Community Care Hospital

“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 review and interviews, the hospital failed to ensure a patient complaint of alleged sexual abuse was recognized as a grievance. This deficient practice was evidenced by failing to correctly identify a patient grievance for 1 (#3) of 3 (#1-#3) patients reviewed for complaints/grievances. Findings: Review of hospital policy titled “Complaints and Grievances: Patient/Family,” approved June 2025, revealed in part: “Policy Statement: The investigation process for patient complaints and grievances must be initiated within 24 hours. The complaint/grievance resolution process shall take precedence over any and all previously scheduled activities, including but not limited to: administrative scheduled time off, provision of clinical care, and off-site meetings. Purpose: To assure that all Community Care Hospital patient complaints and grievances are addressed and resolved in a timely manner, as well as improve the service provided to patients. Definitions: Patient complaint- any concern expressed by the patient or family member concerning care or service that can be addressed promptly, on the spot, by the staff or managers present. Patient grievance- a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient’s representative when the patient issue cannot be resolved promptly by staff or manager present. If a complaint cannot be resolved promptly by staff present, and as a result is referred to a manager or to the Patient Representative, it is considered a grievance. Concerns regarding the following issues are automatically considered patient grievances: The exercise of patient rights regarding his/her care, Premature discharge, Privacy and safety of the patient, Confidentiality and access to patient records, Civil rights or issues of disability, Accusations of abuse.” Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: “11. Facility Investigation (Administrative Review) and Final Investigative Report: In accordance with regulations, facilities are directed to process an allegation of abuse or neglect as a grievance in accordance with facility Grievance Processes and Abuse/Neglect policies. In accordance with §482.13, an allegation of abuse/neglect is to be treated as a grievance even if the complainant recants or indicates that the issue is resolved. A written response must be issued to the reporting patient or patient’s representative. In many cases, the presentation of an abuse investigation handled in this manner will satisfy surveyor reviews related to the manner in which a facility processes grievances.” Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 11/01/2024 with an admit diagnosis of Schizoaffective Disorder, Bipolar type. Review of nursing note on 11/03/2024 at 6:05 PM revealed in part the following: Patient #3’s mother called to inform her that we are investigating the accusation of him being raped in his sleep last night. In an interview on 06/25/2025 at 12:40 PM, S1ADM stated that the facility has not had any complaints or grievances since October 2024 through April 29, 2025. In an interview on 06/25/2025 at 3:17 PM, S3DON stated the mother called and said she was upset Patient #3 told her that he was raped. S3DON stated she informed the mother that incident would be investigated. S3DON confirmed that this incident failed to be identified as a grievance.”

“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: 50453 Based on record review and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by: 1) failure to ensure all exit doors were secured leading to patient elopements; and 2) failure to ensure the elevator was monitored per hospital protocol leading to the elopement of Patient #3. Findings: Review of hospital policy titled “Patient Rights,” approved June 2025, revealed in part: “Procedure: Community Care Hospital supports and protects the basic human, civil, and constitutional rights of all patients. All patients have the right to: 18. The right to receive care in a safe setting.” Review of hospital policy titled “Abuse and/or Neglect of Patients,” approved January 2025, revealed in part: “Purpose: To identify attitudes and behaviors which constitute patient abuse or neglect, and to assure that any incidents of suspected or actual abuse/neglect are reported, investigated, and resolved. To establish a time frame for reported suspected or actual abuse and/or neglect. A. Definitions: Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Neglect- a form of abuse. The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. B. Prevention of Abuse and Neglect: 3. Unit acuity is assessed every shift to determine that the staff to patient ratio is appropriate to meet the specific needs of the patient. C. Identification of Abuse and/or Neglect: 1. Inadequate supervision of patients whose physical or mental condition may result in poor judgment, and who are therefore at risk of injury or illness without supervision. 2. Engaging in sexual conduct of any kind with a patient. D. Reporting Abuse and/or Neglect of Patients: Staff are required to report any incident which they believe might constitute abuse or neglect of patients. Because safety of patients is our first concern, a reasonable suspicion about the observed behavior is sufficient to warrant reporting the situation so that any necessary corrections can be made to prevent or reduce harm to the patient. 2. Prevention of instances of patient abuse/neglect is a goal of this facility.” Review of hospital policy titled “Escorting Patients Off the Unit,” approved January 2025, revealed in part: “Policy Statement: Staff members assigned to escort a patient, or a group of patients shall be responsible for the safety and well-being of the individual and/or group from the time of leaving the unit until return to the unit. Purpose: To establish guidelines for the safe transport of patients off the unit. Procedure, in part: 1. The staff-patient ratio will be no less than two staff members for every group of up to twelve patients when leaving the secured nursing unit. This will apply to meal times and smoke breaks. 2. Prior to leaving the unit, staff members assigned to accompany patients should: a. Evaluate the clinical condition of each patient that the staff member is planning to accompany off the unit. b. Know the number and names of the patients in the group. c. Notify security that the patients are leaving the unit. 3. Security will secure the lobby area and take post in front of the lobby door prior to patients leaving the elevator. 6. Staff members should see that the group stays together.” Review of hospital policy titled “Elopement Assessment and Reporting,” approved January 2025, revealed in part: “Procedure: 1. Nursing personnel should assess the risk for elopement during the admission process by utilizing the elopement assessment questions located on the admit nursing assessment. 2. If the patient is shown to be at risk for elopement, the nurse should contact the admitting physician to have elopement precautions ordered. 3. It is the responsibility of all personnel to report any patient discussing an attempt or intent to leave the facility, attempting to leave the premises, or suspected of being missing, to the charge nurse immediately.” Review of document provided by S1ADM titled “Community Care Hospital Day/Night Shift MHT Duties,” revealed in part: “Reminders: When getting off the elevator, don’t forget to stand in front of it until it closes fully. Some patients might be waiting for the opportunity to jump on when you have stepped away too early. When escorting patients off elevator, staff should exit first as to be between patients and the outside door.” 1) Failure to ensure all exit doors were secured leading to patient elopements. Review of the hospital incident report log revealed the following: Patient #R2 eloped on 10/15/2024 Patient #3 eloped on 11/04/2024 Patient #R1 eloped on 01/13/2025 Observations of front lobby on 06/25/2025 at 4:30PM revealed S10SEC sitting behind desk facing the front lobby door. During inspection of front lobby door, the door was not secured from inside the facility and could be pushed open allowing exit out of the facility. In an interview on 06/25/2025 at 4:35 PM, S10SEC confirmed that the front lobby door is not secured from the inside and can be pushed open allowing exit out of the facility. S10SEC further confirmed the front lobby door is secured from the outside and security/staff have to allow entrance into the facility. S10SEC stated prior to patients leaving the unit with staff, they are notified by staff, at which point security will take post in front of lobby door to secure the exit. Security further confirmed that if a patient attempts to elope and security is sitting behind the desk, they are not able to secure the front lobby door in order to prevent patient elopement. 2) Failure to ensure the elevator was monitored per hospital protocol leading to the elopement of Patient #3. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 11/01/2024 with an admit diagnosis of Schizoaffective Disorder, Bipolar type. On 11/03/2024 Patient #3 was placed on elopement precautions. Further review of Patient #3’s medical record revealed a nursing note from 11/04/2024 that revealed in part the following: Informed that Patient #3 was able to get in elevator and through front door. MHT grabbed him but Patient #3 was able to get away. Police have been notified. 2:00 PM- Mother notified. 3:00 PM- Mother called and stated her son called her from someone’s phone, they tried to talk him to going back but Patient #3 refused. 8:00 PM- Mother called and concerned that Patient #3 has not returned. Review of incident report involving Patient #3 revealed in part the following: Date/Time of Incident: 11/04/2024 at 1:45 PM Type of Incident: Elopement Describe what happened: Per Security guard, patient got off elevator and ran out front door. Review of document titled “Investigation Form” for Patient #3 revealed in part the following: Date/Time: 11/04/2024 at 1:45 PM Persons involved: S8MHT and S9RN Witnesses: Watched camera Description of Incident/Summary of Interview(s): S8MHT called for elevator on 4th floor using her key and pressing button. S8MHT then decided to go down the stairs instead. When elevator arrived, Patient #3 got on and took elevator to first floor, running out front door. S8MHT was standing outside. S8MHT attempted to grab Patient #3 but he pushed her away. Next Investigative Steps: Police called. Mother called to inform about elopement. Mother called back at 3 PM after she talked to Patient #3. Patient #3 encouraged to return but refused. Actions to be Taken: S8MHT was terminated for neglect behavior 11/04/2024. Signed by administrator on 11/05/2024 at 11:22 AM. In an interview on 06/25/2025 at 3:30 PM, S3DON confirmed that S8MHT did not wait for the elevator to arrive and ensure the doors closed prior to taking the stairs off the unit. S3DON further confirmed S8MHT did not follow hospital protocol for the elevator and that she was terminated.”

