Longleaf Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting as evidenced by the failure to fully search a new patient for contraband and/or other items not allowed in the patient care area prior to entering the intake holding area. Findings: A review of hospital policy titled, “Searches,” policy number: SEM-007, last reviewed 01/2025, revealed in part: “POLICY: The hospital will conduct searches as necessary to assure a safe environment for patients and staff. All patients and patients’ belongings will be searched for dangerous articles and/or contraband upon admission. After admission all patients suspected of possessing drugs, sharp objects, matches/lighters, or other items potentially dangerous to themselves or others shall be searched. AUTHORIZATION: Search is a clinical intervention and should be implemented by the clinical staff. PROCEDURE: 1. Admission Personnel: Informs patients on admission regarding the purpose, nature, and extent of belongings searches, as well as what items are not permissible on the units.” A review of hospital policy titled, “Metal Detector Use,” policy number: SEM-017, last reviewed 01/2025, revealed in part: “PURPOSE: To ensure physical safety for staff and patients in all patients care areas. To establish procedures for use of handheld portable metal detectors. POLICY: In order to assure physical safety for staff and patients, persons here for assessment will be asked to leave purses in their cars or store in a locker in lobby. They are to empty pockets and are to be scanned with metal detector before the assessment is done. Patients entering the facility for partial hospitalization and intensive outpatient programming will be scanned prior to entering the patient care area. PROCEDURE: 2. Voluntary Patients: Admission Staff: Instructs patient to empty pockets of all objects; scans patient with scanner to detect the presence of potential hidden objects. If objects are detected on scan, requests the patient surrender them to staff member, additionally informs the nursing staff on positive metal detector scan. Nursing staff is notified of positive scan in order to be aware of potential for additional concealed items in patient belongings.” A review of hospital policy titled, “Contraband,” PolicyStat ID: 17970683, last approved and effective 05/2025, revealed in part: “POLICY Upon admission a thorough search will be made of the patient, purses, pockets, luggage, and belongings.” An observation of the intake area during a walk-through of the hospital on 05/26/2026 from 1:20 p.m. to 2:23 p.m. revealed Patient #R1 being escorted by S5BHA from the lobby to the intake area of the hospital. Patient #R1 was a voluntary admission and was being escorted with all his belongings. Patient #R1 voluntarily gave his belongings to S5BHA and emptied the contents of his clothing pockets. Afterwards, S5BHA instructed Patient #R1 to enter Room “a” which included Patient #R2 awaiting the admission intake process. During this previously mentioned procedure, S5BHA failed to scan Patient #R1 with the metal detection device for any potential metal objects being located or hidden within the patient’s clothing and/or attached to the patient’s body. This deficient practice had the potential to place all current and future patients within Room “a” in an unsafe environment as Patient #R1 could have smuggled metal items and/or other items that would be considered prohibited, into the patient care areas that could be used for self-injurious behaviors and/or for harm/injury to others. In an interview on 05/27/2026 and accompanied on this hospital walk-through, S2DON and S3QC confirmed the above-mentioned findings. In an interview on 05/27/2026 at 1:45 p.m., S6IRN (intake nurse) confirmed any new patient that enters Room “a” should be scanned for items contraindicated in the patient care area, which would include the scanning of the patient’s clothing/body with the metal detector.”

“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: 51596 Based on record review and interview, the facility failed to ensure patients were free from all forms of abuse or harassment. This deficient practice was evidenced by failure to report an incident of alleged abuse in accordance with applicable local, State, or Federal law for 1 (Patient #3) of 5 patients sampled for Patient Rights. Findings: Review of the hospital’s policy titled “Abuse and Neglect”, revised 03/2026, revealed, in part: “Policy: It is the policy of the Hospital that any staff who witness or suspect a patient has been abused either physically or verbally will report such abuse to the appropriate authority immediately. This includes patient-to-patient, staff-to-patient or suspicion that a patient may have been or is at risk for abuse, neglect and/or exploitation from caregivers, family or others outside of the hospital. This suspicion may be based upon verbal report, visual observation, physical evidence or upon behaviors which provides reasonable belief that a patient may have been or may become a victim. Procedure: 1. Staff who witness or suspect the patient has been abused either physically or verbally will report such abuse to the Administrator on Call, Quality/Risk immediately. This includes patient-to-patient or staff-to-patient abuse or neglect. 2. Notifications b. Adults ages 18 through 60, contact the LA Department of Health and Hospital Services.” Review of the hospital’s policy titled “Patient Rights”, revised 03/2026, revealed, in part: “Policy: The Hospital protects and promotes patient’s rights that are extended to all patients and promotes discrimination. Procedures: 1. The following rights shall be afforded to all patients and are not subject to modification: g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse.” Review of Patient #3’s medical record revealed an admission date of 04/08/2026 with diagnoses including Unspecified Psychoses and Adjustment Disorder. Review of Patient #3’s Psychiatric Progress Note, dated 04/16/2026 at 8:45 a.m. by S6APRN, revealed, in part: staff report patient was attacked by another patient this morning. Review of the hospital’s Self-Reports submitted to the appropriate State Health Agency dated 02/2026 to 04/23/2026 failed to reveal a report of Patient #3 having been attacked by another patient. Review of the hospital’s Incident Reports dated 02/2026 to 04/23/2026 failed to reveal an incident of Patient #3 being attacked by another patient. Interview with S3DOC on 04/28/2026 at 11:28 a.m. revealed on 04/16/2026 Patient #3 was sharing a room with Patient #R7. S3DOC denied knowledge of Patient #3 being attacked by Patient #R7. Review of Patient #R7’s Nursing Progress Note dated 04/16/2026 at 5:50 a.m. by S7RN revealed, in part: the patient had become physically aggressive, attacking the other patient in the room. Interview with S4DOR on 04/28/2026 at 11:59 a.m. revealed she was not aware Patient #R7 had attacked Patient #3 prior to being questioned by the surveyor. Interview with S3DOC on 04/28/2026 at 11:59 a.m. revealed she was not aware Patient #R7 had attacked Patient #3 prior to being questioned by the surveyor. S3DOC confirmed she should have been notified immediately when Patient #R7 attacked Patient #3, but was not. S3DOC confirmed nursing staff should have initiated a Self-Report immediately when Patient #R7 attacked Patient #3, but they did not.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44763 Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. This deficient practice was evidenced by: 1) failure to correctly identify and follow the grievance policy for 1 (#2) of 11 (#1-#11) patients reviewed for complaints/grievances (see findings Tag A-0118); 2) failure to document the reason the patient did not participate in the treatment plan for 1 (#4) of 11 (#1-#11) patient treatment plans reviewed (see findings Tag A-0130); 3) failure to remove patient identification labels after the patient was discharged (see findings Tag A-0143); 4) failure to provide a safe environment potentially leading to adolescent sexual abuse (see findings Tag A-0144); 5) failure to provide a safe and secure environment potentially allowing psychiatric patients accessibility to the swimming pool (see findings Tag A-0144); 6) failure of the hospital to have a process in place to ensure criminal background checks are being performed, and applicants are being screened for convictions that bar employment (see findings Tag A-0144); 7) failure to perform observations per hospital policy for 3 (#2, #3, #4) of 11 (#1-#11) patient records reviewed (see findings Tag A-0144); 8) failure to ensure physician orders were implemented for 1 (#3) of 11 (#1-#11) patient records reviewed (see findings Tag A-0144); 9) failure to ensure contraband items were not accessible to patients (see findings Tag A-0144); 10) failure to ensure allegations of potential abuse and/or neglect were reported to the LDH (Louisiana Department of Health) HSS (Health Standards Section) within 24 hours of the hospital becoming aware of the allegation for 2 (#5, #6) of 11 (#1-#11) patients reviewed (see findings Tag A-0145); 11) failure to maintain 1:1 observations per physician order for Patient #8 who was on self-harm precautions (see findings Tag A-0145); 12) failure to obtain a physician’s order for the use of seclusion for 1 (#1) of 3 (#1, #3, #4) patients reviewed for restraint or seclusion of a total sample of 11 (see findings Tag A-0168); and 13) failure to document a one hour face-to-face in 1 (#4) of 3 (#1, #3, #4) patients reviewed for restraint/seclusion initiation (see findings Tag A-0178). An Immediate Jeopardy situation was identified on 09/11/2025 at 3:15 PM and reported to S2DOC, S4DON, S5DCS, S3DRM and signed at 3:17 PM by S29CFO. The Immediate Jeopardy situation was a result of the hospital failing to provide a safe and secure environment potentially allowing psychiatric patients accessibility to the swimming pool. The Immediacy was lifted on 09/15/2025 at 11:03 AM when S1CEO, S3DRM, S4DON, and S2DOC were notified of the approval of the hospital’s written removal plan. The plan included the following: 1.) The hospital failed to provide care in a safe setting as evidence by failure of the hospital to provide a safe and secure environment for psychiatric patients. 2.) The hospital failed to provide a secure environment, potentially allowing psychiatric patients accessibility to the swimming pool. 3.) The hospital must take immediate action to prevent serious injury, serious harm, serious impairment, or death to provide a safe and secure environment for psychiatric patients. -Longleaf Behavioral employees and leadership are committed to the safety and well-being of all their patients. Individual patients who are on any precautions i.e., Elopement, Suicide are screened and monitored based off the level of their observation precautions. These levels range from Q [every] 5 minute observations, Q15 minute observations or the highest level One to One observations. -Immediate Actions: The facility notified a pool company upon receipt of the IJ. At 3:30 PM a staff member was assigned to the swimming pool area to ensure patient safety. [Stated Name] Pool Company began draining the swimming pool at 4:00 PM. The facility requested quotes and Saturday morning construction began to fill the pool with dirt. On Sunday 09/14/2025 the swimming pool has been permanently decommissioned and filled with dirt. This action has been taken to eliminate any potential safety hazards or related concerns. -Ongoing monitoring: Chief Executive Officer (CEO) and Director of Plant Operations (DPO) shall assign an individual to monitor exit doors on unit A and unit B leading to the pool area 24/7, until complete of the filling of the pool with dirt. On Sunday 09/14/2025 the swimming pool has been permanently decommissioned and filled with dirt. The Chief Nursing Officer (CNO) shall reeducate staff and obtain attestations on all observation precautions i.e., Suicide, Elopement by 09/16/2025. The Proactive Risk Assessment (PRA) shall be reviewed along with documentation. -Responsible parties: CEO, DPO, CNO, Director of Quality/Risk An Immediate Jeopardy situation was identified on 09/17/2025 at 5:00 PM and reported to S1CEO, S4DON, S3DRM, S2DOC, S5DCS, S29CFO, and others. The Immediate Jeopardy situation was a result of the hospital failing to provide a safe environment potentially leading to adolescent sexual abuse. The Immediacy was lifted on 09/18/2025 at 5:40 PM when S1CEO, S4DON, and S5DCS were notified of the approval of the hospital’s written removal plan. The plan included the following: The intention of this plan is to document immediate steps taken and ongoing actions to ensure that the facility remains in full compliance and address mitigation efforts related to findings which occurred on September 5, 2025, in response to the Immediate Jeopardy (IJ) submitted to Longleaf Behavioral on September 17, 2025. Longleaf Behavioral leadership team is dedicated to the safety and wellbeing of all their patients. The leadership team immediately met to review our internal processes and implemented the following actions: I.) The Sexually Acting Out (SAO) policy, Special Precautions policy, and Abuse and Neglect policy were reviewed for accuracy and compliance with applicable regulations and contained appropriate guidance and procedural expectations. II.) All patients assigned to a Sexually Acting Out (SAO) precaution have been assigned to a room closer to the nursing station. III.) 100% of all new admissions will be reviewed for the appropriateness of their precautions. IV.) All current patients’ precautions have been reviewed for appropriateness. V.) CEO provided a schedule to re-educate on Mission Zero and the Sexually Acting Out (SAO) policy and Abuse and Neglect Policy to all staff. VI.) CNO immediately initiated a plan to meet with all her team members to review the following initiatives: Completed on September 14, 2025. a.) Hallway monitoring plan b.) Hallway monitoring tips c.) Unit management d.) Observation Precaution Education e.) Admission and Check-in Group Boundary Reinforcement f.) Patient expectations / Unit Rules VII.) CNO/Designee on September 6, 2025, immediately started education to “all staff” regarding “not allowing patients to be within other patients rooms.” (see attachment) VIII.) CNO/Designee reviewed all observation levels and precautions ordered by the Providers per shift and compared them to the ObservSmart electronic monitoring platform. The results will be reported in the daily leadership huddle for oversight and tracking. This is to include individuals on 1:1’s, Q [every] 5 and Q15 minute observations. IX.) CNO re-educated all staff on the Observation Patient policy. Education covered round consistently with the observation levels and precautions ordered by the Provider for every patient. Completed on September 14, 2025. X.) CNO re-educated all staff on the Sexually Acting Out (SAO) policy and SAO playbook. Education shall cover rounding consistently with the observation levels and precautions ordered by the Provider for every patient. Completed on September 14, 2025. XI.) CEO designated a leader to call each unit twice a day to query about all incidents and confirm that proper actions have been taken which may include but not limited to increased observations and/or changes in precautions a.) This individual is responsible for confirming actions taken and providing guidance on correcting the deficiencies. All incident reports and results from the leadership rounds will be reviewed in our daily flash to identify any deficiencies in reporting or follow-up actions are needed. XII.) Nursing Supervisors increased physical rounds on all units to 4 times per unit per 24hr period to assess compliance with observation, rounding completion of incident reports and the completion of follow-up actions per policy. If any deficiencies are found, real-time coaching is to occur, and progressive disciplinary actions will be taken immediately when applicable.”

