form revealed a space for two signatures, indicating that two staff members were present for the physical exam. Review of the forms for Patient #1 and Patient #3 revealed there was only one signature on the form for each patient. During an interview on 04/29/2025 at 2:15 PM, S1Director of Performance confirmed that Patient #1 and Patient #3’s “Nursing Admission Assessment” forms did not have two signatures on them. S1Director of Performance also revealed that two staff of the same sex as the patient are to be present for the assessment, which includes a body search, and both staff are to sign off on the assessment forms.”

“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: 40957 Based on record review and interview, the nursing staff failed to ensure a personal property record form was completed upon discharge for 1 (Patient #1) of 3 sampled patients. Findings: Review of the record for Patient #1 revealed an admit date of 02/12/2025. Review of the personal property record form dated 02/13/2025 revealed the patient admitted with several personal items, including three blouses/shirt, three pants/shorts, one pair of shoes, one sweater, four pairs of underwear, three bras, three socks, one deodorant, one toothbrush, one lotion, and four books . Further review of the personal property record form revealed there was no documented evidence at discharge that the patient’s personal items were returned. There was a signature spot on the form, indicating that the items were returned to the patient at discharge, but it was blank. During an interview on 04/29/2025 at 2:20 PM, S1Director of Performance confirmed Patient #1’s personal property record was not signed at discharge by the patient/representative or a staff member. S1Director of Performance further confirmed that there was no documented evidence that the personal items that the patient brought upon admission were returned to her upon discharge.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 17450 Based on observation, record review, and interview, the hospital failed to meet the Conditions of Participation of Patient Rights. This deficient practice was evidenced by the hospital 1) failing to ensure that each patient has the right to be free from all forms of abuse or harassment as evidenced by the hospital failing to identify physical abuse that occurred for one sampled adolescent patient by a staff member (Patient #3) and 2) failing to ensure a complaint by a family member regarding alleged staff to patient physical abuse was recognized as a grievance for 1 (Patient #3) of 5 sampled patients reviewed for complaints/grievances (See findings at Tags A0118 and A0145).”

“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: 17450 Based on observation, record review, and interview the hospital failed to ensure that each patient has the right to be free from all forms of abuse or harassment as evidenced by the hospital failing to identify physical abuse that occurred for one sampled adolescent patient by a staff member (Patient #3). Findings: Review of the hospital policy titled, Abuse and Neglect Assessment (PE.032A, effective 08/2024) revealed in part that child physical abuse is defined as an injury, unreasonable confinement, intimidation or cruel punishment of a child resulting in physical harm or death. Review of an LDH Abuse/Neglect Self Report (Final) dated 03/12/2025 revealed an incident that occurred on 03/11/2025 at 12:50 PM between S2BHT and Patient #3. This report revealed the following timeline of events: 12:58 PM - Patient and tech are sitting at the table and appear to be having an appropriate conversation 12:59 PM - The patient suddenly stood up and approached the tech while he was still sitting as if he was about to attack the tech. The tech went hands on pushing the patient away. The patient and tech struggle and the tech pushes the patient into room 208. 1:00:04 PM - The tech and patient appear to separate, but this is unclear due to camera view 1:00:34 PM - The tech exits the room 1:00:34 PM - The tech is standing at bedroom door 1:00:41 PM - The tech closes the door 1:00:48 PM - Tech in day room, looks at right hand as code green team arrives. 1:02 PM - The patient exits room with staff, noted holding paper to his nose. The patient was placed in seclusion and then nose assessed by House Supervisor. The Self Report further revealed that Patient #3 was interviewed by the Patient Advocate on 03/11/2025 and the patient stated that S2BHT punched him in the nose with his fist. Under Investigation Results on the Self Report, it stated that the hospital was unable to substantiate the allegation due to a lack of evidence. Video surveillance was reviewed and revealed the tech “go hands on” and push the patient, however due to lack of surveillance in the room we were were not able to corroborate the patient’s allegation of being hit in the nose. The patient was noted to have a nosebleed, however we are not able to state the cause of this. The staff was placed on administrative leave 03/11/2025 and cannot return until CPI and verbal de-escalation is complete. On 04/07/2025 at 1:20 PM, the survey team viewed the video of the incident dated 03/11/2025 involving Patient #3 and S2BHT with S3Risk Manager. The video revealed that S2BHT and Patient #3 were sitting at a table in the dayroom when Patient #3 suddenly stood up and pulled up his pants. At that time, S2BHT stood up and forcefully pushed Patient #3 in the chest, pushing the patient across the floor. The tech then pushed the patient a second time until the patient was eventually forcefully pushed so much that he was pushed into his bedroom (which was adjacent to the day room). At no time was the patient observed to put his hands on the tech. The patient was not observed to be aggressive. There were no cameras in the patient’s room, but approximately 30 seconds later, the tech walks out of the patient’s room and pulls his right hand up as if examining his knuckles. One minute later, the code green team (that was called by the nurse to assist with aggressive patients) arrived on the unit. The patient was then observed to be led out of the seclusion room by staff. The patient was holding a bloody tissue to his nose. Observation revealed that as Patient #3 walked by S2BHT, S2BHT smiled/smirked at the patient. There was no audio sound to the video. On 04/07/2025 at 1:40 PM, interview with S3Risk Manager revealed that she interviewed S2BHT on 3/11/2025 after the incident. She stated that when S2BHT was asked how Patient #3 sustained a bloody nose, he had no response. When asked if Patient #3 ever raised his hands to S2BHT, S3Risk Manager stated no. When asked if S2BHT used excessive force with Patient #3, S3Risk Manager stated yes. S3Risk Manager stated that S2BHT did not use proper CPI techniques. S3Risk Manager further stated that she asked S2BHT why he had a smirk on his face as Patient #3 walked by him as he was lead to the seclusion room, and S3BHT had no response. On 04/08/2025 at 11:36 AM, interview with S2BHT (with S2Dir of QA and S3Risk Manager present in room) revealed that he was sitting at a table in the dayroom with Patient #3, when the patient suddenly stood up and came to him, “pulling his pants up like he was going to attack me and then he lunged at me”. S2BHT stated that the patient grabbed him at his chest and then the tech pushed him off. S2BHT stated he was nervous about what the patient was going to do and when the patient came at him again, he pushed him off again to gain distance. S2BHT further stated that the pushing ended up in the patient’s bedroom. S2BHT stated the patient kept trying to attack him, so he pushed the patient again and the patient hit the wall in the room. When asked if that was how the patient sustained a bloody nose, S2BHT stated “I guess”. On 04/08/2025 at 12:05 PM, interview with S2Dir of QA and S3Risk Manager confirmed that the interview the surveyor had with S2BHT did not match what happened on the video. They confirmed that the patient was not observed on video to lunge at the tech or lay hands on the tech. They confirmed that Patient #3 was not the aggressor. They further confirmed that S2BHT was suspended for six days and returned to the hospital to work with adult clients for 30 days, but will then return to work on the adolescent unit on 04/17/2025.”