“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: 50453 Based on record review and interview the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficient practice is evidenced by failure of staff to monitor per hospital policy a 1:1 patient with an intellectual disability possibly leading to a sexual assault. Findings: Review of hospital policy titled “Patient Rights,” approved June 2025, revealed in part: “Procedure: Community Care Hospital supports and protects the basic human, civil, and constitutional rights of all patients. All patients have the right to: 17. The right to be free from all forms of abuse and harassment.” Review of hospital policy titled “Abuse and/or Neglect of Patients,” approved January 2025, revealed in part: “Purpose: To identify attitudes and behaviors which constitute patient abuse or neglect, and to assure that any incidents of suspected or actual abuse/neglect are reported, investigated, and resolved. To establish a time frame for reported suspected or actual abuse and/or neglect. A. Definitions: Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Neglect- a form of abuse. The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. B. Prevention of Abuse and Neglect: 3. Unit acuity is assessed every shift to determine that the staff to patient ratio is appropriate to meet the specific needs of the patient. C. Identification of Abuse and/or Neglect: 1. Inadequate supervision of patients whose physical or mental condition may result in poor judgment, and who are therefore at risk of injury or illness without supervision. 2. Engaging in sexual conduct of any kind with a patient.” Review of hospital policy titled “Patient Observation Record,” approved January 2025, revealed in part: “Purpose: To establish guidelines and procedures for completion of the Patient Observation Record Sheet. To ensure that the patient’s safety and well-being are maintained and documented. Procedure: The RN is responsible for MHT assignments. 1:1 Observation: Observation Requirement: Continuous observation within arm’s length. May not be interrupted for any reason. Privileges: Staff must accompany patient to all areas, including bathroom or group therapy.” Review of hospital policy titled “Staffing Plans and Delivery of Care,” approved January 2025, revealed in part: “Purpose: To define guidelines for the utilization of RN’s and MHT’s, in providing delivery of patient care. Staffing Assessment: Patient care assignments and activities can fluctuate and therefore require ongoing assessment and planning to assure that adequate and qualified staff is available to meet the needs of the patient. The charge nurse, Director of Nursing or designee does this assessment prior to the beginning of each shift and staffing adjustments are made accordingly to accommodate patient needs. Staffing Alternatives: When available personnel are insufficient to meet coverage demand, the charge nurse, Director of Nursing or designee shall evaluate the need for alternative staffing. Available alternatives: Re-assign staff from other units to meet the needs of the patients, if applicable; Contact PRN employees that are interested in working; Contact full time employees that are interested in working overtime hours; Utilize the Director of Nursing or Assistant Director of Nursing, if available, and working does not conflict with maintaining the proper supervision of Community Care Hospital or if administrative duties are not neglected.” Review of Patient #1’s medical record revealed Patient #1 was a 23 year old female admitted on 05/29/2025 with a diagnosis of Major Depressive Disorder (MDD). Review of the Coroner Emergency Certificate (CEC) dated 05/30/2025 revealed in part that Patient #1 had a history of schizophrenia and mild intellectual disability. On 05/30/2025, Patient #1 had an order placed for 1:1 observations. Review of Psychiatric Evaluation dated 05/30/2025 revealed in part: Throughout the interview, Patient #1 was somewhat hypersexual and alluded that she may have asked anybody to help her process her feelings that she can get close to. On the morning of 05/31/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with Patient #2. Further review revealed Patient #1 had orders for 1:1 observations prior to the incident. Patient #1 was transferred on 05/31/2025 to the ER for an evaluation and returned later that night. Review of the Daily Nursing Assignment Sheet dated 05/31/2025 7a-7p revealed a census of 8 patients. Further review revealed that Patient #1 was on a 1:1 level of observation and was assigned to S7MHT and the other patients were assigned to S5MHT. Review of the Daily Nursing Assignment Sheet failed to reveal that S7MHT called out for her shift or that another staff member was reassigned to maintain 1:1 observations of Patient #1. In an interview on 06/24/2025 at 10:15 AM, S3DON confirmed that Patient #1 had an order for 1:1 observations at the time of the incident. S3DON confirmed that at S7MHT was assigned on the assignment sheet for 05/31/2025 7a-7p. S3DON confirmed that S7MHT called out prior to her shift and stated the call out wasn’t communicated. S3DON further confirmed that the night shift MHT’s should not have left their shift until they were relieved by another MHT to replace them. S3DON stated that the other units had available staff that could have been reassigned to meet the needs of the unit. S3DON confirmed S4RN did not attempt to call another unit to send an MHT to maintain 1:1 observations of Patient #1 or call the DON and inform her that they didn’t have staffing to meet the needs of the unit. S3DON stated that the shift started at 7AM, and the incident occurred an hour after shift change. S3DON confirmed 1:1 observations were not performed per hospital policy. S3DON also confirmed that S4RN neglected to maintain provider orders for 1:1 observation for Patient #1, which potentially led to the sexual assault allegation. In an interview on 06/24/2025 at 11:26 AM, S5MHT confirmed that she informed S4RN at the beginning of the shift that S7MHT had not arrived to the unit and that the night shift MHT’s had gone home. S5MHT stated that S4RN’s response was that S7MHT was probably just late. S5MHT also confirmed that at this time she informed S4RN that she was the only MHT and that Patient #1 was a 1:1 observation level. S5MHT further stated that S4RN did not assist in maintaining 1:1 observations of Patient #1. S5MHT also confirmed that at the time of the incident she was the only MHT on the unit.”