“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: 50453 Based on record reviews 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 and follow the grievance policy for 1 (#2) of 11 (#1-#11) patients reviewed for complaints/grievances. Findings: Review of hospital policy number RI-00-011, titled “Grievance, Patient,” date last revised: 04/2020, revealed in part: “POLICY: The hospital will provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to our patients. All patients and their families should have access to a clear process by which they may be heard if they believe their rights or other privileges have not been respected or responded to appropriately by facility or medical staff. All patient grievances will be investigated and the results of the investigation reported back to the complainant. DEFINITION: A patient grievance is a formal or informal written or verbal complaint that is made to the hospital/staff by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with CMS [Centers for Medicare and Medicaid Services] Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to the rights and limitations provided by 42 CRF [Code of Federal Regulation] 489. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirements. PROCEDURE: 1. Staff present who receive a grievance/concern from a patient/patient’s legal representative will take the following steps: Acknowledge receipt of the grievance/concern by documenting the time and date of the grievance on the Patient Grievance Process Tool form. Attempt to resolve the issue at the time of receipt. Document actions taken on the Patient Grievance Process Tool form. Forward Patient Grievance Process Tool form to the Patient Advocate. 2. The Patient Advocate/designee: Will record the concern/grievance on the designated tracking tool. Summarize the unresolved concern on the Grievance Process Tool. Immediately review and assess any reported abuse/neglect. 3. The Patient Advocate or CEO/designee [Chief Executive Officer] will review the grievance and complete the following: Assign follow-up to the appropriate Director/Manager. Establish a date by which time a response is expected. If grievances are not resolved with seven (7) days the patient will be notified the Patient Advocate is still processing the grievance and provided the expected date of resolution. 4. The Director/Manager to whom follow-up was assigned will: Investigate the grievance within two (2) days, including but not limited to: Patient interview; Witness interview; Staff interview; Chart review; Communication with other directors/managers. Record findings of the investigation on the Grievance Process Tool and return to the Patient Advocate. 5. The Patient Advocate will: Review results of the preliminary investigation. Determine action to be taken. Involve CEO and Directors/Managers as necessary to achieve resolution. Complete a written report on the Grievance Resolution Form. Report to the patient should contain the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance and date of completion. Give written report to patient for review, comments and signature. Mail a written report (by certified mail) if the complainant is not the patient or the patient has been discharged. Keep a copy of the report and document resolution on the Grievance Log.” Review of LDH [Louisiana Department of Health] 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.” Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 09/03/2025 with an admit diagnosis of Disruptive Mood Dysregulation Disorder, Schizophrenia, and Autism Spectrum Disorder. Review of Patient #2’s nurse’s note dated 09/06/2025 by S28RN revealed in part, “1650 [4:50 PM] Received (2) separate phone calls from Patient #2’s mother and sent the phone calls to House Supervisor’s office.” “1655 [4:55 PM] Patient #2’s mother called again.” “Demanding to speak to Patient #2.” “Family began to threaten nurse with ‘capital offense’, saying Patient #2 was ‘raped’ and ‘what are ya’ll going to do about it!’ Informed family that an investigation was being conducted and that Patient #2 was interviewed by Administration earlier today.” “Writer then transferred the call to the House Supervisor.” “1812 [6:12 PM] Order received from S12PNP to send Patient #2 to the hospital, as he is saying he was allegedly raped.” “1845 [6:45 PM] EMS [Emergency Medical Services] left with Patient #2, en route [Stated name] with [Stated name] MHT [Mental Health Technician] with Patient #2.” Further review of Patient #2’s medical record revealed that Patient #2 did not return to the hospital after being sent to the ER [Emergency Room]. Review of the Grievances for August 2025 and September 2025 failed to reveal a grievance for Patient #2. In an interview on 09/18/2025 at 5:54 PM, S14PA confirmed the grievance process should have been implemented for Patient #2.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure the patient/patient representative’s right to participate in the development and implementation of his or her plan of care. This deficient practice is evidenced by failing to document the reason the patient did not participate in the treatment plan for 1 (#4) of 11 (#1-#11) patient treatment plans reviewed. Findings: Review of Patient #4’s medical record revealed Patient #4 was admitted on 06/27/2025 with an admit diagnosis of Major Depressive Disorder, Unspecified Mood Disorder, and Disruptive Mood Dysregulation Disorder. A review of Patient #4’s medical record revealed the document Multidisciplinary Master Treatment Plan, with a date of 06/28/2025. The document failed to reveal a signature of the patient or patient legal representative. Further review failed to reveal a reason or an indication that Patient #4 or his legal representative was unwilling or unable to participate. In an interview on 09/16/2025 at 3:10 PM, S8LPN confirmed the above mentioned findings.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 50453 Based on observation and interview, the hospital failed to ensure patients had a right to personal privacy. This deficient practice is evidenced by failing to remove patient identification labels after the patient was discharged. Findings: Observations during a tour on 09/18/2025 from 9:36 AM-10:32 AM of the adolescent girls unit revealed the following: Room ‘r’: revealed a patient identification label taped to the wall who was discharged. The label contained the patient’s name, date of birth, admission date, and medical record number. Room ‘f’: revealed belongings in a brown paper bag belonging to a patient who was discharged with a patient identification label on the paper bag. The label contained the patient’s name, date of birth, admission date, and medical record number. In an interview on 09/18/2025 during the tour, S4DON confirmed the above mentioned findings. S4DON confirmed that both patient identification labels found belonged to patients who had been discharged.”

“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: 44763 50453 Based on observations, record reviews, and interviews, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by: 1) failure to provide a safe environment potentially leading to adolescent sexual abuse; 2) failure to provide a safe and secure environment potentially allowing psychiatric patients accessibility to the swimming pool; 3) failure of the hospital to have a process in place to ensure criminal background checks are being performed, and applicants are being screened for convictions that bar employment; 4) failure to perform observations according to hospital policy for 3 (#2, #3, #4) of 11 (#1-#11) patient records reviewed; 5) failure to ensure physician orders were implemented for 1 (#3) of 11 (#1-#11) patient records reviewed; and 6) failure to ensure contraband items were not accessible to patients. Findings: 1) Failure to provide a safe environment potentially leading to adolescent sexual abuse. Patient #6 Review of Patient #6’s medical record revealed an admission date of 06/20/2025. Review of the Clinical Services’ note dated 08/12/2025 at 1:43 PM by S37SW revealed in part, “Pt [patient] reports that another peer wanted him to do ‘sexual acts’ with him last night. Pt reports that he reported this to nursing. Social worker reported report to risk, supervisor, and manager.” Review of the nurse’s note dated 08/14/2025 at 11:07 AM by S3DRM revealed in part, “Spoke with Patient #6 on 08/13/2025 at approximately 10:00 AM concerning the allegations of a peer wanting him to do ‘sexual acts’ with him, at this time Patient #6 stated ‘it did not happen.’ Patient #6 denies inappropriate behaviors with peers. Patient #6 stated several times during our conversation ‘I want to go to another unit, I don’t like any of these kids’. Encouraged Patient #6 to attend group and to interact with his peers.” In an interview on 09/17/2025 at 8:20 AM S3DRM stated Patient #6 reported the above stated allegation to S37SW who in turn reported the allegation to her. S3DRM confirmed she interviewed Patient #6. S3DRM stated Patient #6 denied the allegation when she spoke to him. S3DRM confirmed she documented in Patient #6’s medical record the day after she interviewed Patient #6. S3DRM stated Patient #6 wanted to go to another unit to play video games or watch tv. S3DRM stated Patient #6 thought he could go to another unit and do whatever he wanted. When asked if the hospital did anything other than interviewing Patient #6, S3DRM confirmed nothing else was done because the allegation was verbal. S3DRM stated Patient #6 denied it. S3DRM stated Patient #6 did not report to her who the peer was. S3DRM then stated she thought it was Patient #4. S3DRM then stated Patient #6 told S37SW that the peer was Patient #4. Patient #4 Incident #1 Review of Patient #4’s medical record revealed an admission date of 06/27/2025. Review of Patient #4’s nurse’s note dated 08/22/2025 at 4:22 PM by S28RN revealed in part, “1545 [3:45 PM] Patient #4 is being placed in SAO [Sexually Acting Out] precautions for asking a peer to join his club ‘swinging & stuff’ (2 days ago per MHT) [Mental Health Technician].” In an interview on 09/16/2025 at 10:37 AM, S4DON confirmed that when Patient #4 was put on SAO precautions, he was moved to furthest room from the nurse station with 2 other patients. Patient #1 Review of Patient #1’s medical record revealed an admission date of 07/16/2025. Review of the nurse’s note dated 09/05/2025 at 7:50 PM by S18RN revealed in part, “1950 [7:50 PM] Patient #1 approached nurse’s station, stood in front of panel. Patient #1 asked what would happen if I swallowed a screw. This RN, asked Patient #1 if he swallowed screw. Patient #1 stated, yes, very anxious pacing. I instructed Patient #1 to sit down. I needed to obtain vitals signs. I also instructed Patient #1 not to eat or drink anything, and instructed staff he was NPO [nothing by mouth].” Further review of the note revealed, “2235 [10:35 PM] [stated name] RN from [stated hospital], stated ‘Patient #1 he was sexually assaulted by 4 people. [Stated name] said they would PEC [physician’s emergency certificate] patient for safety. Patient #1 stated, if he came back to [stated hospital]. He would kill himself.” “0433 [4:33 AM] [stated name] called this RN, reported KUB [kidney, ureter, bladder imaging test] negative, no screw seen.” Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 09/03/2025. Review of Patient #2’s Physician orders revealed in part the following: 09/06/2025 at 10:50 AM- Observation 1:1 due to allegations of being sexually inappropriate with a peer. Review of Patient #2’s nurse’s note dated 09/06/2025 by S28RN revealed in part, “0800 [8:00 AM] Instructed per House Supervisor to separate Patient #2 and (3) other patients from the rest of the population. Patient #2 and the (3) other patients were taken to the small day room, with their own MHT.” “0900 [9:00 AM] order received from S12PNP for Patient #2 to be a no roommate.” Further review of the note revealed, “1045 [10:45 AM] order received from S12PNP to place Patient #2 on 1:1 observation. This was done with S10MHT in place as his 1:1 MHT.” Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 08/22/2025. Review of Patient #3’s Physician orders revealed in part the following: 09/07/2025 at 9:00 AM- Observation Q5 minutes due to allegations of sexually acting out inappropriately with a peer. Review of Patient #3’s nurse’s note dated 09/06/2025 at 3:15 PM by S28RN revealed in part, “0800 [8:00 AM] Instructed per House Supervisor to separate Patient #3 and (3) other patients from the rest of the population. Patient #3 and the (3) other patients were taken to the small day room, with their own MHT.” Further review of the note revealed, “0900 [9:00 AM] order received from S12PNP for Patient #3 to be a ‘no roommate’.” Patient #4 Incident #2 Review of Patient #4’s nurse’s note dated 09/06/2025 at 3:22 PM by S28RN revealed in part, “0800 [8:00 AM] Instructed per House Supervisor to separate Patient #4 and (3) other patients from the rest of the population. Patient #4 and the (3) other patients were taken to the small day room, with their own MHT.” “0900 [9:00 AM] order received from S12PNP for Patient #4 to be a ‘no roommate’. Further review of the note revealed, “1045 [10:45 AM] order received from S12PNP to place Patient #4 on 1:1 observation. This was done with S9MHT in place as his 1:1 MHT.” In an interview on 09/10/2025 at 11:00 AM S3DRM stated on 09/05/2025 at 7:50 PM Patient #1 reported he swallowed a screw to the RN. S3DRM stated the RN contacted the MD [medical doctor] and said send Patient #1 to ED [emergency department]. S3DRM stated once Patient #1 arrived to the ED, he reported to the ED staff that swallowing a screw was a lie and reported he was sexually assaulted. S3DRM stated ED staff notified the hospital either the house supervisor or the charge nurse on duty of the allegation Patient #1 reported to the ED staff. S3DRM stated at that point they did not know who was involved. S3DRM stated about 10:45 PM ED staff notified the hospital of the alleged sexual assault. S3DRM stated around 3:00 AM - 5:00 AM on 09/06/2025 the ED called and said Patient #1 was not coming back to the hospital. S3DRM stated all the boys that were mentioned to be involved in the sexual assault reported by Patient #1 were put in the small dayroom together with staff members as they woke up on the morning of 09/06/2025. S3DRM stated they were separated from the other patients. S3DRM stated S9MHT and S10MHT were in the small dayroom with the patients before the patients were put on 1:1 observations. While reviewing her investigation findings of the sexual assault with the surveyors, S3DRM stated Patient #2 stated he was asked to go to Room ‘n’ by Patient #4 and he went. S3DRM stated Patient #2 stated himself, Patient #4, Patient #3, and Patient #1 were in the room. S3DRM stated Patient #5 may have also asked Patient #2 to go to the room as well. S3DRM stated Patient #5 was in the room and at some point left the room. S3DRM stated Patient #2 stated that Patient #4 did Patient #1 and it was easy. She stated Patient #2 stated he tried to do Patient #1 but his was too big. S3DRM stated Patient #2 stated Patient #4 did him and his was too little and didn’t hurt but made his butt itch. S3DRM stated no one reported Patient #5 being involved at that time. S3DRM stated the boys were willing participants in the sexual acts performed with each other. S3DRM stated more interviews were conducted with the patients involved. S3DRM stated Patient #4 admitted that he had sex with one of the kids. S3DRM stated she did not remember which one. S3DRM stated Patient #5 reported he and Patient #4 kissed and had sex. S3DRM stated Patient #3 denied involvement, then reported he and Patient #2 kissed. In an interview on 09/17/2025 at 3:29 PM, S3DRM confirmed the hospital had not implemented any new corrective actions to prevent future occurrences. She confirmed the corrective actions the hospital did implement were all actions that had been in place prior to the sexual allegation on 09/05/2025. S3DRM confirmed the hospital re-enforced education to staff. Review of the Bed Assignment Sheet dated 09/17/2025 Unit A (adolescent girls unit) revealed patients on SAO (sexually acting out) precautions were assignment to rooms ‘e’, ‘c’, ‘d’, ‘r’, ‘f’, ‘a’, and ‘b’. Observation on 09/17/2025 at 11:35 AM - 12:08 PM accompanied by S3DRM of the adolescent girls unit revealed patients on SAO precautions were assigned to rooms ‘e’, ‘c’, ‘d’, ‘r’, ‘f’, ‘a’, and ‘b’. Further observation revealed these rooms were located furthest from the nurse’s station. Observation on 09/18/2025 at 5:00 PM - 5:08 PM accompanied by S4DON of the adolescent girls unit revealed patients on SAO precautions were assigned to rooms ‘b’, ‘a’, ‘f’, and ‘s’. In an interview during the observation on 09/18/2025, S4DON confirmed patients on SAO precautions were now assigned to rooms closer to the nurse’s station. 