“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: 17450 Based on record review and interview, the hospital failed to ensure each patient’s right to receive care in a safe setting. The deficient practice was evidenced by failure of nursing staff to accurately complete twice daily suicide risk assessments for 7 (Patients # 3, 5, R1, R2, R3, R4, R5) of 10 patients (#1-5 & R1-R5) reviewed for suicide precautions. Findings: Review of the policy titled, Suicide Assessment AMSR (Assessing and Managing Suicide Risk), with an effective date of 05/2024, revealed in part “Reassessment of Risk: 1. Reassessment of suicidality will occur every waking shift for any patient on suicide precautions or who exhibits a sudden or significant change in mental status. This is documented using the Daily/Shift Suicide Risk Assessment forms or other applicable format. All other patients will be screened using a screening tool at least daily in acute settings. 2. All other patient will be screened using a screening tool at least daily in acute settings by Brentwood Hospital. 3. Patients who continue, or begin to present at higher-risk for suicidality are to continue on, or be evaluated for, heightened observations or precaustions, as outline below. 4. Patients, who no longer meet criteria (lower risk status) for heightened protective measrues or precautions upon reassessment will be evaluated for a decrease in precautions by a physician who will provide appropriate orders... 7. All reassessments shal be considered by the treatment team and incorporated into the patient’s individualized treatment plan as indicated and as outlined in the Treatment planning.” Patient #R1 Review of the medical record for Patient #R1 revealed the patient was admitted on 01/28/2025 with suicidal and homicidal ideations. Review of the orders for Patient #R1 revealed the patient was placed on suicide precautions at the time of admission and the order remained active throughout the admission. Review of the medical record for “Daily Suicide Risk Assessment” revealed the assessments were not performed on 02/02/2025 during the day shift, 02/03/2025 during the evening shift, and 02/04/2025 during the day shift. Further review of the “Daily Suicide Risk Assessments” present in the record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part: 01/29/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NEW ADMIT NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/29/2025 at 9:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/29/2025 at 4:00 PM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/30/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/30/2025 at 9:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/30/2025 at 4:00 PM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/31/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/31/2025 at 9:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/31/2025 at 4:00 PM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/01/2025 at 6:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/01/2025 at 8:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- No change insight limited Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/01/2025 at 7:30 PM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/02/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/03/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/03/2025 at 8:30 AM Risk State as compared to previous shift: [NO ANSWER] Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/05/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/05/2025 at 9:00 AM Risk State as compared to previous shift: LOWER Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/05/2025 at 3:48 PM Risk State as compared to previous shift: LOWER Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/06/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/06/2025 at 9:45 AM Risk State as compared to previous shift: LOWER Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/06/2025 at 4:00 PM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/06/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/07/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/06/2025 at 5:00 AM Risk State as compared to previous shift: SIMILAR; Why? (indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/07/2025 at 11:00 AM Risk State as compared to previous shift: SIMILAR; Why? (indicate most important factors for assessment)- NO CHANGE Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] In an interview on 02/26/2025 at 9:26 AM, S1Risk Manager verified the hospital policy. If the patient is on suicide precautions, the nursing staff are supposed to completely fill out the “Daily Suicide Risk Assessment” form on each shift, day and evening. S1Risk Manager also verified the orders for suicide precautions were active the entire time Patient #R1 was admitted. In an interview on 02/26/2025 at 9:53 AM, S1Risk Manager verified the suicide risk assessments were not performed as required per policy. Patient #R2 Review of the medical record for Patient #R2 revealed admission on 02/21/2025 with a diagnosis of major depressive disorder. Patient #R2 was admitted to Room b. Review of the orders revealed Patient #R2 was placed on suicide precautions at the time of admission and the order was still active. Review of the “Daily Suicide Risk Assessment” revealed assessments were not performed on 02/22/2025 for the evening shift, 02/24/2025 for the evening shift, and 02/23/2024 for the day and evening shift. Further review of the “Daily Suicide Risk Assessments” present in the record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part: 02/22/2025 at 8:50 AM Risk State compared to previous shift: [BLANK] Why?(indicate most important factors for assessment): NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/23/2025 at 3:00 PM Risk State compared to previous shift: [BLANK] Why?(indicate most important factors for assessment): [BLANK] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/24/2025 at 10:00 AM Risk State compared to previous shift: LOWER Why?(indicate most important factors for assessment): [BLANK] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/25/2025 at 8:15 AM Risk State compared to previous shift: LOWER Why?(indicate most important factors for assessment): NO THOUGHTS POSITIVE COPING SKILLS Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] During a tour of the patient’s unit on 02/26/2025 at 11:17 AM, S4RN verified Patient #R2 was on suicide precautions. On 02/26/2024 at 11:25 AM, S1Risk Manager verified the suicide risk assessments were not performed as required per policy. Patient #R3 Review of the medical record for Patient #R3 revealed admission on 02/19/2025 with a diagnosis of alcohol and drug use disorder. Review of the physician orders revealed Patient #R3 was admitted with suicide precautions. Review of the “Daily Suicide Risk Assessment” sheets revealed assessments were not performed for the day and evening shift of 02/21/2025 and 02/23/2025, the evening shift of 02/24/2025 and the evening shift of 02/25/2025. Further review of the “Daily Suicide Risk Assessments” present in the record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part: 02/19/2025 at 2:00 PM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/20/2025 at 8:20 AM Risk State as compared to previous shift: [NO ANSWER] Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/20/2025 at 8:00 PM Risk State as compared to previous shift: SIMILAR Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/24/2025 at 11:00 AM Risk State as compared to previous shift: [NO ANSWER] Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/25/2025 at 2:00 PM Risk State as compared to previous shift: [NO ANSWER] Why? (indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] On 02/26/2025 at 10:58 AM, S1Risk Manager verified the suicide risk assessments were not performed as required per policy. On 02/26/2025 at 11:03 AM, during a tour of Patient #R3’s unit, S2MHT verified that Patient #R3 was on suicide precautions. Patient #R4 Review of the medical record for Patient #R4 revealed an admission of 02/18/2025 with diagnosis of alcohol use disorder. Review of current physician orders revealed the patient had an order for suicide precautions. Review of the “Daily Suicide Risk Assessment” sheets revealed assessments were not performed on 02/19/2025 for the evening shift, 02/21/2025 for the day and evening shift, 02/22/2025 for the day and evening shift, 02/23/2025 for the day and evening shift, 02/24/2025 for the day shift, and 02/25/2025 for the night shift. Further review of the “Daily Suicide Risk Assessments” present in the record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part: 02/19/2025 at 7:40 AM Risk State as compared to previous shift: [BLANK] Why? (indicate most important factors for assessment)- [BLANK] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/20/2025 at 8:20 AM Risk State as compared to previous shift: [BLANK] Why? (indicate most important factors for assessment)- [BLANK] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/20/2025 at 8:00 PM Risk State as compared to previous shift: [SIMILAR] Why? (indicate most important factors for assessment)- [BLANK] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/24/2025 at 11:00 AM Risk State as compared to previous shift: [BLANK] Why? (indicate most important factors for assessment)- [BLANK] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/25/2025 at 2:00 PM Risk State as compared to previous shift: [BLANK] Why? (indicate most important factors for assessment)- [BLANK] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] On 02/26/2025 at 11:00 AM, observation revealed Patient #R4 was at group therapy in the unit. At that time, interview with S2MHT revealed that Patient #R4 was on suicide precautions. On 02/26/2025 at 11:05 AM, S3RN confirmed the Patient #R4 had been on suicide precautions since admit. On 02/26/2025 at 2:30 PM, S1Risk Manager revealed that Patient #R4’s record was reviewed and confirmed the patient had been on suicide precautions since admit. S1Risk Manger verified that the suicide risk assessments were not performed twice daily as required by policy. Patient #R5 Review of the medical record for Patient #R5 revealed an admission of 02/24/2025 with diagnosis of major depressive disorder and suicidal ideations. Review of physician orders revealed no order for suicidal precautions. Review of the record revealed no “Daily Suicide Risk Assessment” sheets were completed. On 02/26/25 at 11:25 AM, S1Risk Manager verified the above missing suicide risk assessments. Review of Patient #R5’s “Daily Nurse Progress Note” dated 02/25/2025 at 9:30 AM revealed the patient “endorses thoughts of suicide”. Further review of this form/progress note revealed a section titled “AMSR Daily Screen”. Under this section it asked “Since you were last asked, have you actually had thoughts about killing yourself”. The nurse checked “Yes”. On 02/26/2025 at 11:30AM, S4RN verified that Patient #R5 had been on suicide precautions since admit. On 02/26/2025 at 1:50 PM, interview with S1Risk Manager stated that there was no order put in for suicide precautions upon admit. She stated that it was on the patient’s intake paperwork, but never got put in the electronic medical record system. S1Risk Manager further stated that the order for suicide precautions was just entered into the patient’s medical record at this time, after being questioned by the surveyor. S1Risk Manager further verified she was unable to provide any “Daily Suicide Risk Assessment” forms for Patient #R5. Patient #3 Review of the medical record for Patient #3 revealed the patient was admitted on 01/08/2025 with suicidal ideations. Review of the orders for Patient #3 revealed the patient was placed on suicide precautions at the time of admission and the order remained active throughout the admission. Review of the Patient #3’s medical record for completed the “Adolescent Daily Self Report” revealed the following in part: 01/08/2025 1) How are you feeling this morning? “Empty” 3) Do you feeling like hurting yourself? “Yes” If YES, Last thought: “Would anyone miss me” 5) Do you feel depressed? “Yes” If YES, rate (0-10): “8” 01/09/2025 1) How are you feeling this morning? “Depressed” 3) Do you feel like hurting yourself? “Yes” If YES, Last thought: “I don’t remember” 5) Do you feel depressed? “Yes” If YES, rate (0-10): “9.5” 01/10/2025 1) How are you feeling this morning? “Depressed” 3) Do you feel like hurting yourself? “Yes” If YES, Last thought: “I wanna cut my wrist open.” 5) Do you feel depressed? “Yes” If YES, rate (0-10): “10” 7) Are you having irritability/mood swings? “Yes” 9) Are you having confusion/difficulty concentrating? “Yes” 10) Are you having visual hallucinations? “Yes” If YES, please explain what you are seeing: “People” 11) Are you having auditory hallucinations? “Yes” If YES, please explain what you are hearing: “Creepiness and whispering” 01/12/2025 1) How are you feeling this morning? “Depressed” 3) Do you feel like hurting yourself? “Yes” If YES, Last thought: [LEFT BLANK] 5) Do you feel depressed? “Yes” If YES, rate (0-10): “9” 7) Are you having irritability/mood swings? “Yes” 9) Are you having confusion/difficulty concentrating? “Yes” 10) Are you having visual hallucinations? “Yes” If YES, please explain what you are seeing: “A girl with wet black hair standing” 11) Are you having auditory hallucinations? “Yes” If YES, please explain what you are hearing: “Crying and yelling” 01/13/2025 1) How are you feeling this morning? “Depressed/tired” 3) Do you feel like hurting yourself? “Yes” If YES, Last thought: “I don’t remember.” 5) Do you feel depressed? “Yes” If YES, rate (0-10): “10” 7) Are you having irritability/mood swings? “Yes” 8) Are you having crying spells? “Yes” 9) Are you having confusion/difficulty concentrating? “Yes” 10) Are you having visual hallucinations? “Yes” If YES, please explain what you are seeing: “A man” 11) Are you having auditory hallucinations? “Yes” If YES, please explain what you are hearing: “Crying” 01/14/2025 1) How are you feeling this morning? “Numb” 3) Do you feel like hurting yourself? “Yes” If YES, Last thought: “I want to cut my wrist.” 5) Do you feel depressed? “Yes” If YES, rate (0-10): “9” 7) Are you having irritability/mood swings? “Yes” 8) Are you having crying spells? “Yes” 9) Are you having confusion/difficulty concentrating? “Yes” 10) Are you having visual hallucinations? “Yes” If YES, please explain what you are seeing: “A tall woman in a white dress.” 11) Are you having auditory hallucinations? “Yes” If YES, please explain what you are hearing: “Help over and over in a weird voice.” 01/16/2025 1) How are you feeling this morning? “Numb” 3) Do you feel like hurting yourself? “Yes” If YES, Last thought: “I don’t remember.” 5) Do you feel depressed? “Yes” If YES, rate (0-10): “9” 7) Are you having irritability/mood swings? “Yes” 9) Are you having confusion/difficulty concentrating? “Yes” 10) Are you having visual hallucinations? “Yes” If YES, please explain what you are seeing: “A woman” 11) Are you having auditory hallucinations? “Yes” If YES, please explain what you are hearing: “Help” 01/18/2025 1) How are you feeling this morning? “Depressed” 3) Do you feel like hurting yourself? “Yes” If YES, Last thought: “I wanna kill myself.” 5) Do you feel depressed? “Yes” If YES, rate (0-10): “8” 7) Are you having irritability/mood swings? “Yes” 9) Are you having confusion/difficulty concentrating? “Yes” 01/19/2025 1) How are you feeling this morning? [LEFT BLANK] 3) Do you feel like hurting yourself? “Yes” If YES, Last thought: “I don’t remember.” 5) Do you feel depressed? “Yes” If YES, rate (0-10): “7” 9) Are you having confusion/difficulty concentrating? “Yes” Review of the Patient #3’s Physician Daily Progress Notes revealed the following in part: On 01/09/2025 at 9:30 AM - Patient #3 is positive for suicidal ideations and depression. Treatment was just beginning. Currently on suicidal precautions. Signed by S6MD. On 01/13/2025 at 10:01 AM - Patient #3 was positive for suicidal ideations and depression. Affect was depressed and anxious. Though content was suicidal content with no plan, didn’t want to be alive. Perception with auditory hallucinations of moaning or crying mostly at night time. Patient #3 was in DCFS custody. She was on and should remain on suicidal precautions. Signed by S6MD. On 01/14/2025 at 8:32 AM - Patient #3 was positive for depression, flat affect, didn’t want to be alive but had no plan to kill herself. She had increased anxiety and worrying about siblings because she did not know where/who they were with. She described her mood as “numb” with suicidal thought content with no plan. Her perception had no hallucinations but she did at times hear things at night time. She had no change in her suicide risk, and was still positive for suicidal ideations. She was on and was to remain on suicidal precautions. Signed by S6MD. On 01/15/2025 at 9:10 AM - Patient #3 reported her depression was still the same. Still felt suicidal and wanted to cut herself. She was apathetic with decreased sleep and appetite disturbances. She had a flat and depressed affect with suicidal thought content with thoughts to cut. She was on and was to remain on suicidal precautions. Signed by S6MD. On 01/16/2025 at 11:58 AM - Patient #3 was anxious, isolative, and guarded. She was rambling and thought blocking. She told the nurse her arm was scratched and bleeding. Patient #3 denied the scratch was self-harm and stated the scratch was an accident. Patient #3 stated to S7NP “I don’t really feel anything right now” when asked about her mood. Patient #3 continued to have suicidal thought content and stated to S7NP she “wished she weren’t alive but wasn’t sure why just didn’t like living anymore.” She shared she had been having visual and auditory hallucinations at night time and on during the prior night she saw a little girl crying in the corner of her room. She stated the crying didn’t bother her and sometimes her mom saw stuff too. She was on and should remain on suicidal precautions. Signed by S7NP. On 01/17/2025 at 10:15 AM - Patient #3 was withdrawn, guarded with anxiety, depression and had mood swings with crying spells. She had refused to attend group the prior day. She presented during the assessment with a blunted affect with suicidal thought content she reported had occurred before getting out of bed that morning. She was positive for suicidal ideations and could not identify any reason to live. She was on and should remain on suicidal precautions due to her elevated suicidal risk due to her very depressed state and danger to self. Signed by S7NP. Review of Patient #3’s Daily Nurse Progress Notes revealed the following in part: On 01/14/2025 at 8:40 AM - Patient #3 admitted to feeling suicidal but did not have a plan or specific reason. Patient #3 was questioned about stress and depression. Patient #3 denied having a plan. Patient #3 was encouraged to talk to staff when feeling suicidal and encouraged to use positive coping skills. Staff continued to monitor for mood, behavior, and safety every 15 minutes. On 01/17/2025 at 10:00 AM - Patient #3 reported thoughts of suicidal ideation but stated she had no plan or intent to act on the thoughts. Patient #3 was withdrawn most of day and rarely interacted in group or with peers. On 01/19/2025 at 9:00 AM - Patient #3 was participating in group activities. Patient had thoughts of suicidal ideation. Nurse and RN spoke to patient and patient stated “I don’t know why I feel depressed and like I want to kill myself.” Patient did state “I don’t know how I would hurt myself.” Patient had not hurt herself at that time. Patient remained on every 15 minute observations and was closely monitored. Review of Patient #3’s Interdisciplinary Notes within her medical record revealed the following in part: On 01/15/2025 at 10:00 PM - During observation rounds, Patient #3 reported injury. Nurse observed a scratch on patient’s left forearm that was actively bleeding. Patient #3 was assisted to the nurse’s station, nurse staff on unit cleaned and bandaged wound. Nursing staff will continue to monitor during every 15 minute observation rounds. Signed by S8RN. Review of the medical record for “Daily Suicide Risk Assessment” revealed the assessments were not performed during the following day shifts: 01/13/2025, 01/23/2025, 01/25/2025; and were not performed during the following evening shifts: 01/11/2025, 01/13/2025, 01/15/2025, 01/20/2025, 01/21/2025, 01/23/2025, and 02/03/2025. Further review of the “Daily Suicide Risk Assessments” in Patient #3’s medical record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part: 01/08/2025 at 12:37 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: [NO ANSWER] Why? (Indicate most important factors for assessment)- NEW ADMIT Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/08/2025 at 10:26 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/08/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/09/2025 at 9:30 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/09/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/10/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/10/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/11/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/12/2025 at 8:00 AM Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/12/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/14/2025 at 9:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [YES] 2. Suicidal Thoughts with Method: Have you been thinking about how you might do this? [NO] 3. Suicidal Intent (without Specific Plan): Have you had these thought and had some intention of acting on them? [NO] 4. Suicide Intent with Specific Plan: Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/14/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/15/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/16/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/16/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/17/2025 at 1:11 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/17/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/18/2025 at 9:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [YES] 2. Suicidal Thoughts with Method: Have you been thinking about how you might do this? [NO] 3. Suicidal Intent (without Specific Plan): Have you had these thought and had some intention of acting on them? [NO] 4. Suicide Intent with Specific Plan: Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- Pt states she has no intention on acting on thoughts Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/18/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/19/2025 at 9:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/20/2025 at 6:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/20/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/21/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/22/2025 at 10:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/22/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/24/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/24/2025 at 10:13 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/26/2025 at 4:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/26/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: [NO ANSWER] Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/27/2025 at 3:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/27/2025 at 9:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/27/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/28/2025 at 9:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/28/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/29/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/30/2025 at 6:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/30/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/30/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/31/2025 at 1:14 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 01/31/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/01/2025 at 11:50 AM - This assessment was only dated, timed and marked with RN initials indicating the previous suicide risk assessment had been reviewed. The remainder of assessment was incomplete. Risk State as compared to previous shift: [NO ANSWER] Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/01/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/02/2025 at 10:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- [NO ANSWER] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/02/2025 at 8:00 PM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] 02/03/2025 at 8:00 AM 1. Thoughts: Since you were last asked, have you actually had thought about killing yourself? [NO] 5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end your life while hospitalized? [NO] Risk State as compared to previous shift: SIMILAR Why? (Indicate most important factors for assessment)- NO CHANGES Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/resources, consultations, or special precautions.)- [NO ANSWER] On 02/26/2025 9:45 AM, S1Risk Manager reviewed the Patient #3’s record and confirmed Patient #3 was on suicide precautions during her admission and did not have suicide risk assessment forms fully completed for every shift and should per hospital policy. Patient #5 Review of the medical record for Patient #5 revealed an admission date of 02/05/2025 and a discharge date of 02/10/2025. Intake documentation revealed the patient was having suicidal ideations with plans to hang self. Review of the physician admission orders dated 02/06/2025 at 1:00 AM revealed an order to place the patient on suicide precautions. Review of the “Daily Suicide Risk Assessment” sheets revealed assessments were not performed on 02/07/2025 for the evening shift, 02/08/2025 for the evening shift, and 02/09/2025 for the evening shift. Further review of the “Daily Suicide Risk Assessments” present in the record revealed incomplete documentation by the nursing staff. Review of the assessments revealed in part: 02/06/2025 (no time) Risk State as compared to previous shift: [SIMILAR] Why? (indicate most important factors for assessment)- [BLANK] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/08/2025 at 6:00 AM Risk State as compared to previous shift: [SIMILAR] Why? (indicate most important factors for assessment)- [NO CHANGES] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/09/2025 at 10:08 AM Risk State as compared to previous shift: [LOWER] Why? (indicate most important factors for assessment)- [DENIES SI] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/10/2025 at 6:00 AM Risk State as compared to previous shift: [SIMILAR] Why? (indicate most important factors for assessment)- [NO CHANGE] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] 02/10/2025 at 9:10 AM Risk State as compared to previous shift: [LOWER] Why? (indicate most important factors for assessment)- [BLANK] Actions taken: (Response to Identified Changes: Indicate nursing interventions, safety planning, referrals/ resources, consultations, or special precautions.): [BLANK] On 02/26/2025 9:30 AM, S1Risk Manager reviewed the patient’s record and confirmed that all patients on suicide precautions should have a Daily Suicide Risk Assessment form completed each shift. Further interview confirmed Patient #5 was on suicide precautions during her admission and did not have suicide risk assessment forms completed for every shift. On 02/26/2025 at 2:50 PM, during the exit conference, S9CEO questioned the findings presented by the survey team and S1Risk Manager verified the findings. S1Risk Manager stated that she had reviewed the above sampled patients medical records and was unable to locate the information. 48537”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 20310 40957 Based on policy review, observation, and interview, the hospital failed to have an effective infection prevention and control program as evidenced by placing uncovered and uncontained brown paper bags containing red bio-hazard bags used to dispose of personal protective equipment in the hallway outside the rooms of patients with active infections. Findings: Review of the hospital’s policy labeled Infectious Waste Management, IC7.009 (last revised 10/2024) revealed, in part: I. Policy It is the policy of this facility to establish and maintain a plan for the safe handling, storage, management and disposal of infectious waste to reduce the risk of exposure of patients, staff, the public, and the environment. II. Procedure 1. Definition 1. Infectious waste is defined as any waste, solid or liquid, that is or has had, known or suspected contact with any bodily fluid or body substance. 2. Examples of such waste include, but are not limited to: 3. Isolation trash (in part) 2. Collection and Packaging 1. Infectious waste will be segregated from other waste by containing in disposable red plastic bags labeled as bio-hazardous at the site of use. The bag is securely tied and then carried to the biohazard holding room and placed in an appropriately labeled biohazard container with a lid. Observation of the 4 South hallway on 01/14/2025 at 8:15AM revealed bio-hazard red bags placed inside of brown paper bags were sitting on the floor next to the doors (two different doors adjacent to each other) of three patients who were quarantined due to Influenza diagnosis. The red bags protruded over the tops of the brown bags, which were open to air and uncontained. During an interview on 01/14/2025 at 8:20AM, S1 Performance Improvement was asked why the red bags stay in the hallways. S1 Performance Improvement reported the bio-hazard bags were for PPE (Personal Protective Equipment) disposal. During an interview on 01/15/2025 at 9:30AM, S1 Performance Improvement confirmed the bio-hazard bags were open to air and the bags should have been contained properly.”