“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: 50453 Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by: 1) failure to accurately self-report an incident involving alleged sexual assault of a patient with an intellectual disability; and 2) failure to self-report incidents involving allegations of abuse/neglect within 24 hours to the Department of Health and Hospitals in 5 (#3, #R1-#R4) of 5 (#3, #R1-#R4) incidents reviewed for abuse/neglect. Findings: 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.” Review of hospital policy titled “Abuse and/or Neglect of Patients,” approved January 2025, revealed in part: “Community Care Hospital implements the Louisiana State mandated report law.” 1) Failure to accurately self-report an incident involving alleged sexual assault of a patient with an intellectual disability. Review of Patient #1’s medical record revealed Patient #1 was a 23 year old female admitted on 05/29/2025 with a diagnosis of Major Depressive Disorder (MDD). Review of the Coroner Emergency Certificate (CEC) dated 05/30/2025 revealed in part that Patient #1 had a history of schizophrenia and mild intellectual disability. Review of the progress note on 06/02/2025 by S6MD revealed in part: Patient #1 has history of schizophrenia and mild intellectual disability. On 05/30/2025, Patient #1 had an order placed for 1:1 observations. Review of Psychiatric Evaluation dated 05/30/2025 revealed in part: Throughout the interview, Patient #1 was somewhat hypersexual and alluded that she may have asked anybody to help her process her feelings that she can get close to. On the morning of 05/31/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with Patient #2. Further review revealed Patient #1 had orders for 1:1 observations prior to the incident. Patient #1 was transferred on 05/31/2025 to the ER for an evaluation and returned later that night. Review of Patient #2’s medical record revealed Patient #2 was a 44 year old male admitted on 05/27/2025 with a diagnosis of Depression, Suicidal Ideations, and Auditory Hallucinations. On the morning of 05/31/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with Patient #2. Further review revealed Patient #2 was discharged on 05/31/2025 into police custody. Review of the Daily Nursing Assignment Sheet dated 05/31/2025 7a-7p revealed a census of 8 patients. Further review revealed that Patient #1 was on a 1:1 level of observation and was assigned to S7MHT. Review of the Hospital/Licensed Provider Abuse/Neglect Initial Report finalized on 05/05/2025 revealed in part the following documentation: Incident Type: Alleged Neglect (Patient to Patient Sexual Assault) Date/Time of Incident: 05/31/2025 at 8:02 AM Date/Time of Discovery: 05/04/2025 at 8:05 PM Patient Information documented on report included: Patient #1 as Victim/Aggressor not documented Patient #2 as Victim/Aggressor not documented Incident details revealed in part: Patient #1 and Patient #2 were discovered in Room a by S5MHT engaged in sexual activity. Penetration was not observed by S5MHT. Five minutes after the incident all patients except Patient #1 went down to breakfast. Patient #1 requested to remain on the floor with S4RN. Patient #1 stated that she went into the bathroom voluntarily, that she pulled her pants down, but she didn’t know what was going to happen. Patient #1 stated later that intercourse occurred. Patient #1 wanted to press charges and law enforcement was notified. Patient #2 was taken into police custody. Patient #1 was sent to ER for an evaluation. During readmission nursing assessment she prompted the following notation, Patient #1 “denies ever having been sexually, physically or emotionally abused.” Patient #1 was on 1:1 observation status. Patient #2 was on Q15 minute observation. Census on the unit was 9 patients. Assigned Staff: 1 RN, 2 MHT’s. Staff Present: 1 RN, 1 MHT. Initial Actions Taken revealed in part the following: Patient #1 and Patient #2 were separated and Patient #2 went down to breakfast, with Patient #1 remaining on the unit, creating greater separation. Patient #2 was detained by law enforcement. No other patients were involved in the direct incident. When Patient #1 returned to the facility she was admitted to a different floor to avoid uncomfortable interaction or embarrassment. S4RN was suspended until further notice for failing to facilitate and maintain the 1:1 status on Patient #1. Comments Section revealed in part the following: Excerpts from nursing note describing the events of 06/02/2025: Patient #1 told the MHT that she wants to tell the truth and that it was the voices telling her to say that she was raped. Patient #1 admits that she had sex but he did not force her. At 2 PM, Patient #1 met with the detective. Patient #1 admits that she had sex but she had agreed to it and Patient #1 does not want Patient #2 to go to jail for something that he did not do. Investigation Results revealed in part: The allegation is unable to substantiate due to lack of evidence. Update, the allegations of sexual assault have been found to be unsubstantiated (see comment section). The report failed to reveal that Patient #1 had an Intellectual disability. Further review of the report failed to reveal that S7MHT, who was assigned to Patient #1, had called out for her shift. The report also failed to reveal that 1:1 observations were not being followed for Patient #1 prior to the incident. Additionally, the report failed to substantiated the allegation of neglect. In an interview on 06/24/2025 at 10:15 AM, S3DON confirmed that Patient #1 was 1:1 at the time of the incident. S3DON confirmed that at S7MHT was assigned on the assignment sheet for 05/31/2025 7a-7p. S3DON confirmed that S7MHT called out prior to her shift and it wasn’t communicated. S3DON confirmed that prior to Patient #1 telling S4RN about the alleged rape, S3DON did not know that there was not enough staff to perform 1:1 observation and ensure patient safety. S3DON further confirmed that S4RN assign another staff member to Patient #1 in order to maintain the order for 1:1 observation, which potentially led to the sexual assault allegation. In an interview on 06/24/2025 at 11:26 AM, S5MHT confirmed that upon arrival to her shift on 05/31/2025 when S7MHT did not arrive for her shift, she informed S4RN that she was the only MHT and that Patient #1 was 1:1 observation. S5MHT stated that she tried to keep Patient #1 with her while she performed unit tasks. S5MHT also confirmed that S4RN made no attempt to assist with performing 1:1 observations of Patient #1 or call another unit to get assistance with coverage. S5MHT stated when she went to put up the vital sign machine, she was unable to locate Patient #1. S5MHT stated she then discovered Patient #1 and Patient #2 in the bathroom together and separated them. S5MHT confirmed that at time of discovery she had not been told by Patient #1 about the alleged rape. S5MHT further confirmed that Patient #1 asked to remain on the unit with the nurse while S5MHT took the other patients to breakfast. S5MHT also stated that prior to exiting the unit with the other patients, she informed S4RN that she discovered Patient #1 and Patient #2 in the bathroom together. In an interview on 06/24/2025 at 2:16 PM, S1ADM confirmed the above mentioned findings. S1ADM also confirmed the report did not reveal that Patient #1 had an intellectual disability. S1ADM confirmed that the report was unsubstantiated because Patient #1 recanted her original statement of rape and stated to law enforcement she wasn’t telling the truth. S1ADM confirmed that staff neglected to provide a safe environment for Patient #1 by not ensuring that she remained on 1:1 observations as ordered by the provider. 2) Failure to self-report incidents involving allegations of abuse/neglect within 24 hours to the Department of Health and Hospitals in 5 (#3, #R1-#R4) of 5 (#3, #R1-#R4) incidents reviewed for abuse/neglect. Review of the hospital’s Incident Log for October 2024 to January 2025 revealed the following incidents involving allegations of abuse/neglect listed: Patient #3 Review of the hospital’s Incident Report involving Patient #3 revealed in part the following: Date/Time of Incident: 11/03/2024 (no time) Type of Incident: Sexual Behavior Describe what happened: Patient stated that he was raped last night in his sleep. He called his mother to also report that he was raped. In an interview on 06/25/2025 at 2:40 PM, S1ADM stated he did not self-report the sexual assault because Patient #3 was psychotic. Patient #3 (2nd Incident) Review of the hospital’s Incident Report involving Patient #3 revealed in part the following: Date/Time of Incident: 11/04/2024 at 1:45 PM Type of Incident: Elopement Describe what happened: Per Security guard, patient got off elevator and ran out front door. Patient #R1 Review of the hospital’s Incident Report involving Patient #R1 revealed in part the following: Date/Time of Incident: 01/13/2025 (no time) Type of Incident: Elopement Describe what happened: Security called and stated Patient #R1 ran past him and out the back door as staff were entering in hospital. Patient #R2 Review of the hospital’s Incident Report involving Patient #R2 revealed in part the following: Date/Time of Incident: 10/15/2024 at 12:00 PM Type of Incident: Elopement Describe what happened: Patient #R2 was in the cafeteria, then he went into bathroom within cafeteria. Patient #R2 then ran into the lobby and escaped through the front exit. Patient #R3 Review of the hospital’s Incident Report involving Patient #R3 revealed in part the following: Date/Time of Incident: 12/12/2024 at 12:45 PM Type of Incident: Elopement Describe what happened: Patient #R3 jumped over gate on smoking patio. Patient #R4 Review of the hospital’s Incident Report involving Patient #R4 revealed in part the following: Date/Time of Incident: 10/14/2024 at 3:15 PM Type of Incident: Sexual Behavior Describe what happened: Patient #R4 states she asked male peer to tie her hair back. States he squeezed her left breast. In an interview on 06/24/2025 at 2:14 PM, S1ADM confirmed the above mentioned incidents were not self-reported. S1ADM further confirmed they were only reported to law enforcement.”