2) Failure to provide a safe and secure environment potentially allowing psychiatric patients accessibility to the swimming pool. Tour of the outdoor patient area of the adolescent female unit (Unit A) was performed on 09/11/2025 at 11:42 AM - 11:52 AM accompanied by S4DON. Observation revealed a fence that could potentially be used to gain access to the swimming pool. This fence was black with tiny holes in the fencing with 3 rows of wire at the top. Further observation of the fence revealed the fence had brackets at each corner and could potentially be used to climb the fence. This fence was the only barrier between the swimming pool and the outdoor patient area of the adolescent female unit. Observation of the swimming pool revealed dark green/brown colored water with tan/brown colored debris, preventing the ability to visualize past the second step of the pool to the bottom surface. Tour of the outdoor patient area of one adult unit (Unit B) was performed on 09/11/2025 at 1:08 PM accompanied by S4DON. Observation revealed a fence that could potentially be used to gain access to the swimming pool. This fence was chain-linked with red, plastic slates through the chain-links with 3 rows of wire at the top. Further observation of the fence revealed areas where the red, plastic slates were missing, therefore potentially enabling the fence to be climbed. This fence was the only barrier between the swimming pool and the outdoor patient area of one adult unit. Review of current patients on Unit A and Unit B on 09/11/2025 revealed a total of 20 patients on elopement precautions. Review of current patients on Unit A and Unit B on 09/11/2025 revealed a total of 26 patients on suicide precautions. Review of the hospital’s policy titled “Elopement Precautions and Response”, revised 04/2020, failed to identify how staff would search the swimming pool in the event of an elopement. In an interview on 09/11/2025 at 1:16 PM S4DON confirmed the pool is dark and murky and the bottom of the pool could not be visualized in its current condition. S4DON stated staff are quick to respond to elopements. S4DON stated if someone would jump into the pool, staff could hear the splash. 3) Failure of the hospital to have a process in place to ensure criminal background checks are being performed, and applicants are being screened for convictions that bar employment. Review of the memo HHS 24-S-12 released 12/18/2023 regarding Criminal Convictions that Bar Employment of Unlicensed Persons or Ambulance Personnel revealed in part: “It is the responsibility of all employers that employ non-licensed persons or ambulance personnel to know which convictions bar employment. Louisiana Revised Statute 40:1203.3 covers criminal convictions that bar an employer from hiring a non-licensed person or ambulance personnel.” Review of personnel files was performed on 09/18/2025. The review revealed 1 unlicensed staff member with a disqualifying criminal record. S15MHT was hired on 02/17/2025. Criminal background check was completed on 02/11/2025. Review of the personnel file for S15MHT revealed a criminal background check revealing the following arrest for S15MHT: Aggravated Battery with a dangerous weapon (R.S. [Revised Statute] 14:34) Aggravated Assault (R.S. 14:37) Theft Charge (R.S. 14:67) In an interview on 09/18/2025 at 5:30 PM, S4DON stated she was unaware of S15MHT’s criminal background check with convictions that bar employment. S4DON confirmed that S15MHT is employed on the adolescent unit. In an interview on 09/18/2025 at 5:47 PM, S7MHTS confirmed that S15MHT worked the night of 09/17/2025 and stayed over the morning of 09/18/2025 to help with staffing. 4) Failure to perform observations according to hospital policy for 3 (#2, #3, #4) of 11 (#1-#11) patient records reviewed. Review of hospital policy number AS-00-016, titled “Observations, Patient,” last revised 11/2024, revealed in part: “POLICY: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. PROCEDURE: 6. Documentation of Observations: a. Proximity-Based Electronic Technology: i. Staff documents all levels of observation on each patient’s profile on the facility issued device using proximity-based electronic technology. The observation report is then printed and becomes a part of the patient record at discharge. Each entry is to include the following: Location, Behavior/Activity, Time is recorded electronically when the entry is made, Signatures are completed electronically by the assigned staff using their unique login to the system. ii. Ordered precautions should be entered into the patient profile and are visible to the staff rounding on the patient. iii. Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and or to back fill time frames that were not completed in a timely manner. iv. Documentation of 1:1 observation occurs every 15 minutes even though the patient is being observed continuously. 7. Q [Every] 15 Minute Observations: iv. Patient is monitored at minimum once in every 15-minute block of time. vi. During the observations staff are to: i. Make direct visual contact; look for signs of danger or distress, even if the patient is in the bathroom. ii. Observe sleeping patients close enough to confirm they are not in distress. iii. Remain vigilant for specific risks for patients on Special Precautions. iv. Allow reasonable privacy for dressing and bathing - visualize through a slightly open bathroom door. vi. Observe the patient’s environment for potential hazards that can be corrected. 8. Q5 Minute Observations: a. Patient is placed on Q5 minutes if their behavior is unpredictable and there is potential risk for harm to self and others yet behavior is not at the point requiring constant 1:1 observation. b. Patient is monitored at a minimum once in every 5-minute block of time. c. RN [Registered Nurse] will assess patient a minimum of two times per day and document patient condition in the progress note. During the observations staff are to: vii. Make direct visual contact; look for signs of danger or distress, even if the patient is in the bathroom. viii. Observe sleeping patients close enough to confirm they are not in distress. ix. Remain vigilant for specific risks for patients on Special Precautions such as missing linen, patient lingering near exits, boundary violations and report to RN immediately. x. Allow reasonable privacy for dressing and bathing - visualize through a slightly open bathroom door. xii. Observe the patient’s environment for potential hazards that can be corrected. 9. 1:1 Observation: a. 1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others. b. Requires a precaution level. d. Staff will document rounds a minimum of every 15 minutes while continuously monitoring the patient 1:1. e. Staff who are assigned to monitor the patient on 1:1 observation will have no other assignments. G. Staff are to remain within visual range and close proximity (easy reach) of patient at all times. There should be nothing between the patient and assigned staff. h. Staff are to remain in the room with the patient during dressing, bathing and/or toileting. Charge RN/RN Designee: a. Assignment for Observations will be done by the Charge RN/RN Designee. The assignment sheet will reflect the time period and team members assigned to that time period. Any changes made during the shift should be indicated on the assignment sheet accordingly. c. The Charge RN/RN Designee should observation [SIC] at least once per 8-hour shift (twice per 12-hour shift) to assess the general safety of the unit/milieu and to check in with the team member assigned to observations to provide an additional opportunity for the assigned team member to report on safety concerns. d. Each RN is responsible for general oversight of the safety observations his/her assigned patients and for increasing the level of observation, such as to Q5 or 1:1 in the event that it is deemed that the patient’s level of risk has increased. BHA [Behavioral Health Associate] Conducting Observations: a. Staff completing observations will not be responsible for other duties but may assist with patient needs as long as it doesn’t delay observations. Documentation: 1. Documentation of Observations will be completed in real time (as observations are being conducted) and by the person conducting the observations. Note: there may be times in which actual entries are delayed due to an emergency. Documentation should be made as a late entry as soon as possible with a note indicating the reason for the delay if appropriate.” Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 09/03/2025 with an admit diagnosis of Disruptive Mood Dysregulation Disorder, Schizophrenia, and Autism Spectrum Disorder. Review of Patient #2’s Physician orders dated 09/03/2025 revealed in part the following observation orders: 09/03/2025 at 8:48 AM- Observation Q15 minutes. 09/06/2025 at 10:50 AM- Observation 1:1 due to allegations of being sexually inappropriate with a peer. Review of Patient #2’s Patient observation sheet for 09/04/2025 revealed in part the following: 3:38 AM - 3:55 AM (17 minutes between observations); observer S19MHT 4:17 AM- 4:41 AM (24 minutes between observations); observer S19MHT 9:04 AM - 9:21 AM (17 minutes between observations); observer S20MHT 11:29 AM - 11:47 AM (18 minutes between observations); observer S20MHT In an interview on 09/09/2025 at 4:20 PM, S6NE confirmed the above mentioned findings. S6NE confirmed that Patient #2 was not monitored every Q15 minutes per hospital policy. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 08/22/2025 with an admit diagnosis of Schizoaffective Disorder/Bipolar Type, Conduct Disorder, Disruptive Mood Dysregulation Disorder, and Major Depressive Disorder. Review of Patient #3’s Physician orders dated 08/22/2025-09/15/2025 revealed in part the following observation orders: 08/22/2025 at 10:09 PM- Observation Q15 minutes. 08/25/2025 at 9:00 AM- Observation Q5 minutes, indication aggression 08/26/2025 at 9:00 PM- Observation 1:1 at bedtime due to increased aggression toward roommate until a room is open to make patient a no roommate. 09/03/2025 at 2:49 PM- Observation Q5 minutes during the day and Observation 1:1 at bedtime due to Homicidal Ideations. Stop date: 10/02/2025. 09/04/2025 at 2:00 PM- Observation Q5 minutes; discontinued 09/07/2025 at 2:58 AM. 09/07/2025 at 9:00 AM- Observation Q5 minutes due to allegations of sexually acting out inappropriately with a peer. Review of Patient #3’s Patient observation sheets revealed in part the following: 09/04/2025: 7:39 AM-7:45 AM (6 minutes between observations); observer S21MHT 7:59 AM-8:08 AM (9 minutes between observations); observer S21MHT 9:18 AM-9:29 AM (11 minutes between observations); observer S15MHT 1:00 PM-1:07 PM (7 minutes between observations); observer S21MHT 1:14 PM- 1:21 PM (7 minutes between observations); observer S21MHT 2:57 PM-3:04 PM (7 minutes between observations); observer S20MHT 4:18 PM-4:24 PM (6 minutes between observations); observer S21MHT 8:48 PM-8:56 PM (8 minutes between observations); observer S19MHT 09/05/2025: 8:48 AM-8:55 AM (7 minutes between observations); observer S22MHT 9:41 AM-9:52 AM (9 minutes between observations); observer S22MHT 10:13 AM-10:21 AM (8 minutes between observations); observer S23MHT 10:50 AM-11:03 AM (13 minutes between observations); observer S23MHT 2:40 PM-2:48 PM (8 minutes between observations); observer S23MHT 2:52 PM-2:59 PM (7 minutes between observations); observer S22MHT 7:17 PM-7:23 PM (6 minutes between observations); observer S11MHT 09/06/2025: 10:58 AM-11:08 AM (10 minutes between observations); observer S24RN 11:10 AM-11:17 AM (7 minutes between observations); observer S22MHT 2:18 PM-2:27 PM (9 minutes between observations); observer S24RN 2:48 PM-2:57 PM (9 minutes between observations); observer S25MHT 6:36 PM-6:49 PM (13 minutes between observations); observer S28RN 09/07/2025: 8:05 AM-8:13 AM (8 minutes between observations); observer S23MHT 9:43 AM-9:50 AM (7 minutes between observations); observer S23MHT 3:33 PM-3:44 PM (11 minutes between observations); observer S26MHT 4:14 PM-4:22 PM (8 minutes between observations); observer S23MHT 4:47 PM-4:57 PM (10 minutes between observations); observer S23MHT 6:14 PM-6:34 PM (20 minutes between observations); observer S23MHT 7:29 PM-7:38 PM (9 minutes between observations); observer S16MHT 7:38 PM-7:51 PM (13 minutes between observations); observer S27MHT In an interview on 09/15/2025 at 4:20 PM, S8LPN confirmed the above mentioned findings. S8LPN further confirmed that Patient #3 was not monitored every 5 minutes per hospital policy. Patient #4 Review of Patient #4’s medical record revealed Patient #4 was admitted on 06/27/2025 with an admit diagnosis of Major Depressive Disorder, Unspecified Mood Disorder, and Disruptive Mood Dysregulation Disorder. Review of Patient #4’s Physician orders dated 06/27/2025-09/10/2025 revealed in part the following observation orders: 07/22/2025 at 5:00 PM- Observations Q15 minutes; discontinued 08/04/2025 at 6:03 PM. 08/04/2025 at 7:00 PM- Observations Q5 minutes; discontinued 08/15/2025 at 7:12 PM. 08/16/2025 at 9:00 AM- Observations Q5 minutes; discontinued 08/20/2025 at 4:09 PM. 08/20/2025 at 5:00 PM- Observations Q15 minutes; discontinued 08/21/2025 at 6:12 AM. 08/21/2025 at 6:12 AM- Observation Q5 minutes; discontinued 08/23/2025 at 9:34 AM. 08/23/2025 at 9:32 AM- Observation 1:1; discontinued 08/26/2025 at 8:41 PM. 08/26/2025 at 9:00 PM- Observation Q5 minutes; discontinued 09/06/2025 at 10:49 AM. 09/06/2025 at 10:47 AM- Observation 1:1; discontinued 09/10/2025 at 6:01 PM. Review of Patient #4’s Patient observation sheets revealed in part the following: 08/02/2025: 4:28 PM-4:54 PM (26 minutes between observations); observer S21MHT 08/04/2025: 9:52 PM-10:04 PM (12 minutes between observations); observer S11MHT 08/05/2025: 3:44 PM-3:52 PM (8 minutes between observations); observer S31MHT 3:57 PM-4:06 PM (9 minutes between observations); observer S31MHT 7:49 PM-7:57 PM (8 minutes between observations); observer S32MHT 9:12 PM-9:20 PM (8 minutes between observations); observer S11MHT 08/15/2025: 12:54 AM-1:10 AM (16 minutes between observations); observer S33MHT 2:38 PM-2:45 PM (13 minutes between observations); observer S21MHT 3:15 PM-3:39 PM (24 minutes between observations); observer 21MHT 4:24 PM-5:20 PM (56 minutes between observations); observer S7MHTS 08/16/2025: 3:19 AM-3:29 AM (10 minutes between observations); observer S19MHT 3:29 AM-3:42 AM (13 minutes between observations); observer S19MHT 3:42 AM-3:50 AM (8 minutes between observations); observer S19MHT 3:54 AM-4:04 AM (10 minutes between observations); observer S19MHT 4:05 AM-4:15 AM (10 minutes between observations); observer S19MHT 7:13 PM-8:02 PM (59 minutes between observations); observer S36MHT 08/17/2025: 5:09 PM-5:22 PM (13 minutes between observations); observer S34MHT 08/20/2025: 7:24 PM-8:01 PM (36 minutes between observations); observer S19MHT 08/21/2025: 3:18 AM-3:37 AM (19 minutes between observations); observer S19MHT 4:03 AM-4:21 AM (18 minutes between observations); observer S19MHT 08/22/2025: 9:15 PM-9:24 PM (9 minutes between observations); observer S11MHT 10:47 PM-10:55 PM (8 minutes between observations); observer S11MHT 08/23/2025: 2:31 AM-2:44 AM (13 minutes between observations); observer S11MHT 08/25/2025: 3:36 AM-3:56 AM (10 minutes between observations); observer S27MHT 4:37 AM-4:59 AM (22 minutes between observations); observer S27MHT 2:47 PM-3:05 PM (18 minutes between observations); observer S20MHT 09/02/2025: 12:22 AM-1:20 AM (58 minutes between observations); observer S35MHT 09/04/2025: 1:11 AM-1:19 AM (8 minutes between observations); observer S19MHT 2:08 AM-2:18 AM (10 minutes between observations); observer S19MHT 3:45 AM-3:55 AM (10 minutes between observations); observer S19MHT 3:55 AM-4:04 AM (9 minutes between observations); observer S19MHT 4:17 AM-4:27 AM (10 minutes between observations); observer S19MHT 4:27 AM-4:41 AM (14 minutes between observations); observer S19MHT 09/05/2025: 9:39 AM-9:52 AM (13 minutes between observations); observer S22MHT In an interview on 09/16/2025 at 4:13 PM, S8LPN confirmed the above mentioned findings. 