“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: 17450 Based on observation, record review and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by 3 patients climbing the fence on the playground and eloping from the hospital in the past month (Patients #4, #5, #6). Findings: Patient #4 Review of the medical record revealed this 15 year old male was admitted on 11/02/2024 with diagnosis of suicidal ideations. Review of an LDH Abuse/Neglect Self-Report dated 11/03/2024 revealed the following: 8:49AM - Patient walked out of gym door leading to outside, followed by MHT. The patient ran to different areas of the fence attempting to climb. 8:49:45AM - The patient begins climbing where the two fences meet as MHT is walking toward the patient. 8:49:59AM - The patient crosses over the fence. The report further revealed that the patient was located later that day at a family member’s home. Patient #5 Review of the medical record revealed this 16 year old male was admitted on 11/14/2024 with a diagnosis of schizophrenia. Review of an LDH Abuse/Neglect Self-Report dated 11/22/2024 revealed the following: 8:40AM - 2North unit is leaving the gym and preparing to exit the playground area. The patient feels the fence as he stands adjacent to the gate door. 8:40:53AM - Patient walked over to gate door and began climbing. He loses grip and begins climbing fence again. The nurse is standing by. 08:41:17AM - Patient jumps fence and elopes. The report further stated that Patient #5 was located the next day, 11/23/2024. Patient #6 Review of the medical record revealed this 17 year old patient was admitted on 11/23/2024 with a diagnosis of major depressive disorder. Review of an LDH Abuse/Neglect Self-Report dated 11/27/2024 revealed the patient’s unit was in the gym and another patient kicked the gym entrance door and it opened. The MHT was a few feet away opening the bathroom door for another patient. The report further revealed: 8:30:09AM - A patient kicks the gym entrance door and it opens 8:30:24AM - Another patient walks out of the gym door 8:30:28AM - Patient #6 walks out the gym door, looks back and runs to the gate with the door and climbs the gated door. 8:30:54AM - Patient #6 is seen sliding through the top of the gated door and running toward the street 9:00AM - MHTs prepare to exit playground and is noted looking for Patient #5 (unaware that he had eloped). 9:12AM - Code Dove called (elopement) 9:50AM - Patient #6 arrives back to facility per police. On 12/09/2024 at 12:00PM, observations of the outside playground revealed S3Maintenance was replacing old and broken zip ties around the exit door where Patient #6 had squeezed through the fencing above the exit door. Interview with S3Maintenance at that time revealed that this morning was the first time he had been notified of the fence issues. He further stated he had ran out of zip ties and metal clamps but they were on order. On 12/10/2024 at 9:30AM, interview with S1Director of Plant Operations revealed that she was first notified about possible issues with the fence in the playground by S2CEO on the afternoon of 12/06/2024. She stated that S2CEO informed her that there were openings in the mesh of the fence that needed to be repaired. S1Director of Plant Operations stated that the fence was not repaired until yesterday morning, with the fence being reinforced with new zip ties and metal clamps at some of the openings where patients could possibly use to climb the fence. On 12/10/2024 at 9:40AM, tour of the outside playground area with S1Director of Plant Operations revealed the area was surrounded by a 12 foot fence with two exit doors. One of the doors to exit the playground had hinges that had a protrusion on the inside of the playground that would allow foot or hand placement on the hinges that would make it easier to climb the fence. There was another exit door on the playground that had a box with key access located on the inside of the playground that would allow a patient easier access to climb the fence. Observation of the entire fenced area revealed gaps between the fencing and the metal poles on 3 corners that could be used to facilitate climbing the fence. These areas also contained brackets/clamps that patients could use to climb the fence and elope. On 12/10/2024 at 10:00AM, interview with S1Director of Plant Operations revealed that the fence was supposed to be a “no climb” fence, but the patients were still climbing over the fence. When asked if there had been interventions put into place regarding the exposed hinges/brackets on the inside of the playground or other areas on the fencing that could facilitate climbing, she stated no. She stated a fencing company had been called to look at the fence, but they had not been to the hospital yet. On 12/10/2024 at 1:30PM, interview with S4Director of PI confirmed that the patients are continuing to utilize the playground, although there continues to be areas in the fencing that could allow patients to climb over and elope from the hospital.”

“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: 17450 Based on observation, record review and interview, the hospital’s performance improvement activities program failed to implement actions to prevent recurrence of adverse patient events following 3 patient elopements from secured areas (Patient #4, #5, #6). Findings: Patient #4 Review of the medical record revealed this 15 year old male was admitted on 11/02/2024 with diagnosis of suicidal ideations. Review of an LDH Abuse/Neglect Self-Report dated 11/03/2024 revealed the following: 8:49AM - Patient walked out of gym door leading to outside, followed by MHT. The patient ran to different areas of the fence attempting to climb. 8:49:45AM - The patient begins climbing where the two fences meet as MHT is walking toward the patient. 8:49:59AM - The patient crosses over the fence. The report further revealed that the patient was located later that day at a family member’s home. The area on Self-Report titled “Investigation Results” revealed that the investigation found that the door leading from the gym to the playground was not latching properly and the door has been reset. The investigation did not indicate any issues with the fencing in the playground. Patient #5 Review of the medical record revealed this 16 year old male was admitted on 11/14/2024 with a diagnosis of schizophrenia. Review of an LDH Abuse/Neglect Self-Report dated 11/22/2024 revealed the following: 8:40AM - 2North unit is leaving the gym and preparing to exit the playground area. The patient feels the fence as he stands adjacent to the gate door. 8:40:53AM - Patient walked over to gate door and began climbing. He loses grip and begins climbing fence again. The nurse is standing by. 08:41:17AM - Patient jumps fence and elopes. The report further stated that Patient #5 was located the next day, 11/23/2024. The area on the Self-Report titled “Investigation Results” revealed that the nurse verbally attempted to get the patient to come down from the fence but feared that a physical attempt would cause harm to her or the patient. The patient was noted to be on elopement precautions, however elopement precautions indicate the patient shall remain on the unit. The staff member has received 1:1 education by the nurse manager and will sign off on elopement policy. The investigation did not indicate any issues with the fencing in the playground. Patient #6 Review of the medical record revealed this 17 year old patient was admitted on 11/23/2024 with a diagnosis of major depressive disorder. Review of an LDH Abuse/Neglect Self-Report dated 11/27/2024 revealed the patient’s unit was in the gym and another patient kicked the gym entrance door and it opened. The MHT was a few feet away opening the bathroom door for another patient. The report further revealed: 8:30:09AM - A patient kicks the gym entrance door and it opens 8:30:24AM - Another patient walks out of the gym door 8:30:28AM - Patient #6 walks out the gym door, looks back and runs to the gate with the door and climbs the gated door. 8:30:54AM - Patient #6 is seen sliding through the top of the gated door and running toward the street 9:00AM - MHTs prepare to exit playground and is noted looking for Patient #5 (unaware that he had eloped). 9:12AM - Code Dove called (elopement) 9:50AM - Patient #6 arrives back to facility per police. On 12/09/2024 at 12:00PM, observations of the outside playground revealed S3Maintenance was replacing old and broken zip ties around the exit door where Patient #6 had squeezed through the fencing above the exit door. Interview with S3Maintenance at that time revealed that this morning was the first time he had been notified of the fence issues. He further stated he had ran out of zip ties and metal clamps but they were on order. On 12/10/2024 at 9:30AM, interview with S1Director of Plant Operations revealed that she was first notified about possible issues with the fence in the playground by S2CEO on the afternoon of 12/06/2024. She stated that S2CEO informed her that there were openings in the mesh of the fence that needed to be repaired. S1Director of Plant Operations stated that the fence was not repaired until yesterday morning (12/09/2024), with the fence being reinforced with new zip ties and metal clamps at some of the openings where patients could possibly use to climb the fence. On 12/10/2024 at 9:40AM, tour of the outside playground area with S1Director of Plant Operations revealed the area was surrounded by a 12 foot fence with two exit doors. One of the doors to exit the playground had hinges that had a protrusion on the inside of the playground that would allow foot or hand placement on the hinges that would make it easier to climb the fence. There was another exit door on the playground that had a box with key access located on the inside of the playground that would allow a patient easier access to climb the fence. Observation of the entire fenced area revealed gaps between the fencing and the metal poles on 3 corners that could be used to facilitate climbing the fence. These areas also contained brackets/clamps that patients could use to climb the fence and elope. On 12/10/2024 at 10:00AM, interview with S1Director of Plant Operations revealed that the fence was supposed to be a “no climb” fence, but the patients were still climbing over the fence. When asked if there had been interventions put into place regarding the exposed hinges/brackets on the inside of the playground or other areas on the fencing that could facilitate climbing, she stated no. She stated a fencing company had been called to look at the fence, but they had not been to the hospital yet. On 12/10/2024 at 1:30PM, interview with S4Director of PI confirmed that the patients are continuing to utilize the playground, although there continues to be areas in the fencing that could allow patients to climb over and elope from the hospital.