“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 failing to immediately address any clinical assessments on 2 (#1, #3) of 3 (#1-#3) patient records reviewed for alleged sexual assault. Findings: Review of hospital policy titled, “Admit Nursing Assessment,” approved January 2025, revealed in part: “Purpose: To systematically collect relevant data about the patient as the initial step of the nursing process. To continually collect and review patient specific data throughout the patient’s hospitalization. To accurately document assessment findings on an approved form in the medical record. 5. Assess each patient at the time of admission and continually throughout the patient’s hospitalization at least twice a day or as warranted by changes in the patient’s care needs though the systematic collection of data in the following areas: biophysical, psychosocial, risk/environmental and educational.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 05/29/2025 with a diagnosis of Major Depressive Disorder (MDD). Review of the Coroner Emergency Certificate (CEC) dated 05/30/2025 revealed in part that Patient #1 had a history of schizophrenia and mild intellectual disability. On the morning of 05/31/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with Patient #2. Nursing Notes revealed in part, that the incident occurred at 8:03 AM. Patient #1 was interviewed by law enforcement. Patient #1 was transferred on 05/31/2025 at 10:15 AM to the ER for an evaluation. Review of Patient #1’s medical record failed to reveal documented evidence that a clinical assessment was performed by a nurse or provider following the alleged sexual assault prior to being transferred to the ER for an evaluation. In an interview on 06/25/2025 at 2:00 PM, S3DON confirmed that a clinical assessment was not documented by a nurse or the provider following the alleged sexual assault of Patient #1. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 11/01/2024 with an admit diagnosis of Schizoaffective Disorder, Bipolar type. Review of nursing note on 11/03/2024 at 6:05 PM revealed in part the following: Patient #3’s mother called to inform her that we are investigating the accusation of him being raped in his sleep last night. Patient #3’s mother talked about how Patient #3 has made accusations of being raped at prior hospitals and when it was investigated it was not substantiated. Review of Patient #3’s medical record failed to reveal documented evidence that a clinical assessment was performed by a nurse or provider following the alleged sexual assault. In an interview on 06/25/2025 at 2:45 PM, S1ADM and S3DON confirmed that a clinical assessment was not documented by a nurse or the provider following the alleged sexual assault of Patient #3. S1ADM stated that camera footage was reviewed and no one entered his room throughout the night.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient. This deficient practice was evidenced by: 1) failure to update the treatment plan following an incident for 2 (#1, #3) of 3 (#1-#3) patient records reviewed; and 2) failure of the nursing staff to include medical diagnoses in the treatment plan for 2 (#1, #2) of 3 (#1-#3) patient treatment plans reviewed. Findings: Review of hospital policy titled, “Master Treatment Plan/Weekly Update Treatment Plan,” approved January 2025, revealed in part: “PURPOSE: To provide comprehensive, individualized plan of treatment for each patient. Procedure: B. Treatment plans will be individualized to address patient specific problems, identified through clinical assessments.” 1) Failure to update the treatment plan following an incident for 2 (#1, #3) of 3 (#1-#3) patient records reviewed. Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 05/29/2025 with an admit diagnosis of Major Depressive Disorder and a wound to her left arm from a suicide attempt prior to admission. Further review of Patient #1’s medical record revealed on 05/30/2025 that Patient #1 attempted to tear her stitches from her left arm. Further review failed to reveal that wound care was added to Patient #1’s treatment plan. In an interview on 06/25/2025 at 1:19 PM, S3DON confirmed the above mentioned findings. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 11/01/2024 with an admit diagnosis of Schizoaffective Disorder, Bipolar type. Review of Patient #3’s physician orders revealed in part that Patient #3 was placed on elopement precautions on 11/03/2024 at 6:40 PM. Further review of Patient #3’s treatment plan failed to reveal that Patient #3’s treatment plan was updated to include risk for elopement. In an interview on 06/25/2025 at 3:06 PM, S1ADM confirmed the above mentioned findings. 2) Failure of the nursing staff to include medical diagnoses in the treatment plan for 2 (#1, #2) of 3 (#1-#3) patient treatment plans reviewed. Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 05/29/2025 with Major Depressive Disorder and a wound to her left arm from a suicide attempt prior to admission. Further review of Patient #1’s medical record revealed Patient #1 had a past medical history of HTN and GERD. Review of Patient #1’s treatment plan failed to reveal a treatment plan for the wound, HTN, or GERD. In an interview on 06/25/2025 at 1:19 PM, S3DON confirmed the above mentioned findings. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 05/27/2025 with depression, suicidal ideations, and auditory hallucinations. Further review of Patient #2’s medical record revealed Patient #2 had a past medical history of Schizoaffective disorder, Asthma, GERD, HIV, High Cholesterol, and HTN. Review of Patient #2’s treatment plan failed to reveal a treatment plan that included Asthma, GERD, High Cholesterol, or HTN. In an interview on 06/25/2025 at 3:10 PM, S3DON confirmed the above mentioned findings.”

“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: 50453 Based on record review and interview, the hospital failed to ensure all medical record entries were complete. This deficient practice is evidenced by failing to ensure medical records contained sufficient information to identify the patient for 2 (#1, #3) of 3 (#1-#3) medical records reviewed. Findings: Patient #1 A review of Patient #1’s medical record revealed the following documents completed by hospital staff: Columbia-Suicide Severity Rating Scale, dated 05/29/2025 Psychiatric Evaluation Note, dated 05/30/2025 History and Physical Examination (pages 1-4), dated 05/30/2025 Further review of Patient #1’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents. In an interview on 06/25/2025 at 2:30 PM, S3DON confirmed the above mentioned medical record documents did not contain information to identify the patient. Patient #3 A review of Patient #3’s medical record revealed the following documents completed by hospital staff: History and Physical Examination (pages 1-3), dated 11/01/2024 Consent to Release/Obtain information, not dated Columbia-Suicide Severity Rating Scale, dated 11/01/2024 Further review of Patient #3’s medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents. In an interview on 06/25/2025 at 4:00 PM, S3DON confirmed the above mentioned medical record documents did not contain information to identify the patient.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. Findings: During the facility tour February 6, 2025 between the hours of 8:00 a.m. to 9:30 a.m. the elevator recall fire alarm system had a trouble alarm and lacked a annual certification from a license ed fire alarm company. The interview with Maintenance Supervisor revealed the facility was not aware that the required annual fire alarm inspection had not been conducted on the fire alarm system nor was the Maintenance Supervisor aware the fire alarm was indicating a battery trouble alarm.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital failed to ensure each patient/patient representative was informed of patient rights. This deficient practice is evidenced by failure to inform patient/patient’ representative of patient’s rights in advance in a language or manner non-English speaking Patients #1 and #2 could understand. Findings: Review of psychiatric hospital’s policy titled “Patient Rights”, approved 01/2024, revealed in part: Community Care Hospital supports and protects the basic human, civil, and constitutional rights of all patients. All patients have the right to ...6. receive, as soon as possible, the services of a translator or interpreter to facilitate communication between the patient and the hospital’s health care personnel ...7 ...participate in the development and implementation of his/her plan of care ... Patient #1 Review of Patient #1’s medical record revealed an admission date of 08/19/2024 with diagnoses Major depressive disorder and anxiety disorder. Review of Biopsycholsocial Assessment dated 08/20/2024 revealed primary language was Spanish. Review of Conditions of Admission and Consents dated 08/19/2024 at 12:22 p.m. failed to reveal evidence the psychiatric hospital used an interpreter/translator to assist with Patient #1’s understanding and agreement with the acknowledgment of his rights as a patient, privacy rights, restraint rights, safe keeping of his personal property, and end of life decisions. Patient #2 Review of Patient #2’s medical record revealed an admission date of 08/07/2024 with diagnoses substance abuse, psychosis and anxiety. Review of Psychiatric Evaluation dated 08/07/2024 revealed patient’s primary language was Spanish. Review of Conditions of Admission and Consents dated 08/07/2024 at 5:15 a.m. failed to reveal evidence the psychiatric hospital used an interpreter/translator to assist with Patient #1’s understanding and agreement with the acknowledgment of his rights as a patient, privacy rights, restraint rights, safe keeping of his personal property, and end of life decisions. In an interview on 09/24/2024 at 8:40 a.m., S2DON confirmed the above findings regarding Patient #1 adn Patient #2.