5) Failure to ensure physician orders were implemented for 1 (#3) of 11 (#1-#11) patient records reviewed. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 08/22/2025 with an admit diagnosis of Schizoaffective Disorder/Bipolar Type, Conduct Disorder, Disruptive Mood Dysregulation Disorder, and Major Depressive Disorder. Review of Patient #3’s Physician orders dated 08/22/2025-09/15/2025 revealed in part the following orders: 08/26/2025- Order: Observation 1:1 at bedtime. Per order Patient will be 1:1 at bedtime due to increased aggression toward roommate until a room is open to make patient a NO roommate. (start at 9:00 PM) 08/27/2025- Q5 observation, Increased aggression toward roommate, until a room is open to make patient a NO roommate. (start at 10:00 AM, discontinued 09/03/2025 at 2:50 PM) 09/03/2025 - Observation Q5 minutes during the day and Observation 1:1 at bedtime due to Homicidal Ideations. (start at 2:49 PM, Stop date: 10/02/2025) 09/08/2025 - No Roommate; indication Sexual Acting Out that puts others at risk. (start date 09/09/2025 at 9:00 AM, end date 09/11/2025 at 9:00 AM) 09/08/2025 - Blocked Room; Comments: continue no roommate orders that was implemented 09/06/2025 (start date 09/08/2025 at 9:00 PM) Review of Patient #3’s nurse’s note dated 09/03/2025 at 12:06 PM by S42RN revealed in part, “8/27/25 at 1505 [3:05 PM] Patient #3 is upset b/c [because] he and his roommate were separated (different rooms) due to not respecting each other’s personal space.” “Patient #3 further explained that he wants to kill himself by ‘snapping my neck with my own hands’. Notified S12PNP.” Review of Patient #3’s nurse’s note dated 09/06/2025 at 3:15 PM by S28RN revealed in part, “9/5/25 at 1450 [2:50 PM] Patient #3 told S30RN that he wanted to hurt himself or someone else. Patient #3 stated that he wanted to ‘get out of here’ and that his plan was to take the metal pieces off the ceiling tiles. S12PNP was notified of this by S30RN.” Further review of the note for 09/06/2025 revealed, “0800 [8:00 AM] Instructed per House Supervisor to separate Patient #3 and (3) other patients from the rest of the population. Patient #3 and the (3) other patients were taken to the small day room, with their own MHT [Mental Health Technician].” Further review of the note revealed, “0900 [9:00 AM] order received from S12PNP for Patient #3 to be a ‘no roommate’.” Review of Patient #3’s social worker note dated 09/03/2025 at 4:00 PM by S37SW revealed in part, “Patient #3 reports that he is going to ‘kill him tonight.’ Patient #3 reports that he is going to kill peer on the unit and then kill himself.” Review of the Bed list for the adolescent boys unit from 08/24/2025-09/07/2025 revealed in part the following: 08/24/2025-08/29/2025: Patient #3 sharing a room with Patient #6. 08/30/2025-09/02/2025: Patient #3 sharing a room with Patient #7. 09/03/2025-09/05/2025: Patient #3 moved to share a room with Patient #1 and Patient #4. 09/06/2025: Patient #3 moved into a room without a roommate. Further review failed to reveal that the physician orders entered on 08/26/2025 to make Patient #3 a no roommate were implemented until after Patient #3 was involved in an alleged sexual allegation on the night of 09/05/2025. In an interview on 09/15/2025 at 4:30 PM, S8LPN confirmed that Patient #3 was not made a no roommate until 09/06/2025, the morning after the alleged sexual allegation. Review of Patient #3’s Physician orders dated 08/22/2025-09/15/2025 revealed in part the following orders: 08/27/2025 - Paper scrubs. (start at 10:00 AM, discontinued 09/03/2025 at 2:50 PM) 09/05/2025 - Paper scrubs. (start at 3:27 PM, discontinued 09/15/2025 at 11:29 AM) Review of Patient #3’s nurse’s note dated 09/03/2025 at 12:06 PM by S42RN revealed in part, “8/27/25 at 1550 [3:50 PM] order obtained from S12PNP to put Patient #3 in paper scrubs and seated near the nurses station.” Review of the unit bed assignment sheet for 09/10/2025-09/11/2025 revealed that Patient #3 was listed as being in paper scrubs. Observations during a tour on 09/10/2025 from 3:18 PM - 4:01 PM failed to reveal Patient #3 dressed in paper scrubs. Observations during a tour on 09/11/2025 from 9:08 AM - 9:27 AM failed to reveal Patient #3 dressed in paper scrubs. In an interview on 09/11/2025 at 9:31 AM, S4DON confirmed that Patient #3 was not wearing paper scrubs. S4DON confirmed that the unit bed assignment sheet has Patient #3 listed as being in paper scrubs. S4DON stated that if a patient has an order for paper scrubs the patient should be in paper scrubs. 6) Failure to ensure contraband items were not accessible to patients. Review of hospital policy number RI-00-015, titled “Contraband,” last revised 05/2020, revealed in part: “PROCEDURE: 2. Staff will consider the following to be contraband: a. General: i. Any item deemed unsafe by any staff member. ii. Any item with strings. iii. Any item with sharp edges.” Observations during a tour on 09/09/2025 from 9:58 AM-11:24 AM revealed the following: Room’n’: -One pair of tennis shoes with 4 elastic strings tied to the shoes -One tube of toothpaste In an interview on 09/09/2025 at 11:19 AM, S4DON and S7MHTS confirmed the above mentioned findings were contraband. Observations during a tour on 09/10/2025 revealed the following: Room ‘o’: -One pair of tennis shoes with 4 elastic strings tied to the shoes -Toothbrush next to sink. In an interview on 09/10/2025 at 3:48 PM, S4DON confirmed the above mentioned findings were contraband.”

“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: 44763 48537 50453 Based on record reviews and interviews, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficient practice is evidence by: 1) failure to ensure allegations of potential abuse and/or neglect were reported to the LDH (Louisiana Department of Health) HSS (Health Standards Section) within 24 hours of the hospital becoming aware of the allegation for 2 (#5, #6) of 11 (#1-#11) patients reviewed; and 2) failure to maintain 1:1 observations per physician order for Patient #8 who was on self-harm precautions. Findings: Review of hospital policy number RI-7, titled “Abuse and Neglect,” date last revised 04/2020, revealed in part: “POLICY: It is the policy of the Hospital that any staff who witness or suspect a patient has been abused either physically or verbally will report such abuse to the appropriate authority IMMEDIATELY. This includes patient-to-patient, staff-to-patient or suspicion that a patient may have been or is at risk for abuse, neglect and/or exploitation from caregivers, family or others outside of the hospital. This suspicion may be based upon verbal report, visual observation, physical evidence or upon behaviors which provides reasonable belief that a patient may have been or may become a victim. PROCEDURE: 1. Staff who witness or suspect the patient has been abused either physically or verbally will report such abuse to the Administrator on Call (AOC) IMMEDIATELY after notifying the appropriate authorities. This includes patient-to-patient or staff-to-patient abuse or neglect. 3. Patient-to-Patient Abuse: a. The registered nurse will place the patient committing the offense on every (Q) 5 minute observations or 1:1 observation and notify the attending/covering physician. b. The registered nurse will complete a nursing assessment of the patient who was abused to evaluate the patient’s physical and mental condition. c. The registered nurse will notify the designated family contact and/or legal representative of the patient who was abused. 4. Staff-to-Patient Abuse or Neglect: a. The staff member shall be notified of the allegation and suspended from duty, pending results of the investigation. 7. Documentation: a. The Medical Record shall include documentation of examinations, treatment given, any referrals made to other care providers and to community agencies. 8. Investigation: a. Reports of Abuse or Neglect which occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff assigned by the CEO (Chief Executive Officer.) b. Interviews related to the investigation will be completed by the Risk Manager, Human Resources Director or the Patient Advocate, as assigned by the Chief Executive Officer. 9. Follow-Up: a. The CEO/designee shall notify the agency or contracted service provider the results of the investigation as related to the agency or contract staff. b. If the allegation of abuse against staff is substantiated through a thorough and complete investigation, the staff member shall be terminated and reported to the appropriate licensing board, and regulatory agencies as applicable. c. If the allegation against a staff member is not substantiated they will be returned to duty and will be paid for the time off.” Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: “4. Self-Reporting: In the interest of providing information that will indicate the facility’s compliance with CMS Regulation 482.13(c) (3) regarding abuse, neglect, and harassment, as well as La R.S. 40:2009.20, the following processes have been developed. It should be noted that a facility’s decision to self-report does not eliminate the possibility of an onsite investigation being conducted in response to allegations and/or relevant information received. Although LA R.S. 40:2009.20 requires a facility to report knowledge of incidents of abuse, within twenty-four hours, to either the local law enforcement agency or LDH (or the Medicaid Fraud Unit as applicable), many facilities find it beneficial to self-report to LDH, even if they have notified law enforcement. It is important to note that contacting law enforcement on behalf or at the request of the patient/complainant (e.g. to press charges, etc.) does not satisfy the statute’s intent regarding facility notification. 8: Initial Report (within 24 hours of knowledge): NOTE: 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). The requirement (per statute) is that potential abuse or neglect be reported within 24 hours of knowledge (awareness) of the allegation, suspicion, or occurrence. 12. Special Settings and Considerations: This document describes the type of information needed by the HSS to conduct a thorough review of a hospital’s actions in relation to an allegation that abuse and/or neglect has occurred within the facility. In certain settings, including, but not limited to behavioral health facilities, pediatric units, and geriatric units, incidents involving physical or emotional abuse or sexual acting out between patients may be reportable, as the facility has specific responsibilities relative to providing adequate supervision to prevent these occurrences. Minors below the age of consent, psychiatric patients of any age, and cognitively impaired individuals (such as those with dementia or mental retardation) are not considered capable of consenting to sexual activity in a facility. As a result, sexual acts involving patients that fit these categories cannot be categorized as “consensual” even if both parties engage in the act voluntarily, and are reportable, as are occurrences indicating that the facility may have failed to adequately provide safety for the type of patient being treated.” 1) Failure to ensure allegations of potential abuse and/or neglect were reported to the LDH (Louisiana Department of Health) HSS (Health Standards Section) within 24 hours of the hospital becoming aware of the allegation for 2 (#5, #6) of 11 (#1-#11) patients reviewed. Patient #5 Review of Patient #5’s medical record revealed an admission date of 05/12/2025 for diagnoses which included Disruptive Mood Dysregulation Disorder and Other Conduct Disorders. Review of the psychiatric progress notes for Patient #5 revealed the following in part: On 06/03/2025 at 6:20 PM by S38PNP - “Patient [#5] was involved in a physical altercation with another peer last night, reportedly reacting impulsivity by swinging at the other boy during a heightened emotional exchange. Required staff intervention to deescalate but was able to calm without PRN (as needed) medication.” On 07/11/2025 at 6:43 PM by S38PNP - “Patient [#5] involved in altercations with another boy on unit where he punched the other person first.” On 08/09/2025 at 12:17 PM by S12PNP - “Patient [#5] seen for f/u. Staff reports that pt (patient) was in a physical altercation this morning with a peer.” Review of the physician’s orders for Patient #5 revealed the following in part: On 06/02/2025 - Q5Minute observations for getting into physical altercation with peer; Restrict to unit due to him and another patient got into physical altercation; and Right hand 2 view x-ray for pain to right hand. On 06/12/2025 - Q5Minute observation; Restrict to unit - got into altercation with peer, broke them up then patient ran past MHT (Mental Health Technician) and starting hitting peer again. On 06/14/2025 - Medical practitioner consult for c/o (complaints of) pain to right index finger. On 06/15/2025 - Right hand, 3+ views x-ray of R (right) hand due to R index finger pain-Acute pain due to trauma. On 07/11/2025 - Q5Minute observations-participant in a physical altercation; Restrict to unit due to aggressive behavior; and Olanzapine 10mg (milligrams) PO (by mouth) one time only for aggressive behavior. On 08/05/2025 - Restrict to unit due to an altercation last night, told the aggressors what room the victim was in per night RN’s (Registered Nurse) report On 08/09/2025 - Medical practitioner consult for c/o pain to L (left) hand, s/p (status post) altercation with peer; Q5Minute observations for aggressor in an altercation; and Restrict to unit. Review of the hospital’s incident report log revealed the following incidents for Patient #5 Incident Date/Time: 06/02/2025 at 7:50 PM Code Description: Patient attacked other patient Incident Date/Time: 07/11/2025 at 7:50 AM Code Description: Patient attacked other patient Incident Date/Time: 08/09/2025 at 9:30 AM Code Description: Patient attacked other patient Injury Type: Other Review of the Hospital’s self-reports submitted to HSS revealed none of the aforementioned physical altercation incidents involving Patient #5. In an interview conducted on 09/16/2025 at 4:45 PM with S2DOC (Director of Compliance), she stated the aforementioned physical altercation incidents involving Patient #5 were not self-reported to HSS. Patient #6 Review of Patient #6’s medical record revealed an admission date of 06/20/2025. Review of the Clinical Services’ note dated 08/12/2025 at 1:43 PM by S37SW revealed in part, “Pt [patient] reports that another peer wanted him to do ‘sexual acts’ with him last night. Pt reports that he reported this to nursing. Social worker reported report to risk, supervisor, and manager.” Review of the nurse’s note dated 08/14/2025 at 11:07 AM by S3DRM revealed in part, “Spoke with Patient #6 on 08/13/2025 at approximately 10:00 AM concerning the allegations of a peer wanting him to do ‘sexual acts’ with him, at this time Patient #6 stated ‘it did not happen.’ Patient #6 denies inappropriate behaviors with peers. Patient #6 stated several times during our conversation ‘I want to go to another unit, I don’t like any of these kids’. Encouraged Patient #6 to attend group and to interact with his peers.” In an interview on 09/17/2025 at 8:20 AM S3DRM confirmed the hospital did not report the above stated sexual allegation reported by Patient #6 to LDH/HSS because the allegation was verbal. S3DRM stated Patient #6 denied the allegation. S3DRM then clarified Patient #6 denied sexual acts when she spoke with Patient #6. 2) Failure to maintain 1:1 observations per physician order for Patient #8 who was on self-harm precautions. Review of hospital policy number AS-00-016, titled “Observations, Patient,” last revised 11/2024, revealed in part: “POLICY: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. iv. Documentation of 1:1 observation occurs every 15 minutes even though the patient is being observed continuously. 7. Q [Every] 15 Minute Observations: iv. Patient is monitored at minimum once in every 15-minute block of time. 8. Q5 Minute Observations: a. Patient is placed on Q5 minutes if their behavior is unpredictable and there is potential risk for harm to self and others yet behavior is not at the point requiring constant 1:1 observation. b. Patient is monitored at a minimum once in every 5-minute block of time. c. RN [Registered Nurse] will assess patient a minimum of two times per day and document patient condition in the progress note. During the observations staff are to: vii. Make direct visual contact; look for signs of danger or distress, even if the patient is in the bathroom. viii. Observe sleeping patients close enough to confirm they are not in distress. ix. Remain vigilant for specific risks for patients on Special Precautions such as missing linen, patient lingering near exits, boundary violations and report to RN immediately. x. Allow reasonable privacy for dressing and bathing - visualize through a slightly open bathroom door. xii. Observe the patient’s environment for potential hazards that can be corrected. 9. 1:1 Observation: a. 1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others. b. Requires a precaution level. d. Staff will document rounds a minimum of every 15 minutes while continuously monitoring the patient 1:1. e. Staff who are assigned to monitor the patient on 1:1 observation will have no other assignments. G. Staff are to remain within visual range and close proximity (easy reach) of patient at all times. There should be nothing between the patient and assigned staff. h. Staff are to remain in the room with the patient during dressing, bathing and/or toileting.” Patient #8 Review of Patient #8’s medical record revealed Patient #8 was admitted on 08/19/2025 with an admit diagnosis of Conduct Disorder, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Reactive Attachment Disorder, Anxiety Disorder, and Expressive Language Disorder. Review of Patient #8’s Psychiatric Evaluation on 08/20/2025 revealed in part the following: Patient #8 currently in the custody of Indiana DCFS, readmitted to subacute program following significant regression in behaviors after discharge to a group home. Patient #8 has a complex psychiatric history, with longstanding pattern of dangerous self-harm behaviors. He has engaged in the ingestion of foreign objects such as screws and a battery, which have required multiple endoscopies and surgical interventions. Patient #8’s history further includes sexually inappropriate behaviors with peers. Suicide precautions will remain in place, and interventions will be implemented to reduce the risk of elopement and ingestion of foreign bodies. Review of Patient #8’s Psychiatry Progress Notes revealed in part the following: On 08/26/2025 at 1:07 PM by S12PNP - “The Patient [#8] reports that on Sunday he swallowed an object due to feeling anxious and unable to communicate with staff because ‘they were busy’.” On 09/02/2025 at 9:32 AM by S12PNP - “The Patient [#8] disclosed that he swallowed a small toothpaste tube over a week ago but reported that it has since passed without complication.” On 09/09/2025 at 9:51 AM by S12PNP - “9/8- The patient’s [#8] progress was reviewed with treatment team today.” “Staff report that the Patient [#8] engaged in self-harming behavior yesterday, requiring evaluation in the emergency department; the patient reports no pain today. Staff also note that the patient [#8] has made allegations of sexually inappropriate behaviors and has documented his statement, which will be forwarded to risk management for review.” On 09/15/2025 at 10:03 AM by S12PNP - “Staff report Patient #8 ingested a piece of plastic yesterday; the patient states this occurred while in the shower.” On 09/16/2025 at 12:08 PM by S12PNP - “Staff reports that pt [Patient #8] put a paper medicine cup in his penis last night. He was sent to ED [emergency department].” “Pt reports that he urinated the paper out last night. Patient reports he does not have any pain. Patient reports that the first time he inserted a screw it did hurt but states ‘it doesn’t hurt anyone’ [SIC]. Pt is on 1:1 observation and will remain on 1:1 observation. Order will be placed to have pts [patients] bathroom/shower door removed and he will need to be monitored when using the bathroom and shower.” Review of Patient #8’s nurse progress note on 09/15/2025 at 7:45 PM by S18RN revealed in part, “1945 [7:45 PM] Patient #8 ambulated to nurses station with 1:1 MHT [Mental Health Technician] (S34MHT). Patient #8 verbalized to this RN, ‘I put 2 paper medications cups in my penis.’ Patient #8, S34MHT and myself [S18RN] walked him to [stated room], assessed, unable to feel or see paper cups.” Review of Patient #8’s provider orders revealed in part the following: 08/19/2025- Observation Q15 minutes; discontinued 08/24/2025 at 1:19 PM. 08/24/2025 at 2:00 PM- Observation Q5 minutes due to self-harm; discontinued 09/02/2025 at 9:57 AM. 08/27/2025 at 3:50 PM- Restrict to Unit Continuous due to stating threats of self-harm; discontinued 08/28/2025 at 5:30 PM. 08/27/2025 at 6:07 PM- Patient #8 not to be alone in his room, paper scrubs; discontinued 08/28/2025 at 11:48 AM. 09/02/2025 at 10:00 AM- Observation Q15 minutes; discontinued 09/03/2025 at 6:42 AM. 09/02/2025 at 6:09 PM- Transfer Patient #8 to hospital, comments: shoved a screw in his urethra. 09/03/2025 at 10:00 AM- Observation 1:1; discontinued 09/04/2025 at 8:34 AM. 09/04/2025 at 2:00 PM- Observation Q5 minutes; discontinued 09/08/2025 at 12:53 PM. 09/08/2025 at 8:13 AM- Transfer Patient #8 to hospital, comments: shoved a screw in his urethra. 09/08/2025 at 12:52 PM- Observation 1:1 due to self-harm. 09/15/2025 at 7:56 PM- Transfer Patient #8 to hospital. 09/15/2025 at 11:17 PM- Observation 1:1, comments: puts foreign objects in open body orifices requiring close observation. 09/16/2025 at 12:13 PM- Remove bathroom/shower door. Patient must be monitored when using the bathroom and shower. In an interview on 09/18/2025 at 2:20 PM, S3DRM stated that the incident on 09/15/2025 involving Patient #8 occurred while Patient #8 was in the shower prior to shift change. S3DRM confirmed Patient #8 had orders for 1:1 observation at the time of incident. S3DRM stated that while Patient #8 was showering, a code was called on the unit and Patient #8’s 1:1 MHT broke policy and broke visual contact with Patient #8 to assist with the code. S3DRM stated that S23MHT was put on administrative leave following the incident. Review of Patient #8’s observation sheet for 09/15/2025 revealed in part: S9MHT was assigned to Patient #8 as the 1:1 MHT. S9MHT documented Patient #8 was in bedroom at 7:11 PM, and in Bathroom/Shower at 7:15 PM, 7:19 PM, and 7:24 PM. S23MHT documented Patient #8 was in the dayroom at 7:13 PM. S34MHT took over as Patient #8’s 1:1 MHT at 7:27 PM while Patient #8 was in the Bathroom/Shower. S34MHT documented Patient #8 was in dayroom at 7:29 PM. In an interview on 09/18/2025 at 3:10 PM, S3DRM confirmed that Patient #8’s observation sheet for 09/15/2025 revealed S9MHT was the assigned 1:1 MHT for Patient #8. S3DRM unable to answer why S23MHT was put on administrative leave when S9MHT was documenting 1:1 observations on Patient #8 at the time of incident.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure the use of seclusion was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice was evidenced by failing to obtain a physician’s order for the use of seclusion for 1 (#1) of 3 (#1, #3, #4) patients reviewed for restraint or seclusion of a total sample of 11. Findings: Review of the hospital’s policy titled “Seclusion and Restraint”, revised 04/2020, revealed in part, “Seclusion: Policy: 3.) Seclusion may only be ordered by a psychiatrist and only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled-out.” Further review of the policy revealed in part, “Procedure: 3.) A psychiatric practitioner may order seclusion for a period of time not to exceed: a.) Four hours for patients age 18 and older b.) Two hours for patients 13-17.” Review of Patient #1’s medical record revealed an admission date of 07/16/2025. Review of the Seclusion/Restraint Flowsheet dated 08/15/2025 at 6:33 PM by S13RN revealed in part, seclusion was initiated at 3:45 PM and ended at 4:00 PM. Review of the Seclusion/Restraint Progress Note dated 08/15/2025 at 6:41 PM by S13RN revealed in part, “Patient was fighting staff due to not wanting to be compliant in putting paper scrubs on. Patient was fighting multiple staff members and stripped off all of his clothes. Patient was not able to be de escalated and was put into seclusion at 1545 [3:45 PM]. Once patient was in seclusion he was then calm and sitting at 1550 [3:50 PM], patient was not visibly showing signs of aggression. Patient was released at 1600 [4:00 PM] and came out of seclusion quietly and calmly. Patient was only in seclusion for 15 minutes.” Review of the physician’s orders failed to reveal an order for seclusion. In an interview on 09/15/2025 at 11:43 AM S6NE confirmed there was no documentation of a physician’s order for seclusion included in Patient #1’s medical record.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50453 Based on record review and interview, the psychiatric hospital failed to ensure a one-hour face-to-face assessment was performed with the initiation of restraint/seclusion. The deficient practice is evidenced by failure to document a one hour face-to-face in 1 (#4) of 3 (#1, #3, #4) patients reviewed for restraint/seclusion initiation. Findings: Review of hospital policy number TX-16, titled “Seclusion and Restraint,” last revised 04/2020, revealed in part: “SECLUSION: POLICY: 2. Hospital leadership strives to eliminate the use of seclusion through staff training, thorough assessment, effective treatment planning, management of the environment, and ongoing performance improvement efforts. PROCEDURE: 7. A practitioner or registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status. The in-person evaluation includes the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention.” Review of Patient #4’s medical record revealed an admission date of 06/27/2025 with an admit diagnosis of Major Depressive Disorder, Unspecified Mood Disorder, and Disruptive Mood Dysregulation Disorder. Review of Patient #4’s Seclusion/Restraint One Hour Face to Face Assessment revealed in part the following: Initiation of Intervention Date/Time: 09/09/2025 at 3:45 PM Face to Face Assessment Date/Time: 09/09/2025; no time documented Type of Intervention: Seclusion In an interview on 09/16/2025 at 2:58 PM, S8LPN confirmed the one hour face-to-face time of evaluation was not documented on 09/09/2025 for Patient #4.”

“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: 44763 Based on record reviews and interviews, the hospital failed to recognize factors related to patient safety and quality of improvement. This deficient practice was evidenced by failure of the hospital to investigate the possibility of adolescent patient-to-patient sexual contact and provide a space free from sexual harassment after the patient requested to be moved to another unit for 1 (#6) of 11 (#1-#11) patient records reviewed. Findings: Review of the hospital’s policy titled “Abuse and Neglect”, revised 04/2020, revealed in part, “Investigation: a.) Reports of Abuse or Neglect which occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff as assigned by the Chief Executive Officer.” Review of Patient #6’s medical record revealed an admission date of 06/20/2025. Review of the Clinical Services’ note dated 08/12/2025 at 1:43 PM by S37SW revealed in part, “Pt [patient] reports that another peer wanted him to do ‘sexual acts’ with him last night. Pt reports that he reported this to nursing. Social worker reported report to risk, supervisor, and manager.” Review of the nurse’s note dated 08/14/2025 at 11:07 AM by S3DRM revealed in part, “Spoke with Patient #6 on 08/13/2025 at approximately 10:00 AM concerning the allegations of a peer wanting him to do ‘sexual acts’ with him, at this time Patient #6 stated ‘it did not happen.’ Patient #6 denies inappropriate behaviors with peers. Patient #6 stated several times during our conversation ‘I want to go to another unit, I don’t like any of these kids’. Encouraged Patient #6 to attend group and to interact with his peers.” In an interview on 09/17/2025 at 8:20 AM S3DRM stated Patient #6 reported the above stated allegation to S37SW who in turn reported the allegation to her. S3DRM confirmed she interviewed Patient #6. S3DRM stated Patient #6 denied the allegation when she spoke to him. S3DRM confirmed she documented in Patient #6’s medical record the day after she interviewed Patient #6. S3DRM stated Patient #6 wanted to go to another unit to play video games or watch tv. S3DRM stated Patient #6 thought he could go to another unit and do whatever he wanted. When asked if the hospital did anything other than interviewing Patient #6, S3DRM confirmed nothing else was done because the allegation was verbal. S3DRM stated Patient #6 denied it. S3DRM stated Patient #6 did not report to her who the peer was. S3DRM then stated she thought it was Patient #4. S3DRM then stated Patient #6 told S37SW that the peer was Patient #4.”