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that all medical records were accurately written for 2 (Patient #4, #5) of 4 (Patient #3, #4, #5, #6) records reviewed for accuracy. Findings: Patient #4 Review of an LDH Abuse/Neglect Self-Report dated 11/03/2024 at 8:49AM revealed the patient climbed the fence on the playground and eloped from the hospital. Review of Patient #4’s nurses notes dated 11/03/2024 at 10:09AM revealed the nurse notified the patient’s mother that he had eloped. Review of Patient #4’s observation sheet dated 11/03/2024 revealed the tech documented that the patient was in the gym and cooperative at 8:57AM and was in the dining room and cooperative at 10:57AM. On 12/10/2024 at 2:20PM, S4Director of PI reviewed the patients record with the surveyor and confirmed the inaccurate documentation on the observation sheet dated 11/03/2024. She confirmed the patient had not been located at those times and was not in the hospital. Patient #5 Review of an LDH Abuse/Neglect Self-Report dated 11/22/2024 at 8:40AM revealed the patient climbed the fence on the playground and eloped from the hospital. Further review of the report revealed the patient was located the next day, 11/23/2024. Review of Patient #5’s nurses notes dated 11/22/2024 at 8:40AM stated the patient was traveling from the gym to the main building and the patient climbed over the gate. Writer shouted for the patient to get down off the gate, but the patient continued climbing and escaped. Review of nurses notes dated 11/22/2024 at 10:00AM revealed patient appears isolative, minimal talking. Nods his head and gives thumbs up or down to writer. Climbed over gate and escaped. On 12/10/2024 at 2:10PM, S4Director of PI reviewed the patient’s record with the surveyor and confirmed that the nurses note dated 11/22/2024 at 10:00AM was inaccurate because the patient had eloped and was not at the hospital at that time.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 20310 Based on observation and interview, the hospital failed to ensure that patients received care in a safe setting as evidenced by having a patient care environment with hazards that presented: 1.) Ligature risks and 2.) Unsafe patient room door locks. Findings: 1.) Ligature Risk On 10/07/2024 between 3:20 p.m. and 3:50 p.m., a tour of the hospital’s first floor patient bathrooms revealed the following potential ligature points that could be used by a patient: -Main lobby - 2 bathroom toilet seats, - Administration conference room - bathroom toilet seat, door knob, water sprinkler and removable ceiling tiles with other structural ligature points, - Administration conference room bathroom anteroom - water sprinkler and removable ceiling tiles with other structural ligature points, - 1 South men’s and women’s showers located prior to entering the unit - toilet seats, shower room toilet seat on the unit, - 1 West patient rooms 176, 178, 180-185, 187, patient bathroom located at the end of the hall on the left - toilet seats, - 1 Tower seclusion room, patient rooms 110-116 - toilet seats. In an interview on 10/07/2024 at 3:50 p.m., S2PI Dir verified the toilet seats, water sprinklers and structural support above the ceiling tiles as potential ligature points. She also verified all areas identified are used by patients potentially with suicidal ideation. On 10/08/2024 between 9:30 a.m. and 10:30 a.m.,a tour of the hospital’s second floor patient rooms and bathrooms revealed the following ligature points that could be used by the patient: - 2 South bathroom by laundry room toilet seat; - 2 South Extension rooms 245, 247, 256, 258 toilet seats, removable ceiling tiles with other structural ligature points; - 2 North Enhanced boys bathrooms by laundry, in shower rooms and seclusion room toilet seats. No toilets located in patient rooms; - 2 West hallway bathroom and patient rooms 278-279 toilet seats; - 2 Tower seclusion room bathroom and patient rooms 228-231 toilet seats On 10/08/2024 between 1:30 p.m. and 2:10 p.m., a tour of the hospitals 3rd and 4th floors patient bathrooms revealed toilet seat ligature points in the following rooms: - 3rd floor Adult Enhanced unit seclusion room toilet, patient rooms 333-339, 341 and the 2 shower room toilets; - 3 South patient rooms 358, 360, 362, 364-371 and 2 shower rooms at the end of the hall; - 3 West patient rooms 380-389 and shower room on the left at the end of the hall; - 3 Tower patient rooms 310- 316, the hall bathroom and seclusion room; - 4 ASD seclusion room bathroom toilet and 2 hallway bathroom toilets; - 4 West 4 hallway bathroom toilets. No bathrooms in patient rooms. - 4 Tower patient rooms 409- 413 2.) Unsafe patient room door locks During the hospital tour on 10/07/2024 and 10/08/2024 an observation of all the hospital patient room locks revealed they automatically locked upon closing and staff had to utilize a key to access. The hospital has 128 licensed patient rooms. This presents as a patient safety issue as a patient could place an object in the key hole rendering key access useless. The patient would then be locked in the room and could harm themselves or others while staff attempted to gain access. In an interview on 10/8/2024 at 2:10 p.m. S2PI Dir verified the above findings for the ligature and patient room door lock safety issues. In an interview on 10/08/2024 at 2:20 p.m., S1Adm verbalized an understanding of the potential safety issues with the toilet ligature risk and patient doors automatically locking. He stated, he had not thought about those as issues. In an interview on 10/08/2024 at 2:20 p.m., S3Plant Operations Manager verified the locks on all patient rooms automatically lock when the door is closed. He also verified that it is possible for a patient to place something in the keyhole rendering it impossible to open the patient door with a key. He stated he would have to be contacted to come and remove the entire door handle and lock and if it were after hours it would take some time for maintenance to drive to the hospital and complete the removal. 17450 38777”

“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: 20310 Based on record review and interview, the hospital’s performance improvement activities program failed to implement actions to prevent recurrence of adverse patient events following a patient’s elopement from a secured unit for 1 (Patient #5) of 2 patients (Patients #3, #5) reviewed for elopement events in a total sample of 9. Findings: Review of the facility’s LDH Self Report (initial and final) dated 10/08/2024 revealed the following: On 10/07/2024 at 9:24 a.m., S4Counselor was exiting through the rear doors of 2 North (Adolescent Boys Enhanced Unit) when Patient #5 ran behind her and tried to leave the unit. S4Counselor can be seen trying to push him back in, however she was overpowered. At 9:26:33 a.m., Patient #5 left through the outpatient clinic doors, ran through hallway, and then to the outside. He was chased by staff, however they were not able to catch him. Review of the facility’s investigation results revealed: There were multiple staff present on the milieu at the time of the incident; however, the patient took advantage of a moment when a staff member was exiting the unit to leave. Despite the staff’s immediate efforts to retrieve the patient they were unsuccessful. The patient has since been located by local police and has returned to our facility. To improve overall safety, we have set up a meeting to discuss deactivating the 2 North exit door that leads to the outpatient area. We will continue to assess for opportunities for improvement related to patient safety. On 10/09/2024 at 11:15 a.m., an interview with S2PI Dir confirmed no changes had been made to address the traffic flow through the secured unit into an unsecured area of the hospital, and the door had not yet been deactivated. On 10/09/2024 at 12:45 p.m., an interview with S5MHT confirmed there were 9 boys on the 2 North Adolescent Boys Enhanced Unit unit the morning of 10/07/2024 when she arrived for her shift. She stated Patient #5 had been discharged earlier and was waiting for transportation. When the discharge was canceled, Patient #5 had become very upset and was in the timeout room, cooling off. When S4Counselor walked into the unit and through toward the back exit door, he followed her and stopped at the laundry room where S6MHT was doing laundry. When S4Counselor went down the hall and out the exit door, S5MHT saw Patient #5 running down the hall to catch the door before it closed. S5MHT and S6MHT immediately followed him out of the door, into the hallway and outside the building. Patient #5 went underneath the ramp railing and down the hill before they could catch up with him. S5MHT confirmed there had been no changes to the staff using the unit as a walkthrough area to get to the unsecured area in the outpatient clinic, and that the traffic flow is fairly heavy for this purpose at all times during the day, including today. On 10/09/2024 at 1:07 p.m., an interview with S6MHT confirmed she was on the 2 North unit the morning of 10/07/2024 to transport Patient #5 to another facility following his discharge. While she was on the unit, the discharge got canceled due to placement issues. Patient #5 got upset, and was crying. He went into the quiet room with the door open, and kept coming in and out of the room. When S4Counselor came into the unit to pass through to the outpatient clinic, Patient #5 followed her as far as the laundry room near the hallway to the outpatient clinic exit door. When S4Counselor went through the exit door, Patient #5 bounded down the hallway and grabbed the door before it closed. S6MHT stated she was in the laundry room and didn’t see him go out, but S5MHT did see him and they both immediately went after him. S6MHT confirmed that she is on the 2 North unit almost every day and that the traffic flow through the unit to the unsecured outpatient clinic is frequent throughout the day. She confirmed that the door has not yet been deactivated.”