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital failured to use an interpreter/translator to assist non-English speaking patients #1 and #2 in understanding and agreeing with multiple consents found in the Conditions of Admissions and Consents packet. Findings: Review of psychiatric hospital’s policy titled “Informed Consent”, approved 01/2024, revealed in part: ... Consents shall be obtained by the patient or legal representative and placed in the patient’s medical record for: treatment by psychiatric hospitalization, treatment by medical procedure, informed consent for medication, general nursing duty, restraint & seclusion, audio/video surveillance, patient identification photography, ineligibility of medication/drug possession, emergency agreement, transport release, personal valuables, bill of rights, assignment of insurance benefits, financial agreement, release of information, notice of advanced directives, privacy practices ...Procedure: Consent for psychiatric and medical treatment shall be signed by the patient or legal guardian at the time of admission and is valid for the duration of the current hospital admission. Patient #1 Review of Patient #1’s medical record revealed an admission date of 08/19/2024 with diagnoses Major depressive disorder and anxiety disorder. Review of Patient #1’s Biopsycholsocial Assessment dated 08/20/2024 revealed patient’s primary language was Spanish. Review of Conditions of Admission and Consents failed to reveal evidence the psychiatric hospital used an interpreter/translator to assist with Patient #1’s understanding and agreement with the acknowledgment of his informed consent to treat: Psychiatric Hospitalization, Consent to Medical Procedures, Informed Consent for Medications, General Duty Nursing Audio/Video Surveillance, Patient Identification photography, Drugs, Emergency Agreement, Transport Release, Assignment of Insurance Benefits, Financial agreement, and Release of Information. Patient #2 Review of Patient #2’s medical record revealed an admission date of 08/07/2024 with diagnoses substance abuse, psychosis and anxiety. Review of Patient #2’s Psychiatric Evaluation dated 08/07/2024 revealed patient’s primary language was Spanish. Review of Conditions of Admission and Consents failed to reveal evidence the psychiatric hospital used an interpreter/translator to assist with Patient #2’s understanding and agreement with the acknowledgment of his informed consent to treat: Psychiatric Hospitalization, Consent to Medical Procedures, Informed Consent for Medications, General Duty Nursing Audio/Video Surveillance, Patient Identification photography, Drugs, Emergency Agreement, Transport Release, Assignment of Insurance Benefits, Financial agreement, and Release of Information. In an interview on 09/24/2024 at 8:40 a.m., S2DON confirmed the above findings regarding Patient #1 and Patient #2.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to meet the Condition of Participation for Governing Body. The hospital’s governing body failed to effectively carry out its responsibilities for the conduct of the hospital for the hospital’s compliance not only with the specific standards of the governing body CoP, but also with the following CoPs. This deficient practice is evidenced by: 1) failure of the governing body to protect and promote each patient’s rights, which resulted in two Immediate Jeopardy Situations. S1ADM was notified on 08/06/2024 at 1:46 p.m. of the first Immediate Jeopardy situation resulting from failure of the hospital to prevent patient access into the kitchen where items that could be used as weapons are kept. S1ADM was notified on 08/07/2024 at 7:56 p.m. of the second Immediate Jeopardy situation resulting from the hospital failure to provide supervision as ordered by the physician. (See Findings in A0115); 2) failure of the governing body to ensure the hospital had an organized nursing service. This noncompliance resulted in a third Immediate Jeopardy situation. S1ADM was notified on 08/08/2024 at 3:35 p.m. the Immediate Jeopardy situation existed resulting from the hospital failure to ensure the registered nurses did not practice out of their scope of practice. (See findings in A0385); 3) failure of the governing body to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators. Failure of the governing body to ensure the hospital’s Quality Assurance and Performance Improvement (QAPI) program identified opportunities for improvement, implemented effective action, measured success and tracked performance. Failure of the governing body to ensure the hospital tracked and analyzed all events involving abuse and neglect. Failure of the governing body to ensure the medical staff and administrative officials were responsible and accountable for implementing and maintaining an ongoing program for quality improvement and patient safety. Failure of the governing body to ensure sufficient staff was available to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital (See findings in A0263); 4) failure of the governing body to ensure an active hospital-wide program for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. Failure of the governing body to ensure programs that demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms (See findings in A0747); 5) failure of the governing body to ensure an effective Utilization Review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs (See findings in A652). 6) failure of the governing body to consult directly with the member/members of the hospital’s medical staff assigned the responsibility for the organization and conduct of the hospital’s medical staff (See findings in A0053).”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47397 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: 1) failure of the hospital to provide supervision as ordered by the physician which resulted in an Immediate Jeopardy Situation. S1ADM was notified on 08/07/2024 at 7:56 p.m. The hospital provided the following plan of removal for the Immediate Jeopardy situation 08/12/2024 at 9:55 a.m.: A. Director of Nursing observed PM shift on 8/7/2024 via remote surveillance. As a result, the MHT from 8/3/2024, who was observed then with electronics, food, and delinquency in Q15 rounded, will be terminated immediately for neglect and false documentation during the 8/7/2024 PM shift. B. Immediate reeducation of RNs and MHTs to include: 1. Purpose-To establish guidelines and procedures for completion of the Patient Observation Record Sheet. To ensure that the patient’s safety and well-being are maintained and documented. To have a continuous record of patient behavior and location. 2. Policy 4.2.0 PATIENT OBSERVATION RECORD a. Emphasizing 15 minute rounds for Mental Health Technicians and 2 hour rounds for Charge Nurses. b. Precaution Level ordered for each patient: i. Suicide Precautions ii. Assault Precautions iii. Elopement Precautions iv. Fall Precautions v. Seizuure Precautions c. Level of Observation ordered for each patient: i. Close Observation with Unit Restriction ii. Close Observation without Unit Restriction iii. Visual Contact iv. 1:1 v. Other 3. Focus on the Mission Statement: a. “It is the mission of Community Care Hospital to continually improve the health and well-being of our patients, and to provide caring and personal treatment to our patients and their families.” 4. Education will be confirmed by the signature of the employee and placed in the personnel file. Return demonstration executed in real time and monitored by video surveillance. C. Immediate real time video review and confirmation of PM shift rounding to include; 2 hour RN rounding and Q15 MHT rounding. D. The Administrator, DON, or designee will view historical video from 18:30 to 06:30 in 2-hour intervals commencing at 20:00, 22:00, 00:00, 02:00, 04:00, and 06:00 while the shift is ongoing “real time.” All 12 hours of video will be reviewed. E. This video review will remain nightly until 90% compliance is demonstrated for Q15s and 100%compliance for 2-hour RN rounds. F. After that compliance level has been maintained for 2 weeks, the video review will change to a random 3 night a week schedule. G. When compliance levels are maintained for 1 month, weekly next day video review will commence on a random night rotation for quality and performance improvement. H. Enforcement of progress discipline will be imposed on all staff members found to be out of compliance including termination. I. Compliance data will be collected and included in the nursing QAPI reports. J. Immediate termination of the Charge Nurse who displayed egregious disregard for the safety and wellbeing of the patients in his care on 08/06/2024. This Charge Nurse will also be reported to the Louisiana Board of Nursing for neglect and false documentation. K. Current staff must complete training prior to shift with ongoing training until total staff is completed On 08/12/2024 at 3:29 p.m., the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiencies remain at Condition levels (See findings in A0144); 2) failure of the hospital to prevent patient access into the kitchen where items that could be used as weapons are kept resulted in an Immediate Jeopardy Situation. S1ADM was notified on 08/06/2024 at 1:46 p.m. The hospital provided the following plan of removal for the Immediate Jeopardy situation 08/07/2024 at 8:37 a.m.: A. It was determined that this door is not a protected fire exit. B. The door can be closed and locked. C. A key lock will be placed on this door immediately on Tuesday 08/06/2024. D. The door will be locked unless food service is underway. At that time, the door will be locked upon ingress and egress. E. A door alarm will be installed by 08/07/2024 that will activate a tone when the door is opened. F. A sign with the following information will be posted on both sides of the door: 1. This Door Must Remain Locked At All Times! 