“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: 50453 Based on record review and interview, the hospital failed to ensure a registered nurse (RN) supervised the care for each patient. This deficient practice is evidenced by: 1) failure to perform a clinical assessment per hospital policy on 1 (#2) of 11 (#1-#11) patients following a change in condition; and 2) failure to administer medications per physician order and hospital policy. Findings: 1) Failure to perform a clinical assessment per hospital policy on 1 (#2) of 11 (#1-#11) patients following a change in condition. Review of hospital policy number AS-00-017, titled “Assessment/Reassessment,” last revised 03/2024, revealed in part: “9. Reassessments: a. Reassessments are conducted by all disciplines as indicated, with documentation provided through a variety of formats, including but not limited to progress notes, nursing notes, medical staff dictation. b. A focused review of the patient’s response to treatment is completed on day and evening shifts and documented on the Nursing Note (minimum of 2 times per calendar day). In addition, each patient is reassessed as necessary based on the patient’s plan for care or change in their condition, including change in the patient’s level of pain, fall risk, suicide risk, etc.” Review of hospital policy number NO: RI-7, titled “Abuse and Neglect,” last revised 04/2020, revealed in part: “PROCEDURE: 7. Documentation: a. The Medical Record shall include documentation of examinations, treatment given, any referrals made to other care providers and to community agencies.” Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 09/03/2025 with an admit diagnosis of Disruptive Mood Dysregulation Disorder, Schizophrenia, and Autism Spectrum Disorder. Review of Patient #2’s nurse’s note dated 09/06/2025 by S28RN revealed in part, “0800 [8:00 AM] Instructed per House Supervisor to separate Patient #2 and (3) other patients from the rest of the population. Patient #2 and the (3) other patients were taken to the small day room, with their own MHT.” “0900 [9:00 AM] order received from S12PNP for Patient #2 to be a no roommate.” “1045 [10:45 AM] order received from S12PNP to place Patient #2 on 1:1 observation. This was done with S10MHT in place as his 1:1 MHT.” “1650 [4:50 PM] Received (2) separate phone calls from Patient #2’s mother and sent the phone calls to House Supervisor’s office.” “1655 [4:55 PM] Patient #2’s mother called again.” “Demanding to speak to Patient #2.” “Family began to threaten nurse with ‘capital offense’, saying Patient #2 was ‘raped’ and ‘what are ya’ll going to do about it!’ Informed family that an investigation was being conducted and that Patient #2 was interviewed by Administration earlier today.” “Writer then transferred the call to the House Supervisor.” “1812 [6:12 PM] Order received from S12PNP to send Patient #2 to the hospital, as he is saying he was allegedly raped.” “1845 [6:45 PM] EMS [Emergency Medical Services] left with Patient #2, en route [Stated name] with [Stated name] MHT [Mental Health Technician] with Patient #2.” Further review of Patient #2’s medical record failed to reveal documented evidence that an assessment or reassessment was performed by a nurse or provider on Patient #2 following the alleged sexual assault prior to being transferred to the ER for an evaluation. In an interview on 09/09/2025 at 3:44 PM, S6NE confirmed that an assessment/reassessment was not documented by a nurse or the provider following the alleged sexual assault of Patient #2. In an interview on 09/10/2025 at 12:29 PM, S3DRM stated during her 2nd interview with Patient #2 on 09/06/2025, Patient #2 disclosed the rape allegations. S3DRM confirmed at this time Patient #2 stated it didn’t hurt, but it made his butt itch. S3DRM stated that she performed a head to toe assessment on Patient #2, but did not document the assessment. S3DRM further confirmed that Patient #2 did not remove any clothing during her assessment. S3DRM also stated that the only thing she remembers about Patient #2’s assessment is he had a cough. 2) Failure to administer medications per physician order and hospital policy. Review of hospital policy number TX-26, titled “Medication Administration and Documentation,” last revised 08/2020, revealed in part: “POLICY: No medication will be administered which does not conform to the guidelines outlined in the following policy. 3. Administration: x. Observe the patient taking the medication. If the medication is taken orally, stay with the patient until he/she has swallowed the drug.” Review of Patient #10’s medical record revealed Patient #10 was admitted on 07/16/2025 with a diagnosis of Intermittent Explosive Disorder. Review of Patient #10’s nursing progress note dated 09/01/2025 at 10:25 PM by S43RN revealed in part, “Patient #10 snorted a crushed Tylenol that she received from a peer. Only symptoms were nausea/vomiting. NP [Nurse Practitioner] was notified.” Review of Patient #11’s medical record revealed Patient #11 was admitted on 07/07/2025 with a diagnosis of Disruptive Mood Dysregulation, Major Depressive Disorder, and Opioid Abuse. Review of Patient #11’s nursing shift note dated 09/01/2025 by S43RN revealed in part, “gave another peer a Tylenol that was supposed to be for her.” Review of Patient #11’s medical record revealed the following medication order: Acetaminophen (Tylenol) 500mg by mouth, every 6 hours as needed for pain. In an interview on 09/18/2025 at 5:05 PM, S3DRM confirmed the above mentioned findings. S3DRM confirmed that when a nurse administers a medication, they are supposed to do a mouth check to ensure the patient swallowed the medication.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 44763 50453 Based on record review and interviews the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient’s needs. This deficiency is evidenced by: 1) failure to ensure MHT’s assigned to a 1:1 patient have no other assignments per hospital policy; and 2) failure of the Registered Nurse to assign nursing personnel to each patient. Findings: Review of hospital policy number AS-00-016, titled “Observations, Patient,” last revised 11/2024, revealed in part: “POLICY: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. PROCEDURE: 6. Documentation of Observations: a. Proximity-Based Electronic Technology: i. Staff documents all levels of observation on each patient’s profile on the facility issued device using proximity-based electronic technology. The observation report is then printed and becomes a part of the patient record at discharge. Each entry is to include the following: Location, Behavior/Activity, Time is recorded electronically when the entry is made, Signatures are completed electronically by the assigned staff using their unique login to the system. ii. Ordered precautions should be entered into the patient profile and are visible to the staff rounding on the patient. iii. Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and or to back fill time frames that were not completed in a timely manner. iv. Documentation of 1:1 observation occurs every 15 minutes even though the patient is being observed continuously. 7. Q15 Minute Observations: iv. Patient is monitored at minimum once in every 15-minute block of time. vi. During the observations staff are to: i. Make direct visual contact; look for signs of danger or distress, even if the patient is in the bathroom. ii. Observe sleeping patients close enough to confirm they are not in distress. iii. Remain vigilant for specific risks for patients on Special Precautions. iv. Allow reasonable privacy for dressing and bathing - visualize through a slightly open bathroom door. vi. Observe the patient’s environment for potential hazards that can be corrected. 8. Q5 Minute Observations: a. Patient is placed on Q5 minutes if their behavior is unpredictable and there is potential risk for harm to self and others yet behavior is not at the point requiring constant 1:1 observation. b. Patient is monitored at a minimum once in every 5-minute block of time. c. RN will assess patient a minimum of two times per day and document patient condition in the progress note. During the observations staff are to: vii. Make direct visual contact; look for signs of danger or distress, even if the patient is in the bathroom. viii. Observe sleeping patients close enough to confirm they are not in distress. ix. Remain vigilant for specific risks for patients on Special Precautions such as missing linen, patient lingering near exits, boundary violations and report to RN immediately. x. Allow reasonable privacy for dressing and bathing - visualize through a slightly open bathroom door. xii. Observe the patient’s environment for potential hazards that can be corrected. 9. 1:1 Observation: a. 1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others. b. Requires a precaution level. d. Staff will document rounds a minimum of every 15 minutes while continuously monitoring the patient 1:1. e. Staff who are assigned to monitor the patient on 1:1 observation will have no other assignments. G. Staff are to remain within visual range and close proximity (easy reach) of patient at all times. There should be nothing between the patient and assigned staff. h. Staff are to remain in the room with the patient during dressing, bathing and/or toileting. Charge RN/RN Designee: a. Assignment for Observations will be done by the Charge RN/RN Designee. The assignment sheet will reflect the time period and team members assigned to that time period. Any changes made during the shift should be indicated on the assignment sheet accordingly. c. The Charge RN/RN Designee should observation at least once per 8-hour shift (twice per 12-hour shift) to assess the general safety of the unit/milieu and to check in with the team member assigned to observations to provide an additional opportunity for the assigned team member to report on safety concerns. d. Each RN is responsible for general oversight of the safety observations his/her assigned patients and for increasing the level of observation, such as to Q5 or 1:1 in the event that it is deemed that the patient’s level of risk has increased. BHA Conducting Observations: a. Staff completing observations will not be responsible for other duties but may assist with patient needs as long as it doesn’t delay observations. Documentation: 1. Documentation of Observations will be completed in real time (as observations are being conducted) and by the person conducting the observations. Note: there may be times in which actual entries are delayed due to an emergency. Documentation should be made as a late entry as soon as possible with a note indicating the reason for the delay if appropriate.” 1) Failure to ensure MHT’s assigned to a 1:1 patient have no other assignments per hospital policy. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 09/03/2025 with an admit diagnosis of Disruptive Mood Dysregulation Disorder, Schizophrenia, and Autism Spectrum Disorder. Review of Patient #2’s Physician orders revealed in part the following observation orders: 09/06/2025 at 10:50 AM- Observation 1:1 due to allegations of being sexually inappropriate with a peer. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 08/22/2025 with an admit diagnosis of Schizoaffective Disorder/Bipolar Type, Conduct Disorder, Disruptive Mood Dysregulation Disorder, and Major Depressive Disorder. Review of Patient #3’s Physician orders revealed in part the following observation orders: 09/04/2025 at 2:00 PM- Observation Q5 minutes; discontinued 09/07/2025 at 2:58 AM. 09/07/2025 at 9:00 AM- Observation Q5 minutes due to allegations of sexually acting out inappropriately with a peer. Patient #4 Review of Patient #4’s medical record revealed Patient #4 was admitted on 06/27/2025 with an admit diagnosis of Major Depressive Disorder, Unspecified Mood Disorder, and Disruptive Mood Dysregulation Disorder. Review of Patient #4’s Physician orders revealed in part the following observation orders: 09/06/2025 at 10:47 AM- Observation 1:1; discontinued 09/10/2025 at 6:01 PM. Review of Unit Assignment Sheet for adolescent boys on 09/06/2025, updated at 10:45 AM, revealed in part: Patient #2: 1:1 observation, assigned to S10MHT. Patient #3: Q5 minute observations. Patient #4: 1:1 observation, assigned to S9MHT. Review of unit bed list for adolescent boys on 09/06/2025 revealed in part: Patient #2: moved to Room ‘m,’ no roommate. Patient #3: moved to Room ‘p,’ no roommate. Patient #4: moved to Room ‘o,’ no roommate. Review of patient observation sheets for 09/06/2025 revealed in part the following: Patient #2: 5:06 PM: location- dayroom; observer S9MHT. 5:14 PM: location- dayroom; observer S9MHT. Patient #3: 4:01 PM-4:29 PM: location- bedroom; observer S9MHT. 4:52 PM-5:05 PM: location- bedroom; observer S9MHT. 5:08 PM-6:11 PM: location- dayroom; observer S9MHT. Patient #4: 11:06 AM-6:11 PM: S9MHT only documented observer. 4:01 PM-5:05 PM: location- bedroom; observer S9MHT. 5:08 PM-6:11 PM: location- dayroom; observer S9MHT. During a tour on 09/10/2025 from 3:18 PM-4:01 PM, observations of Hallway C revealed Room ‘o’ and Room ‘p’ were located next to each other. Further observations revealed the inability to visualize each room simultaneously. In an interview during the tour, S4DON confirmed that if staff were assigned 1:1 on a patient assigned to Room ‘o’ and Room ‘p’, they would have to break visual contact with their assigned patient in order to visualize inside the other room. In an interview on 09/16/2025 at 4:06 PM, S8LPN confirmed that an MHT who is assigned 1:1, should only be documenting on their assigned patient. S8LPN confirmed that S9MHT documented on multiple patients while assigned 1:1 to Patient #4. 2) Failure of the Registered Nurse to assign nursing personnel to each patient. Observations during multiple tours of the electronic monitoring system used by the MHT’s revealed that the MHT’s were able to view all patients assigned to each unit. Further review of the electronic monitoring system failed to reveal each patient was assigned to an MHT. In an interview on 09/09/2025 at 10:32 AM, S20MHT stated he documents on all the unit patients. S20MHT stated his compliance was currently at 74%, because he has been checking the unit and doing other things which is why his compliance rate is low. S20MHT stated that he would have his compliance rate up to 98% by the end of the shift, because he is documenting on all patients on the unit. In an interview on 09/10/2025 at 3:37 PM, S40MHT stated she was working the floor. S40MHT confirmed she had no patients assigned to her. S40MHT confirmed she just documents on patients as she walks around the unit. S40MHT stated she documents on everyone that is not on 1:1 observation. In an interview on 09/10/2025 at 3:43 PM, S9MHT stated that he was 1:1 with Patient #8. S9MHT stated that the only time they are assigned to a specific patient is if the patient is 1:1. In an interview on 09/17/2025 at 11:44 AM S41MHT confirmed she was working the floor with another MHT. S41MHT confirmed she can document on everyone on the unit except the 2 patients that are on 1:1 observations. In an interview on 09/17/2025 at 11:49 AM, S39MHT stated that she was currently monitoring a patient who was 1:1. Observation of S39MHT’s electronic monitoring system revealed that she has access to all patients on the unit. S39MHT further confirmed that MHT’s on the unit are responsible for documenting on all patients. S39MHT confirmed that unless they are 1:1 the MHT’s do not have designated assigned patients.”

“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: 44763 Based on record reviews and interviews, the hospital failed to maintain accurate medical records for each patient. This deficient practice was evidenced by failing to accurately document patient observations every 15 minutes as ordered by the physician for 1 (#1) of 11 patients reviewed. Findings: Review of the hospital’s policy titled “Observations, Patient”, revised 09/2024, revealed in part, “Policy: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN.” Review of Patient #1’s medical record revealed an admission date of 07/16/2025. Review of the physician’s order dated 08/20/2025 at 4:00 PM revealed “observation Q (every) 15 minutes continuous, request type: routine.” Review of the nurse’s note dated 09/05/2025 at 7:50 PM by S18RN revealed in part, “1950 [7:50 PM] Patient #1 approached nurse’s station, stood in front of panel. Patient #1 asked what would happen if I swallowed a screw. This RN, asked Patient #1 if he swallowed screw. Patient #1 stated yes, very anxious pacing. I instructed Patient #1 to sit down. I needed to obtain vitals signs. I also instructed Patient #1 not to eat or drink anything, and instructed staff he was NPO [nothing by mouth].” “2055 [8:55 PM] EMS [emergency medical services] from [stated name] EMS X2. Pt [patient] sitting in chair.” “2100 [9:00 PM] Pt [stated hospital] ER [emergency room] per [stated name] ERMS [sic] x2. Awake and alert X4 Color pink no distress.” Review of Patient #1’s observation sheets dated 09/05/2025 revealed observations were documented as follows in part: 9:13 PM Location: bedroom Behavior: calm Observer: S16MHT 9:26 PM Location: day room Behavior: calm Observer: S17MHT 9:39 PM Location: seclusion room Behavior: calm Observer: S16MHT 9:51 PM Location: bedroom Behavior: appears asleep with chest rise/fall Observer: S17MHT 10:05 PM Location: bedroom Behavior: calm Observer: S16MHT 10:16 PM Location: bedroom Behavior: calm Observer: S16MHT 10:29 PM Location: bedroom Behavior: calm Observer: S16MHT 10:42 PM Location: bedroom Behavior: calm Observer: S16MHT 10:57 PM Location: bedroom Behavior: calm Observer: S16MHT 11:08 PM Location: bedroom Behavior: appears asleep with chest rise/fall Observer: S17MHT 11:20 PM Location: bedroom Behavior: appears asleep with chest rise/fall Observer: S17MHT 11:33 PM Location: bedroom Behavior: appears asleep with chest rise/fall Observer: S17MHT 11:40 PM Location: bedroom Behavior: appears asleep with chest rise/fall Observer: S17MHT In an interview on 09/09/2025 at 3:54 PM S3DRM confirmed Patient #1 left this hospital on 09/05/2025 at 9:00 PM by EMS. S3DRM confirmed staff documented observations on 09/05/2025 from 9:13 PM - 11:40 PM of Patient #1. S3DRM confirmed Patient #1 was not at this hospital during that time. S3DRM confirmed sometimes the techs will document observations even if the patient is not here so their percentages for non-compliance will not go up.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 44763 50453 Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. Findings: Observations during a tour on 09/09/2025 from 9:58 AM - 11:24 AM revealed the following: Room ‘a’: -Bottom screw on room light switch missing. -Baseboard missing between beds. -Laminate on bathroom counter top chipped. -Screw sticking out on bottom left side of bathroom mirror. Room ‘b’: -Mattress for bed B on the floor. -Baseboard on desk broken. -Laminate on desk chipped and exposing wood. -Laminate on top of bookshelf peeling off. -Peeling paint on the walls on both sides of the shower. Hallway ‘A’: -Corner wall panel to the left of fire extinguisher not flush with wall. -Peeling paint on wall next to fire extinguisher. Room ‘h’: -Overhead light in ante room does not turn on. -Paper towels on the floor by the toilet. Room ‘i’: -Entertainment set missing bottom cabinet doors, exposing door brackets with phillip screws. -Chipped paint above baseboard. -Approximately 6 inches of baseboard was missing. -Multiple ceiling tiles with broken corners. Room ‘j’: -Hole in wall near window. -Brown colored stain on wall. -bathroom corner panel not flush with wall. Room ‘k’: -Paint on wall chipped and flaking off. -Overhead light in bathroom not working. -Baseboard around toilet separating from wall and not flush. -Bottom left corner of shower trim has exposed wood. Room ‘l’: -Speaker on wall has a gap and is not flush with wall. -Bottom right corner of wall near shower had holes in the sheetrock. Room ‘m’: -Baseboard has missing sections. -Back of door has splintering wood at top and bottom right corners. -Laminate on bottom left corner is peeling off. -Bathroom vent has brownish/red colored stains. -Overhead light in bathroom not working. Room ‘n’: -2 cracked tiles in bathroom shower. -Bathroom baseboard not flush, exposing the wood behind it. -Bathroom vent has brownish/red colored stains. -Peeling paint to wall near bed A In an interview during the tour, S4DON confirmed the above mentioned findings. Observations during a tour on 09/10/2025 from 3:18 PM - 4:01 PM revealed the following: Room ‘p’: -Flooring in bathroom buckling around toilet and not flush with the wall. In an interview during the tour, S4DON confirmed the above mentioned findings. Observations during a tour on 09/17/2025 from 8:44 AM - 9:09 AM revealed the following: Room ‘q’: -2 holes in the wall between the mirror and soap dispenser with exposed sheet rock. -1 used bottle of shampoo/body wash on shower rail. -Bottom sink cover has a loose screw on the bottom right. In an interview during the tour, S3DRM confirmed the above mentioned findings. Observations during a tour on 09/18/2025 from 9:36 AM - 10:32 AM revealed the following: Room ‘c’: -Bathroom vent has brownish/red colored stains. -Flooring is chipped between bed A and bed B. -Bathroom sink has peeling paint and caulk around the sink. -Toilet paper stuck to ceiling outside shower. Room ‘r’: -Exposed dry wall next to bathroom sink. Room ‘d’: -Overhead light above bed B not working. Room ‘e’: -Bathroom light not working. In an interview during the tour, S4DON confirmed the above mentioned findings.”