“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: 17450 Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to administer sliding scale insulin as ordered by the physician and failing to notify the physician of high blood sugar results for 1 (Patient #4) of 2 sampled diabetic patients (Patients #4, #6) in a total sample of 9. Findings: Review of the medical record for 17 year old Patient #4 revealed an admit date of 09/16/2024 with diagnoses including depression and diabetes. Review of the physician orders dated 09/16/2024 revealed orders for routine insulin daily as well as blood sugar checks four times daily (before meals and at bedtime) with sliding scale Humulin R insulin to be administered. The physician ordered sliding scale insulin for the following blood sugar results: 0-60, give orange juice and call MD 61-200, no insulin required 201-250, 3 units Humulin R 251-300, 5 units Humulin R 301-350, 7 units Humulin R 351-400, 9 units Humulin R Over 400, 12 units Humulin R and call MD Review of the patient’s medical record revealed blood sugar results included the following: 09/24/2024 at 11:11 a.m. - result of 478. No documentation of any Humulin R insulin being administered. No documentation of the physician being notified of the high result. 09/23/2024 at 10:56 a.m. - result of 479. No documentation that the physician was notified. 09/22/2024 at 11:01 a.m. - result of 400 with 12 units Humulin R given. Sliding scale physician orders indicate to give 9 units. 09/22/2024 at 2:03 p.m. - result of 424. No documentation that the physician was notified. 09/21/2024 at 8:56 a.m. - result of 436. No documentation that the physician was notified. 09/21/2024 at 11:11 p.m. - result of 455. No documentation that the physician was notified. 09/20/2024 at 9:07 a.m. - result of 429. No documentation that the physician was notified. 09/20/2024 at 7:52 p.m. - result of 357. No documentation of any Humulin R insulin being administered as ordered per sliding scale. 09/19/2024 at 6:26 a.m. - result of 244. No documentation of any Humulin R insulin being administered as ordered per sliding scale. 09/19/2024 at 11:00 a.m. - no blood sugar documented. Nurses note states “off unit”. 09/19/2024 at 4:32 p.m. - result of 400 with 12 units Humulin R given. Sliding scale physician orders indicate to give 9 units. 09/18/2024 at 6:27 a.m. - result of 233. No documentation of any Humulin R insulin being administered as ordered per sliding scale. 09/18/2024 at 12:16 p.m. - result of 533. No documentation of any Humulin R insulin being administered as ordered per sliding scale. No documentation that the physician was notified of the high result. On 10/09/2024 at 2:50 p.m., interview with S2PI Dir confirmed she was unable to locate in the medical record any evidence that the physician was notified of the blood sugar results over 400, as ordered. S2PI Dir further confirmed there was no documented evidence that the physician’s orders for sliding scale Humulin R insulin was followed for all blood sugar results.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) 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 improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 36293 Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement (QAPI) program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure the Registered Nurse entered the risk flags for behavior monitoring on the Observe Smart tablet. Findings: Review of current and closed medical records failed to reveal behaviors were monitored in accordance with the patient’s Nursing Treatment Plan for 4 of 6 medical record reviewed (Patient #1, #3, #5, #6). In an interview on 08/06/2024 at 2:10 p.m., S1QA Director stated they monitor incident logs and monitor for updates in the patient’s Treatment Plan but they do not currently monitor the Risk Flags on the Patient Observations Sheets to ensure the Registered Nurses are entering the required observation needs into the Observe Smart tablet to reflect the current or updated Treatment Plans.”

“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: 36293 Based on record reviews and interview, the hospital failed to ensure a Registered Nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient’s needs. This deficient practice was evidenced by the Registered Nurse failing to ensure patient’s behaviors were monitored in accordance with the patient’s Nursing Treatment Plan for 4 of 6 medical record reviewed (Patient #1, #3, #5, #6). Findings: Review of the hospital’s policy TX.064 titled, “Safety Rounds/Accountability” revealed in part: Policy: It is the policy of this hospital to provide a safe, secure environment for our patients by ensuring accountability for their well-being. Safety Rounds Procedure: The charge nurse assigns responsibility for completion of patient observation round at the beginning of each shift ... Every patient not on one to one (1:1) precaution will be monitored at least every 15 minutes. Document via the Observe Smart tablet. During shift handoff the staff relinquishing observation round and the oncoming shift round together to ensure all patients are visualized, high risk precautions are in place and environment is checked. Off going staff discuss any issues experienced through the previous shift and the patient’s level of observation. Review of Patient #1’s medical record revealed an Initial Nursing Treatment Plan dated 07/13/2024 and updated 07/23/2024 for Sexual Aggression and Inappropriate Actions and Comments. Review of the Patient Observations Sheets revealed Q15 (every 15) minute monitoring but failed to reveal the risk flags were updated to reflect the current treatment plan. Review of Patient #3’s medical record revealed an Initial Nursing Treatment Plan 07/20/2024 and updated 07/23/2024 for Sexual Aggression and Inappropriate Actions and Comments. Review of the Patient Observations Sheets revealed Q15 minute monitoring but failed to reveal the risk flags were updated to reflect the current treatment plan. Review of Patient #5’s medical record revealed an Initial Nursing Treatment Plan 07/29/2024. The Patient Observations Sheets revealed Q15 minute monitoring but failed to reveal risk flags on the Patient Observation Sheets for 07/29/2024 thru 07/31/2024. Review of Patient #6’s medical record revealed an Initial Nursing Treatment Plan 07/29/2024 and updated 07/30/2024 for Sexual Aggression and Inappropriate Actions and Comments. Review of Patient Observations Sheets revealed Q15 minute monitoring but failed to reveal risk flags on the Patient Observation Sheets for 07/29/2024 thru 08/01/2024. In an interview following review of the medical records on 08/06/2024 at 2:00 p.m., S1QA Director confirmed the Risk Flags for the Patient Observation Sheets were not updated and/or incomplete for Patients #1, #3, #5, and #6.”