2. You Must Lock The Door Each Time You Pass In Or Out! G. Staff will be educated through a communication memo in the Communication binder located on each unit (entered 08/06/2024) and face to face at the beginning of each shift until all current staff have signed off on the education. H. Orientation to which key and confirmation of the “always locked” requirement will be included. I. The education will also include the possible impact on patient and staff safety if the door is not locked. J. Corrective actions to be completed 08/15/2024 including the education of current staff. On 08/07/2024 at 9:00 a.m., the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiencies remain at Condition levels(See findings in A0144); 3) failure to ensure incidents involving serious and unexplainable injuries are investigated and reported in order to determine if abuse or neglect had occurred (See findings in A0145); 4) failure to ensure restraint and seclusion was used only when less restrictive interventions had been determined to be ineffective to protect the patients from harm. (See findings in A0164); 5) failure to ensure the patients basic right to respect, dignity, and comfort while in restraints and seclusion (See findings in A0143); 6) failure to ensure patients on suicide precautions are not provided clothing containing ligature risk (See findings in A0144); 7) failure to ensure staff does not provide items considered ligature risks to patients (See findings in A0144); 8) failure to ensure the hospital’s security staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills (See findings in A0200); 9) failure to ensure security staff personnel records contained documentation demonstrating that Orientation was successfully completed and Patient Rights competencies had been successfully completed upon hire (See findings in A0208); 10) failure to ensure required numbers of staff when transporting patients in the elevator (See findings in A0144); 11) failure to ensure all exit doors were secure (See findings in A0144); 12) failure to ensure patients are escorted off unit in a manner to maintain safety (See findings in A0144); 13) failure to ensure sharps are disposed of in a manner to minimize the potential for injury (See findings in A0144); 14) failure to secure staff personal belongings (See findings in A0144); 15) failure to ensure patients did not have access to items considered ligature risk and contraband (See findings in A0144); 16) failure to ensure maintenance cart filled with tools that could be potential weapons was covered in patient care areas (See findings in A0144); and 17) failure to properly label Embrace Pro Glucose Test Strips and Embrace Pro Control Solutions upon initial opening of new containers (See findings in A0144).”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48050 Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. This deficient practice is evidenced by: 1) the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators (see findings in A-0273); 2) the hospital’s Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement, implement effective action, measure success and track performance related to not having quality improvement activities (see findings in A-0283); 3) the hospital failed to track and analyze all events involving abuse and neglect. The deficient practice is evidenced by failure to investigate several patient-to-patient, patient-to-staff, and staff-to-patient incidents. (see findings in A-0286); 4) the hospital’s governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program (see findings in A-0309) and 5) the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital’s performance by having insufficient staff designated to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital. (see findings in A-0315).”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 44495 Based on record review, and interview the facility failed to meet the requirements for the Condition of Participation (CoP) for Nursing Services. The deficient practice is evidenced by failure of the nursing staff to contact the licensed practitioner for patient orders at the time of admission (see Findings in A-0405). Findings: An Immediate Jeopardy situation was identified after consultation with State Office, on 08/08/2024 at 3:35 p.m., S1ADM was notified that the practice of allowing the nursing staff to fill out the admission and medication orders without consulting the licensed practitioner was outside of the scope of practice for a registered nurse and placed all 19 admitted patients and future admitted patients at risk for serious injury, serious harm, and serious impairment or death. To verify the nursing practice of filling out admission and medication orders without consulting the licensed practitioner was not an isolated event as suggested by S1ADM, S31RN was interviewed on 08/08/2024 at 3:51 p.m. S31RN verified the admitting nurse chose which as needed medications each patient would be prescribed and fill out the admission orders without consulting the admitting licensed practitioner. On 08/12/2024 plan of correction was presented to State Office. The plan included encouraging the use of electronic or faxed orders by the licensed practitioners and discouraging the routine use of verbal admission orders. Nursing staff was immediately re-education on the verbal order policy and the medication administration policy. A final plan to ensure adherence would be developed by 08/14/2024. The Immediate Jeopardy was removed on 08/12/2024 at 3:29 p.m., but there was not enough evidence to determine sustainability of compliance for the Condition of Nursing Services to be cleared. Noncompliance remains at the Condition Level.”

“UTILIZATION REVIEW CFR(s): 482.30 The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. This Condition is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to meet the Conditions of Participation (CoP) of Utilization Review. This deficient practice was evidenced by the hospital failing to have an effective utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. This deficient practice was evidenced by the hospital failing to provide a utilization review (UR) plan that provides for the review of the medical necessity of admissions, duration of stays and professional services rendered to patients furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. (See Findings A-0653).”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47397 Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Infection Control by failure to have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. This was evidenced by failure of the hospital to maintain an infection prevention and control program which included surveillance, prevention, and control of HAIs, and maintainance of a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities (See findings in A749 and A0750).”

“CONSULTATION WITH MEDICAL STAFF CFR(s): 482.12(a)(10) [The governing body must:] §482.12(a)(10) Consult directly with the individual assigned the responsibility for the organization and conduct of the hospital’s medical staff, or his or her designee. At a minimum, this direct consultation must occur periodically throughout the fiscal or calendar year and include discussion of matters related to the quality of medical care provided to patients of the hospital. For a multi-hospital system using a single governing body, the single multi-hospital system governing body must consult directly with the individual responsible for the organized medical staff (or his or her designee) of each hospital within its system in addition to the other requirements of this paragraph (a). This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital’s governing body failed to consult directly with the member/members of the hospital’s medical staff assigned the responsibility for the organization and conduct of the hospital’s medical staff, or his or her designee. This deficient practice is evidenced by failure to provide documented evidence of direct consultation with medical staff assigned the responsibility for the organization and conduct of the hospital’s medical staff, or his or her designee. Findings: Review of the Medical Staff Bylaws, no documented date of last review but was presented to the surveyors as the current bylaws, revealed in part: Section 2. Committees and Subcommittees in part: A ....The function of the Medical Executive Committee shall include, but not be limited to, in part: 2) receiving and acting upon reports and recommendations from medical staff committees, subcomittees, services and assigned activity groups and reporting these activities to the Governing Board. 8) reviewing and discussing matters of hospital and medical staff policy, practice, planning as requested by ...the Governing Board. Review of Governing Board Meeting minutes dated 01/09/2024-07/31/2024, failed to reveal documented evidence of direct consultation with medical staff assigned the responsibility for the organization and conduct of the hospital’s medical staff, or his or her designee. In an interview on 08/05/2024 at1:07 p.m., S1ADM confirmed that the Governing Board Meeting minutes dated 01/09/2024-07/31/2024 failed to reveal documented evidence of direct consultation with medical staff assigned the responsibility for the organization and conduct of the hospital’s medical staff, or his or her designee.”