“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: 44763 50453 Based on observation and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failing to have a clean and sanitary environment. Findings: Observations during a tour on 09/09/2025 from 9:58 AM - 11:24 AM revealed the following: Room ‘g’: -3 bags of trash and 1 bag of linen on floor. Room ‘i’: -Tear in middle seat cushion of couch and 2 holes in back couch cushions. Room ‘j’: -Tear to bottom of bed A’s mattress. Room ‘l’: -Large tear to bottom of bed B’s mattress. -Large hairball in the bathroom shower. In an interview during the tour, S4DON confirmed the above mentioned findings. Observations during a tour on 09/18/2025 from 9:36 AM - 10:32 AM revealed the following: Room ‘d’: -Specimen cup on shelf next to bed B. -Numerous brown stains to the bed linen on bed B In an interview during the tour, S4DON confirmed the above mentioned findings.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure nursing staff followed the policies and procedures of the hospital. This deficiency was made evident by the: 1) failure to document the date and staff signature on paper observation records for 1 (#1) of 4 (#1 - #4) patients reviewed for observations; 2) failure to accurately document wound skin assessments in the daily nursing assessment for 1 (#1) of 4 (#1 - #4) patients reviewed for daily nursing assessments; and 3) failure to document an elopement for Patient #4. Review of the hospital policy #AS-00-016 titled “Observations, Patient” last revised 11/2024, revealed in part: “Policy: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. Procedure: 6. Documentation of Observations b. Paper Documentation including Downtime of an EMR i. Staff documents all levels of observation on each patient’s observation form which becomes a part of the patient record. Each entry is to include the following: Level of Observation; Precaution; Location; Behavior; Activity; Time; and Staff Initial and Signature.” Review of the hospital policy #TX-11-059 titled “Elopement Precautions and Response” last revised 04/2020, revealed in part: “Policy: Staff shall provide appropriate assessment and observation of inpatients who have either verbally or non-verbally expressed a desire to elope from the hospital. Patients who leave the hospital without a discharge order are considered to have “eloped.” This includes patients who are requesting AMA discharge but have not completed the discharge process. Staff shall make every effort to locate the patient and make notifications to designated persons regarding the elopement. Procedure: In order to provide protection to patients who are at high risk for elopement the following shall occur: 9. h. Documenting the sequence of events in the Progress Notes, including: i. Date, time and circumstances under which the patient was noted missing; ii. Action taken to locate patient; iii. Information related to notifications - time, names, relationships to the patient, specific information disclosed; iv. If patient is located but not returned, the disposition of the patient; and v. Incident Report shall be completed and submitted to the Director of Risk Management.” 1) Failure to document the date and staff signature on paper observation records for 1 (#1) of 4 (#1 - #4) patients reviewed for observations. Review of Patient #1’s medical record revealed she was admitted to the hospital on 07/03/2025 from an outside hospital emergency room with a diagnosis of Disruptive Mood Dysregulation Disorder and ADHD Combined Type. Review of Patient #1’s Physician Orders dated 07/03/2025 to present revealed alternating orders of Q15 and Q5 minute staff observation. Review of Patient #1’s paper chart revealed paper copies of the “Patient Observation Record (Q5 and Q15)” for three separate dates. All three paper copies revealed missing documentation of the date of the observation, level of observation and precaution(s) for Patient #1. Two of the paper copies were missing the observing staff’s signature. On 08/11/2025 at 1:30 PM, an interview was conducted with S5DRM during Patient #1’s record review. S5DRM reviewed the three paper copies of the “Patient Observation Record (Q5 and Q15)” in Patient #1’s paper chart. S5DRM confirmed all three copies were missing documentation of the date of observation, level of observation and precaution(s) and two of the copies were also missing the observing staff’s signature. 2) Failure to accurately document wound skin assessments in the daily nursing assessment for 1 (#1) of 4 (#1 - #4) patients reviewed for daily nursing assessments. Review of Patient #1’s Physician Orders dated 07/03/2025 to present revealed the following in part: On 07/04/2025 - Amoxicillin/Potassium Clav 500-125mg PO TID x 7 days for skin and skin structure infection Discontinued on 07/08/2025; and Neomycin/Bacitracin/Polymyxinb (Triple Antibiotic Ointment) Topically BID to right arm x 7days for minor bacterial infection On 07/08/2025 - Wound Care BID Right side upper extremity, rinse wound with normal size, pat dry with 4x4 gauze, cover wound with 4x4 gauze Discontinued on 07/09/2025; Clindamycin HCl 150mg Take 300mg PO TID x 7 days for skin and skin structure infection; and Medical Provider Consult Patient complains of referred/radiating pain from existing wound of the right forearm On 07/09/2025 - Wound Care BID Right side upper extremity, rinse with normal saline, pat dry with 4x4 gauze, cover wound with wet-to-dry dressing, clean wound with normal saline, pack with wet to dry dressing, cover with Mepilex Discontinued on 07/16/2025 On 07/14/2025 - Anaerobic and Aerobic Culture to Right Forearm wound infection for deep disruption or dehiscence of operation wound On 07/15/2025 - Wound Care Daily Right Upper Extremity Rinse wound with normal saline, pat dry with cloth, apply to peri-wound, cover wound with dry dressing. Cleanse the wound with wound cleanser. Perform peri-wound care using skin prep. Apply a secondary dressing with adhesive foam. Pack the wound with iodoform gauze, then secure with tape and Tubigrip. On 07/29/2025 - Transfer Patient to Hospital - outpatient wound clinic sent her to hospital Review of Patient #1’s daily nursing assessments revealed the following in part: On 07/17/2025 at 8:45 PM - Nursing Note - Day Shift: Skin Assessment- Normal; Narrative Daily Progress Note - Not making progress as evidenced by still removing dressing from wound on arm and not following directions. Not making progress toward treatment as evidenced by still removing dressing and sticking screws in wound to arm. Signed by S6RN On 07/18/2025 at 6:05PM- Nursing Note - Day Shift: Skin Assessment- Normal. Signed by S7RN On 07/29/2025 at 4:31 AM - Nursing Note - Night Shift: Skin Assessment- Normal. Signed by S8RN On 08/11/2025 at 1:30 PM, an interview was conducted with S5DRM during Patient #1’s record review. S5DRM confirmed the above daily nursing assessments were incorrect as Patient #1 was actively being treated for a wound to her right forearm. 3) Failure to document an elopement for Patient #4. Review of Patient #4’s medical record revealed he was admitted to the facility on 08/05/2025 from his home for a 90-day subacute treatment for Conduct Disorder; Oppositional Defiant Disorder; ADHD; Reaction to Severe Stress and Disruptive Mood Disorder. Review of Patient #4’s Physician’s Orders dated 08/05/2025 revealed elopement precautions due to a history of elopements from his home. Review of Patient #4’s Nursing Progress Notes on 08/07/2025 revealed no documentation of his successful elopement from the facility. On 08/12/2025 at 5:45 PM, an interview was conducted with S5DRM during his record review. S5DRM confirmed there was no nursing documentation in a progress note or daily assessment note of Patient #4’s elopement from the hospital.”

“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: 44763 Based on record reviews and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure patients were being monitored according to the provider order for 1 (#3) of 3 (#1, #2, #3) patients reviewed. Findings: Review of the hospital’s policy titled “Observations, Patient”, revised 09/2024, revealed in part, “In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN [registered nurse]. Level of observation can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level.” Review of Patient #3’s medical record revealed Patient #3 was admitted on 04/22/2025 with diagnoses of major depressive disorder recurrent severe with psychotic features, attention-deficient hyperactivity disorder combined type, and nightmare disorder. Review of the provider’s order dated 04/28/2025 12:04 PM revealed observation Q (every) 5 - suicide high. Review of the observation sheet dated 04/28/2025 revealed Observation - from 12:11 AM to 11:52 PM interval 15 min (minutes). Review of the observation sheet dated 04/29/2025 revealed Observation - from 12:06 AM to 7:35 AM interval 15 min, Observation - from 7:42 AM to 11:58 PM interval 5 min. The Q15 minute observations status was not changed in the electronic observation system to Q5 minute observations until the day after the order was changed by the provider. Further review of the documents revealed there were 99 observations that were not every 5 minutes from the date/time the order was changed by the provider to the date/time the observation status was changed in the electronic observation system. In an interview on 04/30/2025 at 5:01 PM S3DC verified the above stated findings.”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure the patient’s right to be free from all forms of abuse or harassment. This deficient practice was evidenced by: 1.) failure to ensure allegations of potential abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations and 2.) failure to implement the hospital’s grievance process for an allegation of potential abuse and/or neglect. Findings: 1.) Failure to ensure allegations of potential abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations. Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or LDH. This statute would include any issue under review for the determination whether the facility failed to take prudent action to prevent, and/or respond to an alleged occurrence such as a potential self-injurious behavior or an elopement. Review of the LDH Hospital / Licensed Provider Abuse / Neglect Initial Report form revealed in part, on 02/21/2025 7:00 PM - 7:00 AM shift S4RN was in the process of admitting Patient #2 and she told the admitting nurse that Patient #1 (another patient that was in the adolescent intake area) touched her inappropriately and tried to kiss her. In an interview on 04/29/2025 at 2:34 PM S3DC verified the hospital could not find the documentation of the above stated Self-Report being sent to LDH. 2.) Failure to implement the hospital’s grievance process for an allegation of potential abuse and/or neglect. Review of the hospital’s policy titled “Grievance, Patient”, revised 04/2020, revealed in part, “All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS [Centers for Medicare & Medicaid Services] requirements are considered grievances for the purposes of these requirements.” Review of the LDH Hospital / Licensed Provider Abuse / Neglect Initial Report form revealed in part, on 02/21/2025 7:00 PM - 7:00 AM shift S4RN was in the process of admitting Patient #2 and she told the admitting nurse that Patient #1 (another patient that was in the adolescent intake area) touched her inappropriately and tried to kiss her. Review of the grievance log for February and March 2025 failed to reveal the above stated allegation of potential abuse/neglect as a grievance. In an interview on 04/30/2025 at 10:05 AM S5PA verified the above stated allegation of potential abuse/neglect was not handled as a grievance by the hospital. She stated no one called her regarding this allegation.”

“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 incident reporting and assessments were correctly detailed in the final investigation of its self-reporting process. Review of the hospital’s policy RISK.0210 titled, “Risk Management Incident Reporting Policy” revealed in part: Purpose: The Incident Report is a Risk Management tool that raises awareness of actual or potential exposures to harm. Procedure: An incident is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety. 4.4 If the incident involves a patient, staff must chart relevant factual information in the patient’s medical record. 5.6 Comply with state regulations regarding adverse events. Review of the hospital’s incident reports revealed Patient #2 was in an altercation and suffered a swollen right eye, laceration to the chin and swelling to the face. Patient sent to ER per orders. Review of Patient #2’s medical record revealed a telephone order 07/28/24 18:59 Transfer patient to ER for evaluation after an altercation. Review of the hospital’s LDH Self-Report 07/28/2024 6:30 p.m. revealed in part: 5. Patient #1 went into Patient #2’s room and hit him, unprovoked. MHT’s were present and immediately separated the patients. H. The patients were immediately separated and assessed for injuries. No injuries noted. Interview 08/19/2024 at 4:17 p.m., S2Performance Improvement acknowledged there was no current tracking mechanism to ensure self-reporting was accurately reflected in correlation with incident reporting.”