“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: 36293 Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized 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. This deficient practice is evidenced by the failure to update the care plans of 2 (Patient #4 and 6) of 6 (#1-6) patients reviewed for completed and updated care plans. Findings: Review of the hospital’s policy TX.018 titled, “Multi-Disciplinary Treatment Planning revealed in part: 3. Treatment Team - 1. The master treatment plan shall be reviewed and revised in the treatment team meeting at least every 7 days after it has been initiated for acute patients and more frequently if the patient exhibits significant change of behavior or requires special treatment procedures such as seclusion or restraint. Review of the Treatment Plans for patients Patients #4 and 6 failed to reveal the plans were updated following documented inappropriate sexual behavior. On 03/14/2024 at 2:00 p.m., S1CNO reviewed Patients #4 and 6’s treatment/care plan and acknowledged the treatment/care plans were not updated to include the inappropriate sexual behavior. S1CNO further stated the treatment/care plans should have been updated for the exhibited and documented inappropriate sexual behavior.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 36293 Based on record review and interview, the hospital failed to provide a written notice of grievance resolution to the patient representative for 1 of 2 patients (Patient #1) with a grievance in a total sample of 12 patients. Findings: Review of the hospital’s policy RI.012 titled, “Patient Grievance Procedures” revealed in part: II. Procedure - 7. The hospital will provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. 8. If a prompt resolution is not possible, a written response will be forwarded to the person filing the grievance within seven days of receipt stating the issue is being investigated. A second/final response will be sent when the investigation is completed within 30 days ... This notice will be sent after the investigation is completed. Review of Patient #1’s Interdisciplinary Note dated 02/05/2024 at 7:00 p.m. revealed in part: During discharge process, patient’s father expressed dissatisfaction with hospital and demanded to see reports of prior incidents that occurred with his child while a patient in this hospital. House supervisor aware of situation. Review of the Grievance Log for February 2024 listed Patient #1 as having two separate grievances dated 02/04/202 and 02/05/2024. Review of the grievance letter dated 02/07/2024 revealed it included both above allegations and stated “an investigation was completed” but failed to include the results of the investigation as detailed in the hospital’s policy. An interview 02/21/2024 at 3:00 p.m. with S3Director of Patient Advocacy revealed the written grievance response notice sent to the Patient #1’s father did not include the results of the investigation.”

“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: 17450 Based on record review, and interview, the hospital failed to ensure initial reports of allegations of patient abuse/neglect of care were reported to Louisiana Department of Health (LDH) within 24 hours of awareness of the allegation, as required by LDH-HSS, for 1 (Patient #6 ) of 8 patients reviewed for self-reports to LDH-HSS in a total patient sample of 12. Findings: Review of the policy/procedure titled, Patient Grievance Procedures, revealed in part that when a report of sexual or physical abuse or neglect is received, the Department of Health and Hospitals will be notified within 24 hours from the time the facility was notified of the complaint. Review of the LDH hospital/licensed provider Abuse/Neglect Initial Report form revealed in part that the self-report form was to be completed and submitted via email to HSS within 24 hours of awareness of an allegation of abuse/neglect. Review of the psychiatrist progress note dated 02/06/2024 at 9:38 a.m. revealed that Patient #6 stated she was having back pain and abdominal cramping due to being hit in the stomach last night by a peer. Review of the nurse practitioner progress note dated 02/06/2024 (no time) revealed Patient #6 was struck in the stomach last night. Further review of the note revealed the 16 year old patient was 18 weeks pregnant and was ordered to be sent to the hospital for an ultrasound. On 2/19/2024 at 10:00 a.m., interview with S1Director of QA confirmed that he was unaware of Patient #6 being hit in the stomach. S1Director of QA revealed that there was no evidence that an incident report was initiated or that the incident had been investigated. S1Director of QA further revealed that a Self Report should have been submitted to LDH within 24 hours of the incident, but it was not. On 02/19/2024 at 12:20 p.m., interview with S2CNO revealed that she was unaware that Patient #6 had been hit in her stomach. S2CNO confirmed the patient was currently pregnant.”

“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: 36293 Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized 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. This deficient practice is evidenced by the failure to update the care plans of 5 (Patient #2, 7, 9, 11, 12) of 12 (#1-12) patients reviewed for completed and updated care plans. Findings: Review of the hospital’s policy TX.018 titled, “Multi-Disciplinary Treatment Planning revealed in part: 3. Treatment Team - 1. The master treatment plan shall be reviewed and revised in the treatment team meeting at least every 7 days after it has been initiated for acute patients and more frequently if the patient exhibits significant change of behavior or requires special treatment procedures such as seclusion or restraint. Review of the Treatment Plans for patients Patients #2, 7, 9, 11 and 12 failed to reveal the plans were updated following documented physical altercations with peers and incident reports. On 02/20/2024 at 10:53 a.m., S1Director of QA reviewed Patient #7’s medical record and acknowledged the treatment/care plan was not updated to include assaultive/aggressive behaviors. On 02/21/2024 at 1:53 p.m., S2CNO reviewed Patients #2, #9, #11 and #12’s treatment/care plan and acknowledged the treatment/care plans were not updated to include assaultive/aggressive behaviors. S2CNO further stated the treatment/care plans should have been updated for the assaultive/aggressive behaviors.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) 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 improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 36293 Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice was evidenced by failing to ensure self-reporting of allegations of abuse were completed and submitted to Louisiana Department of Health following incident reports regarding peer to peer sexual abuse allegations for 4 of 8 incident reports reviewed (Patients #1, 2, 3, 4). Findings: Review of the Hospital’s Policy PE.032A titled, “Abuse and Neglect Assessment / Reporting” revealed in part: 1. It is the policy of this hospital to adhered to Louisiana Children’s Code article 609, which provides that a mandatory reporter who has cause to believed that a child’s physical or mental health or welfare is endangered as a result of abuse, sexual abuse or neglect, or that abuse or neglect contributed to the death of a child, must report immediately to the Department of Children and Family Services. Review of the Hospital’s Policy RI.018 titled, “ Alleged Patient Abuse, Neglect, Exploitation” revealed in part: To provide a Response and Notification Plan in the event of a sexual allegation and/or incident. Notify State Agencies as required by state statues. Review of the hospital’s documentation failed to reveal a self-report was filed with Louisiana Department of Health following alleged peer to peer sexual abuse for Patients #1, 2, 3 and 4. Interview 12/13/2023 at 2:00 p.m., S1Director of Risk Management reviewed his documents and confirmed a Self-Report to Louisiana Department of Health was not submitted for Patients 1, 2, 3, 4.”

“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: 36293 Based on record review, observations and interviews, the psychiatric hospital failed to ensure patients received care in a safe setting as evidenced by failing to secure areas of egress while escorting a patient between secure areas. Findings: Review of the hospital’s policy TX.003 titled, “Elopement Procedure” revealed in part: Policy - It is the policy of this hospital to prevent patient elopements whenever possible and to provide consistent methods of follow-up in the event that they do occur. Procedure - Patients most frequently at high risk for elopement are adolescents, chemical dependency patients and patients under involuntary admission status. 8. Patients are managed safely during transport (i.e., gym/mealtimes/outdoors, off-unit areas, therapy offices, off grounds appointments/ER visitation by: Staff position at front and rear of group during transport to keep the group together, not permitting patients to run ahead or lag behind. In the event of an elopement-7. The hospital Safety Officer will conduct an environmental assessment to evaluate any contributing environmental factors. Observation on 11/02/2023 at 9:13 a.m. revealed S3LPN and S4MHT escorting/transporting Patient 2 to the gym. The walkway gate was currently unlocked and open and the driveway gates leading to the street and parking lot were both open. S3LPN was holding Patient 2’s hand as they crossed the driveway toward the locked gym entrance. S4MHT accompanied S3LPN as they unlocked the chained padlock to the gate leading into the interior courtyard of the gym and escorted Patient 2 into the courtyard and locked the gate behind them. Interview on 11/02/2023 at 9:24 a.m., S3LPN acknowledged they were supposed to close and lock the driveway gates prior to exiting the walkway and escorting/transporting the patient to the gym. Interview on 11/02/2023 at 9:30 a.m., S4MHT acknowledged they were supposed to close and lock the driveway gates prior to exiting the walkway and escorting/transporting the patient to the gym.”