“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: 48051 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 was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient’s plan of care for 6 (#6, #R1, #R3 - #R6) of 16 (#1- #7, #R1 - #R9) patient medical records reviewed for care plan development and implementation. Findings: Review of the hospital’s policy titled, “Patient Rights”, approved 06/2024, revealed in part: Procedure, in part: ...All patients have the right to ...7. The right to participate in the development and implementation of his/her plan of care. 8. Make informed decisions regarding his/her care. 9. Be informed of his/her health status, be involved in care planning and treatment, and be able to request or refuse treatment. A medical record review on 08/12/2024 for patient participation in the development and implementation of patient’s treatment plan of care revealed: Patient #6 was admitted 08/05/2024 and the current treatment plan was dated 08/05/2024 at 9:49 a.m. The treatment plan revealed in part: “A Treatment Plan was created or reviewed today, 08/05/2024, for Patient #6.” Further review failed to reveal documentation Patient #6 participated in the development in his plan of care. Patient #R1 was admitted 08/04/2024 and the current treatment plan was dated 08/05/2024 at 9:42 a.m. The treatment plan revealed in part: “A Treatment Plan was created or reviewed today, 08/05/2024, for Patient #R1.” Further review failed to reveal documentation Patient #R1 participated in the development in his plan of care. Patient #R3 was admitted 08/06/2024 and the current treatment plan was dated 08/07/2024 at 9:24 a.m. The treatment plan revealed in part: “A Treatment Plan was created or reviewed today, 08/07/2024, for Patient #R3.” Further review failed to reveal documentation Patient #R3 participated in the development in his plan of care. Patient #R4 was admitted 07/31/2024 and the current treatment plan was dated 08/01/2024 at 9:40 a.m. The treatment plan revealed in part: “A Treatment Plan was created or reviewed today, 08/01/2024, for Patient #R4.” Further review failed to reveal documentation Patient #R4 participated in the development in his plan of care. Patient #R5 was admitted 08/03/2024 and the current treatment plan was dated 08/05/2024 at 9:35 a.m. The treatment plan revealed in part: “A Treatment Plan was created or reviewed today, 08/05/2024, for Patient #R5.” Further review failed to reveal documentation Patient #R5 participated in the development in his plan of care. Patient #R6 was admitted 07/29/2024 and the current treatment plan was dated 07/29/2024 at 9:44 a.m. The treatment plan revealed in part: “A Treatment Plan was created or reviewed today, 08/05/2024, for Patient #R6.” Further review failed to reveal documentation Patient #R6 participated in the development in his plan of care. In an interview on 08/12/2024 at 2:00 p.m. S2DON 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: 47397 Based on observation and interview the hospital failed to ensure Patient #2’s basic right to respect, dignity, and comfort while in restraints and seclusion. Findings: Review of hospital’s policy titled, “Patient Rights,” approved 06/2024, revealed in part: Procedure: ...4. The right to be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment. Review of Patient #2’s medical record revealed a diagnosis of Down’s Syndrome. On 08/05/2024 at 3:15 p.m., a review of video footage for the night of 08/03/2024 at 8:48 p.m. was navigated by S1ADM. Review of footage of Unit A revealed staff carrying Patient #2, naked except for a shirt bunched up around her neck and around her armpits. Patient #2 was carried by her arms and legs out of her bedroom, past Unit A’s nurses station, down Unit A hallway towards Unit A seclusion room. Patient #2 remained in seclusion room on a bare mattress with no sheet and with no clothes to the bottom half of her body. At 12:16 a.m. she was provided with green, drawstring-waist scrub pants just before she left Unit A’s seclusion room. In an interview on 08/08/2024 at 12:30 p.m., S1ADM confirmed the above video findings. In an interview on 08/08/2024 at 12:40 p.m., S2DON stated that staff should have attempted to provide Patient #2 clothing to protect her right to respect and dignity.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 Based on observation, record review, and interview, the hospital failed to ensure patients receive care in a safe setting as evidenced by: 1) failure of the hospital to provide supervision as ordered by the physician of 17 (#1-#3, #5, #6, #R1, #R2, #R4-#R6, #R10-#R16) of 17 (#1-#3, #5, #6, #R1, #R2, #R4-#R6, #R10-#R16) psychiatric patients observed; 2) failure of the hospital to prevent patient access into the kitchen where items that could be used as weapons are kept; 3) failure to ensure patients on suicide precautions are not provided clothing containing ligature risk; 4) failure to ensure staff does not provide items considered ligature risks to patients; 5) failure to ensure required numbers of staff when transporting patients in the elevator; 6) failure to ensure all exit doors were secure; 7) failure to ensure patients are escorted off unit in a manner to maintain safety; 8) failure to ensure sharps are disposed of in a manner to minimize the potential for injury; 9) failure to secure staff personal belongings; 10) failure to ensure patients did not have access to items considered ligature risk and contraband; 11) failure to ensure maintenance cart filled with tools that could be potential weapons was covered in patient care areas; and 12) failure to properly label Embrace Pro Glucose Test Strips and Embrace Pro Control Solutions upon initial opening of new containers. Findings: 1) Failure of the hospital to provide supervision as ordered by the physician to 18 (#1-#3, #5, #6, #R1-#R6, #R10-#R16) of 18 (#1-#3, #5, #6, #R1-#R6, #R10-#R16) psychiatric patients observed. On 08/07/2024 at 2:50 p.m., a review of video footage navigated by S1ADM of Unit C on 08/03/2024 within the timeframe of 12:00 a.m. to 4:24 a.m. revealed the RN did not round every two hours. Further review revealed that the MHTs failed to round between: 12:00 a.m. to 12:30 a.m. (30 minutes) 12:30 a.m. to 2:30 a.m. (2 hours) 2:30 a.m. to 4:24 a.m. (1 hour and 54 minutes) Continued review revealed between 2:48 a.m. until 3:08 a.m. (20 minutes) there was only 1 MHT on the Unit C. On 08/07/2024 at 3:50 p.m. a review of video footage navigated by S1ADM of Unit A on 08/06/2024 from 9:36 p.m. to 11:00 p.m. revealed the registered nurse left the unit at 10:43 p.m. and did not return until 11:00 p.m. (17 minutes) leaving the 2 MHTs alone. Continued review of video footage of Unit A on 08/06/2024-08/07/2024 from 10:10 p.m. to 6:34 a.m. revealed the MHTs failed to round between: 10:10 p.m. to 10:35 p.m. (25 minutes) 11:05 p.m. to 12:12 a.m. (1 hour and 7 minutes) 12:20 a.m. to 12:55 a.m. (35 minutes) 12:55 a.m. to 1:35 a.m. (40 minutes) 1:56 a.m.-3:45 a.m. (1 hour and 49 minutes) 4:23 a.m. to 5:35 a.m. (1 hour and 12 minutes) 5:35 a.m. to 6:34 a.m. (59 minutes) Further review revealed S46RN was sitting in Unit A nursing station, in a chair, slumped with head bobbing and computer inactive at 11:26 p.m. until 2:00 a.m. (2 hours and 34 minutes). Additional review revealed S46RN remained in chair in nurses’ from 2:10 a.m. to 5:05 a.m. (2 hours and 55 minutes). Review of observation records failed to reveal documentation that S46RN completed his every 2 hour rounding as per policy from 12:00 a.m. until 6:00 a.m. (6 hours) on 08/07/2024. Review of patient records for Unit C revealed 1 patient (#R11) on visual contact and suicide precautions, 2 patients (#R12 and #3) on suicide and assault precautions, and 2 patients (#R2 and #R14) on suicide precautions. Review of patient records for Unit A revealed 1 patient (#6) on suicide, withdrawal and fall precautions, 2 patients (#2 and #R5) on seizure precautions and 1 patient (#R3) on visual contact precautions. In an interview on 08/07/2024 at 3:04 p.m., S1ADM confirmed rounding was not implemented per physician orders and hospital policy on patients #1-#3, #5, #6, #R1-#R6, #R10-#R16 by staff on the nights of 08/03/2024 and 08/06/2024-08/07/2024. S1ADM agreed this placed all 18 patients at risk for serious injury, serious harm, serious impairment or death. 2) Failure of the hospital to prevent patient access to items that could be used as weapons by leaving the door to the kitchen open during patient meal time. Observation of area oo 08/06/2024 at 11:28 a.m. revealed 7 (#R1-#R6) patients with 2 MHTs. Further observation revealed door to ss wide open with 1 staff member (S58Kit) in the kitchen preparing meals with her back to the open entry door. Continued observation from outside of the kitchen revealed the back door to the kitchen was ajar. In an interview on 08/06/2024 at 11:29 a.m., S58kit stated the back door is usually open in case she has deliveries or maintenance needs to enter. In an interview on 08/06/2024 at 11:28 a.m., S59MHT stated that the kitchen has many things like knives that are safety issues in the kitchen. S59MHT also reported that patients could elope out the back door of the kitchen or someone could unknowlingly come into the hospital from the open back door of the kitchen. 