“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 review and interview, the hospital failed to have a registered nurse supervise and evaluate the nursing care for each patient. This deficient practice was evidenced by failure to assess and document Patient #2’s condition prior to and following treatment at another hospital’s Emergency Department. Findings: Review of the hospital’s policy RISK.0210 titled, “Risk Management Incident Reporting Policy” revealed in part: 4.4 If the incident involves a patient, staff must chart relevant factual information in the patient’s medical record. Review of Patient #2’s medical record revealed a telephone order 07/28/24 6:59 p.m. Transfer patient to ER for evaluation after an altercation. Review of Patient #2’s medical record revealed in part: 07/28/24 Patient came back from hospital at 10:00 p.m. Further review failed to reveal the RN’s documentation of the injuries requiring the patient to be transferred to another hospital for evaluation in their ER; or the assessment following Patient #2’s return from the ER. Interview 08/19/2024 at 3:00 p.m., S1CNO acknowledged there was no documented assessments in Patient #2’s medical record detailing the injuries prior to being transferred to the ER, and no documentation of an assessment following Patient #2’s return.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by: 1) Failure to complete 15 minute observation checks on 9 (#1 - #5, #11, #12, #18, #19) of 21 (#1 - #21) Patients with physician orders for 15 minute observation checks during a 3.5 hour interval; 2) Failure to complete 5 minute observation checks on 12 (#6 - #10, #13 - #17, #20, #21) of 21 (#1 - #21) Patients with physician orders for 5 minute observation checks during a 3.5 hour interval; and 3) Failure to perform observations checks as ordered on 1(#4) of 6 (#1-#6) patient medical records reviewed. (See findings under Tag A0144)”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to provide care in a safe setting. The deficient practice is evidenced by: 1) Failure to complete 15 minute observation checks on 9 (#1 - #5, #11, #12, #18, #19) of 21 (#1 - #21) patients with physician orders for 15 minute observation checks during a 3.5 hour interval; 2) Failure to complete 5 minute observation checks on 12 (#6 - #10, #13 - #17, #20, #21) of 21 (#1 - #21) patients with physician orders for 5 minute observation checks during a 3.5 hour interval; and 3) Failure to perform observations checks as ordered on 3(#3, #4, #6) of 6 (#1-#6) patient medical records reviewed. Findings: A review of facility policy NO: AS-00-016, “Electronic Patient Observation” being originally approved on 06/2000 and revised on 10/2023 revealed in part, #5. Documentation of Observations, Item b. Ordered precautions should be entered into the patient profile and are visible to the staff on rounding of the patient. Item c. Documentation of the observation is to be completed once the patient has been observed. #6. Q 15 Minute Rounds, Item a. All patients are monitored at minimum once every 15 minute block of time. #7. Q 5 Minute Rounds, Item a. Patient is placed on Q 5 minutes if behavior is unpredictable and there is potential risk for harm to self and others. Item b. Patient is monitored at minimum once in every 5 minute block of time. 1) Failure to complete 15 minute observation checks on 9 (#1 - #5, #11, #12, #18, #19) of 21 (#1 - #21) patients with physician orders for 15 minute observation checks during a 3.5 hour interval A record review of Unit A’s Electronic Patient Observation Sheets for 12/17/2023 from 12:01 a.m. to 11:59 p.m. revealed undocumented observation checks from 6:00 p.m. to 9:30 p.m. on 9 (#1 - #5, #11, #12, #18, #19) of 21 (#1 - #21) Electronic Patient Observation Sheets reviewed with physician orders for 15 minute observation checks. Further, the Electronic Patient Observation Sheets revealed a trend in undocumented observations during the approximate time frames of 7:20 pm to 7:55 p.m., 7:55 p.m. to 8:45 p.m. and 8:45 p.m. to 9:20 p.m. The undocumented observations placed Patients #1-21 at risk for harm during the before mentioned approximate time frames. The Electronic Patient Observation Sheet for each of the 9 (#1 - #5, #11, #12, #18, #19) Patients revealed: Patient #1: Level of observation: every 15 minutes; Risk Status: assault precautions, suicide risk-low. Electronic Patient Observation Sheet revealed observation being performed at 7:13 p.m., 7:51 p.m., 8:26 p.m. and 8:44 p.m. This revealed undocumented observations for 38 minutes, 35 minutes and 18 minutes respectively. Patient #2: Level of observation: every 15 minutes; Risk Status: assault precautions, elopement precautions, suicide risk-high. Electronic Patient Observation Sheet revealed observation being performed at 7:02 p.m., 7:52 p.m., 8:26 p.m. and 8:45 p.m. This revealed undocumented observations for 50 minutes, 34 minutes and 19 minutes respectively. Patient #3: Level of observation: every 15 minutes; Risk Status: elopement precautions, fall precautions, seizure precautions, suicide risk-low. Electronic Patient Observation Sheet revealed observation being performed at 6:31 p.m., 7:04 p.m., 7:14 p.m. and 8:20 p.m. This revealed undocumented observations for 35 minutes and 66 minutes respectively. Patient #4: Level of observation: every 15 minutes; Risk Status: none assigned. Electronic Patient Observation Sheet revealed observation being performed at 7:11 p.m., 7:55 p.m. and 8:32 p.m. This revealed undocumented observations for 44 minutes and 37 minutes respectively. Patient #5: Level of observation: every 15 minutes; Risk Status: suicide precautions, suicide risk-low. Electronic Patient Observation Sheet revealed observation being performed at 7:12 p.m., 8:43 p.m. and 9:20 p.m. This revealed undocumented observations for 91 minutes and 37 minutes respectively. Patient #11: Level of observation: every 15 minutes; Risk Status: none assigned. Electronic Patient Observation Sheet revealed observation being performed at 6:30 p.m., 7:10 p.m., 8:49 p.m. and 9:21 p.m. This revealed undocumented observations for 40 minutes, 99 minutes and 32 minutes respectively. Patient #12: Level of observation: every 15 minutes; Risk Status: assault precautions, elopement precautions, suicide risk-low. Electronic Patient Observation Sheet revealed observation being performed at 7:14 p.m., 7:52 p.m. and 8:31 p.m. This revealed undocumented observations for 48 minutes and 39 minutes respectively. Patient #18: Level of observation: every 15 minutes; Risk Status: assault precautions, elopement precautions, restrict to unit, suicide risk-low. Electronic Patient Observation Sheet revealed observation being performed at 7:23 p.m., 7:57 p.m., 8:39 p.m. and 9:19 p.m. This revealed undocumented observations for 34 minutes, 42 minutes and 40 minutes respectively. Patient #19: Level of observation: every 15 minutes; Risk Status: assault precautions, suicide risk-low. Electronic Patient Observation Sheet revealed observation being performed at 7:14 p.m., 7:51 p.m., and 8:26 p.m. This revealed undocumented observations for 37 minutes and 35 minutes respectively. In an interview on 12/28/2023 at 12:15 p.m. S2DON and S3PI confirmed the undocumented observations on the Electronic Patient Observation Sheets. S2DON and S3PI also confirmed the Electronic Patient Observation Sheets indicated an observation was made late if the sheet revealed > 15 min in the interval column when a patient was on every 15 minute rounds. 2) Failure to complete 5 minute observation checks on 12 (#6 - #10, #13 - #17, #20, #21) of 21 (#1 - #21) Patients with physician orders for 5 minute observation checks during a 3.5 hour interval A record review of Unit A’s Electronic Patient Observation Sheets for 12/17/2023 from 12:01 a.m. to 11:59 p.m. revealed undocumented observation checks from 6:00 p.m. to 9:30 p.m. on 12 (#6 - #10, #13 - #17, #20, #21) of 21 (#1 - #21) Patient’s Electronic Patient Observation Sheet reviewed with physician orders for 5 minute observation checks. Further, the Electronic Patient Observation Sheets revealed a trend in undocumented observations during the approximate time frames of 7:20 pm to 7:55 p.m., 7:55 p.m. to 8:45 p.m. and 8:45 p.m. to 9:20 p.m. The undocumented observations placed Patients #1-21 at risk for harm during the before mentioned approximate time frames. The Electronic Patient Observation Sheet for each of the 12 (#6 - #10, #13 - #17, #20, #21) patients revealed: Patient #6: Level of observation: every 5 minutes; Risk Status: suicide risk-high. Electronic Patient Observation Sheet revealed observation being performed at 7:24 p.m., 7:52 p.m. and 8:20 p.m. This revealed undocumented observations for 28 minutes and 28 minutes respectively. Patient #7: Level of observation: every 5 minutes; Risk Status: assault precautions, elopement precautions, suicide precautions, suicide risk-low. Electronic Patient Observation Sheet revealed observation being performed at 6:09 p.m., 7:57 p.m., 8:42 p.m. and 9:19 p.m. This revealed undocumented observations for 108 minutes, 45 minutes and 37 minutes respectively. Patient #8: Level of observation: every 5 minutes; Risk Status: fall precautions, suicide risk-low. Electronic Patient Observation Sheet revealed observation being performed at 7:14 p.m., 7:55 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 41 minutes, 48 minutes and 36 minutes respectively. Patient #9: Level of observation: every 5 minutes; Risk Status: none assigned. Electronic Patient Observation Sheet revealed observation being performed at 7:16 p.m., 7:55 p.m., 8:43 p.m. and 9:22 p.m. This revealed undocumented observations for 39 minutes, 48 minutes and 41 minutes respectively. Patient #10: Level of observation: every 5 minutes; Risk Status: suicide risk-high. Electronic Patient Observation Sheet revealed observation being performed at 7:11 p.m., 7:26 p.m., 7:56 p.m., 8:40 p.m., 8:49 p.m., 9:01 pm and 9:21 p.m. This revealed undocumented observations for 15 minutes, 30 minutes, 44 minutes, 12 minutes and 20 minutes respectively. Patient #13: Level of observation: every 5 minutes; Risk Status: assault precautions, suicide precautions, suicide risk-high. Electronic Patient Observation Sheet revealed observation being performed at 7:16 p.m., 7:56 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 40 minutes, 47 minutes and 36 minutes respectively. Patient #14:Level of observation: every 5 minutes; Risk Status: suicide precautions, suicide risk-high. Electronic Patient Observation Sheet revealed observation being performed at 6:55 p.m., 7:14 p.m., 8:43 p.m. and 9:20 p.m. This revealed undocumented observations for 19 minutes, 89 minutes and 37 minutes respectively. Patient #15: Level of observation: every 5 minutes; Risk Status: suicide precautions, suicide risk-high. Electronic Patient Observation Sheet revealed observation being performed at 6:54 p.m., 7:11 p.m., 7:55 p.m., 8:42 p.m. and 9:20 p.m. This revealed undocumented observations for 17 minutes, 44 minutes, 47 minutes and 38 minutes respectively. Patient #16: Level of observation: every 5 minutes; Risk Status: elopement precautions, suicide risk-high. Electronic Patient Observation Sheet revealed observation being performed at 6:54 p.m., 7:11 p.m., 7:56 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 17 minutes, 45 minutes, 47 minutes and 36 minutes respectively. Patient #17: Level of observation: every 5 minutes; Risk Status: suicide risk-high. Electronic Patient Observation Sheet revealed observation being performed at 6:34 p.m., 7:03 p.m., 7:12 p.m., 7:15 p.m., and 8:38 p.m. This revealed undocumented observations for 29 minutes, 9 minutes, 3 minutes and 83 minutes respectively. Patient #20: Level of observation: every 5 minutes; Risk Status: suicide precautions, suicide risk-low. Electronic Patient Observation Sheet revealed observation being performed at 6:53 p.m., 7:14 p.m., 7:25 p.m., 7:55 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 21 minutes, 11 minutes, 30 minutes, 48 minutes and 36 minutes respectively. Patient #21: Level of observation: every 5 minutes; Risk Status: suicide risk-high. Electronic Patient Observation Sheet revealed observation being performed at 6:55 p.m., 7:05 p.m., 7:11 p.m., 7:23 p.m., 7:55 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 10 minutes, 6 minutes, 12 minutes, 37 minutes, 47 minutes and 36 minutes respectively. In an interview on 12/28/2023 at 12:15 p.m. S2DON and S3PI confirmed the undocumented observations on the Electronic Patient Observation Sheets. S2DON and S3PI also confirmed the Electronic Patient Observation Sheets indicated an observation was made late if the sheet revealed > 5 min in the interval column when a patient was on every 5 minute rounds. 3) Failure to perform observations checks as ordered on 1(#3, #4, #6) of 6 (#1-#6) patient medical records reviewed A medical record review of revealed observation levels not being performed as ordered on 3 (#3, #4, #6) of 6 (#1 - #6) patient medical records reviewed. This deficient practice placed Patients #1 - #6 at risk for harm. The medical records revealed: Patient #3 A medical record review of revealed an admission on 11/21/2023 with the diagnosis of Major Depressive disorder. Patient #3 was placed on an observation level of every 5 minutes from 11/21/2023 till 12/14/2023 at 5:41 p.m. On 12/14/2023, Patient #3 observation level was changed to every 15 minutes. A review of Patient #3’s Patient Observation Sheets from 12/10/2023 through 12/20/2023 revealed Patient #4 observation level being performed every 15 minutes. Patient #3’s observation level was not being performed as ordered from 12/10/2023 till 12/14/2023 at 5:41 p.m. In an interview on 12/28/2023 at 2:00 p.m. S2DON and S3PI confirmed the observation levels ordered and the patient was not being observed per order from 12/10/2023 till 12/14/2023. Patient #4 A medical record review revealed an admission on 12/17/2023 with the diagnosis of Major Depressive disorder. She was placed on an observation level of every 5 minutes and a precaution level of Suicide Risk. A review of Patient #4’s Patient Observation Sheets from 12/17/2023 through 12/20/2023 revealed Patient #4 observation level being performed every 15 minutes. In an interview on 12/28/2023 at 2:00 p.m. S2DON and S3PI confirmed the observation level ordered and the patient was not being observed per order. Patient #6 A medical record review revealed an admission from 12/12/2023 to 12/20/2023 with a diagnosis of Major Depressive Disorder with Suicidal Ideations. Admission orders revealed an observation level of every 5 minutes. This order was in place during Patient #6’s entire admissions. A review of the Patient Observation Sheets revealed a level of observation being performed every 15 minutes from 12/12/2023 to 12/13/2023. In an interview on 12/28/2023 at 9:45 a.m. S2DON and S3PI confirmed the observation level ordered and the patient was not being observed per order.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to maintain a patient medical record entry for a complete physician order entry. This deficient practice is evident by an incomplete seclusion and restraint order on 1 (Patient #1) of 6 (Patient #1 - #6) sampled patient medical records reviewed. Findings: A medical record review of Patient #1 revealed a physician order on 12/17/2023 for Seclusion and Restraint. The order included an option to choose the type of seclusion and restraint. In part, the order was written as follows: Mark an X for the Type: [ ] Seclusion, [ ] Physical Restraint, [ ] Chemical Restraint, [ ] Mechanical Restraint 2 Point, [ ] Mechanical Restraint 4 Point. The order did not have an item marked for the type to be used. In an interview on 12/28/2023 at 12:15 p.m. S2DON and S3PI confirmed the above mentioned physician order was not complete.”