3) Failure to ensure patients on suicide precautions are not provided clothing containing ligature risk. Review of hospital’s policy titled “Patient Rights” dated 06/2024 revealed in part: All patients have the right to...18. ...receive care in a safe setting. Observations of hospital conference room on 08/05/2024 at 12:30 p.m. revealed stacks of green scrubs including pants with drawstring waistbands that extend to 4 ft 9 inches. Observations of Unit C on 08/05/2024 at 1:41 p.m. guided by S1ADM revealed Patient #1 in green scrubs with drawstring waist. Review of Patient #1’s medical record revealed Patient #1 was admitted on 08/05/2024. Further review revealed admit orders for suicide precautions. Observations of Unit A on 08/05/2024 at 2:08 p.m. guided by S1ADM revealed Patient #6 in green scrubs with drawstring waist. Review of Patient #6’s medical record revealed Patient #6 was admitted on 08/02/2024 at 8:00 p.m. Further review revealed admit orders for moderate suicide precautions. In an interview on 08/05/2024 at 12:57 p.m., S1ADM stated the green scrubs were provided to patients that were admitted without a change of clothing. S1ADM confirmed the green scrubs with drawstrings that extend to 4 ft 9 inches were a ligature risk and should not be available for patient use. In an interview on 08/05/2024 at 1:41 p.m., S1ADM stated that Patient #1 should be provided with alternative clothing immediately for her safety. S1ADM instructed an MHT to provide Patient #1 with appropriate clothing immediately. In an interview on 08/05/2024 at 2:33 p.m., S1ADM stated that Patient #6 should be provided with alternate clothing immediately. 4) Failure to ensure staff does not provide items considered ligature risks to patients. Observation on 08/05/2024 at 10:58 a.m. revealed room e. Continued observation revealed 7 zip ties in closet of room e. Review of census revealed Patient #6 was assigned to room e. Review of Patient #6’s medical record revealed Patient #6 was admitted on 08/02/2024 at 8:00 p.m. Further review revealed admit orders for moderate suicide precautions. In an interview on 08/05/2024 at 10:59 a.m., Patient #6 reported staff gave him the zip ties to help keep his pants from falling off. Patient #6 did not remember when staff gave him the zip ties and he could not recall the staff member’s name. In an interview on 08/052024 at 11:02 a.m., S1ADM verified that Patient #6 should not have zip ties because zip ties were considered a ligature risk. 5) Failure to ensure required numbers of staff when transporting patients in the elevator Review of hospital’s policy titled, “Escorting Patients Off the Unit”, dated 01/2024, revealed, in part: Policy Statement: Staff members assigned to escort a patient, or a group of patients shall be responsible for the safety and well-being of the individual and/or group from the time of leaving the unit until return to the unit. Purpose: To establish guidelines for the safe transport of patients off the unit. Procedure, in part: 1 ....The staff-patient ration will be no less than two staff members for every group of up to ten patients when leaving the secured nursing unit. This will apply to meal times and smoke breaks. 6. Staff members should see that the group stays together. Review of video footage dated 08/06/2024, navigated by S1ADM on 08/08/2024 at 12:59 p.m. revealed the following: View of area rr: 5:10 p.m. - Security guard stood in area rr with 7 patients. S39MHT and Patient #R2 not in camera view. 5:11 p.m. - S39MHT walked out of cafeteria to the elevator and with 7 patients on elevator held elevator door open. 5:12 p.m. - S39MHT held elevator open while security guard walked into cafeteria and walked out from dining room, arm-in-arm with Patient #R2 who appeared unsteady and escorted her on to elevator. 5:13 p.m.-S52MHT walked out of cafeteria with two pitchers of water and was not in the elevator with S39MHT leaving 1 MHT alone with the 8 patients View of Unit C: 5:16 p.m. - S39MHT picked Patient #R2 from under her arms and dragged her off elevator and set her on floor outside elevator. In an interview on 08/08/2024 at 1:05 p.m., S1ADM verified 2 MHT’s should have been in the elevator with 8 patients per hospital policy. 6) Failure to ensure all exit doors were secure. On 08/05/2024 at 11:05 a.m. toured the back stairwell from floor 2 down to first floor with S1ADM. 1st floor back stairwell opens into back hallway with an exit door to front lobby and an exit door to exterior of facility. The back exit door upon inspection was found partially ajar. The door was not secured and could be opened from the outside. During tour on 08/05/2024 at 11:07 a.m., S1ADM confirmed the findings above. On 08/06/2024 at 11:29 a.m., hospital video footage was reviewed for the day of the incident that occurred in room rr on 08/05/2024, navigated by S1ADM. Review of the video footage revealed the following: 08/05/2024 View of room rr: 4:09:39 p.m. - S39MHT enters into room rr and stops at door to stairwell with patients and family walking into room rr. S40MHT is behind the remaining patients and family walking into room rr. 4:09:48 p.m. - A visitor of R7 walks out the front entrance of the facility. 4:09:49 p.m. - R7 runs out front entrance. 4:09:54 p.m. - S39MHT turns and runs out door after R7. 4:10:02 p.m. - S24SEC stands up from desk, walks from desk toward front door. 4:10:07 p.m. - S24SEC at front door. 08/05/2024 View of outside front entrance: 4:09:54 p.m. - R7 viewed running out front door to the left down the street. S39MHT walks out front door. 4:11 p.m. - S39MHT returns to front door without R7 and is talking with visitor. Review of incident report revealed on 08/05/2024 at 4:10 p.m. R7 “left AMA after visitation with family. Patient ran out of front door lobby and jumped into her girlfriends car.” Type of incident: Elopement (law enforcement notified). Witnesses: S39MHT and S40MHT. Action taken: Law enforcement notified: “unavailable” Date & Time: 08/05/2024 at 4:10 p.m. S1ADM notified 4:32 p.m. S6PsyMD notified at 4:22 p.m. During interview on 08/06/2024 at 11:35 a.m. S1ADM confirmed that security is supposed to stand at front door entrance when patients enter and exit room rr. During interview on 08/06/2024 at 11:40 a.m. S1ADM confirmed that staff failed to secure the front door entrance when the patients and family entered room rr. S1ADM confirmed that he was notified of this incident at 5:41 p.m. on 08/05/2024. During interview on 08/06/2024 at 3:00 p.m. S24SEC confirmed that neither S39MHT nor S40MHT informed her that they were coming out of room oo into room rr in order for S24SEC to position herself at the front entrance. 7) Failure to ensure patients are escorted off unit in a manner to maintain safety Review of hospital’s policy titled, “Escorting Patients Off the Unit”, dated 01/2024, revealed, in part: Policy Statement: Staff members assigned to escort a patient, or a group of patients shall be responsible for the safety and well-being of the individual and/or group from the time of leaving the unit until return to the unit. Purpose: To establish guidelines for the safe transport of patients off the unit. Procedure, in part: 1 ....The staff-patient ration will be no less than two staff members for every group of up to ten patients when leaving the secured nursing unit. This will apply to meal times and smoke breaks. 6. Staff members should see that the group stays together. On 08/08/2024 at 11:52 a.m., hospital video review of Unit C on 08/07/2024, navigated by S1ADM revealed the following: 08/07/2024 7:49 p.m. - S18MHT and S39MHT rounding on patients. 7:50 p.m. - S45RN rounds on unit. 7:57 p.m. - S18MHT leaves Unit C with R8 and R9 via stairwell. 8:07 p.m. - S39MHT rounds on remaining patients on the unit. 8:11 p.m. - S18MHT returns to Unit C via elevator with R8 and R9. During an interview on 08/08/2024 at 12:12 p.m. S1ADM confirmed staff are not to take patients off the unit down a stairwell unless the elevator is out of service. S1ADM also confirmed that patients should not leave the unit to go smoke with only 1 MHT. 8) Failure to ensure sharps are disposed of in a manner to minimize the potential for injury Review of hospital policy titled, “Sharps,” last revised January 2023, revealed in part: Policy: Sharps include needles ... and “anything that might produce a puncture wound which would expose patients or employees to blood or other potentially infection material.” Any used contaminated sharp is to be treated as capable of transmitted blood borne pathogens. Purpose: To establish guidelines and procedures for sharps disposal. To minimize the potential of injury by puncture producing items. C. Uncooperative Patients: 1. Self-sheathing needles shall be used whenever possible. 2. The nurse shall be accompanied by as many personnel as deemed necessary to safely administer the infection or perform phlebotomy, or any necessary venipuncture. 3. If non-self-sheathing needles are used, a small sharps container is to be brought to the room prior to the injection, and all procedures as previously stated under needles are to be implemented. During an observation on 08/05/2024 of Unit C, Patient #2 was witnessed having seizure like activity in the main hallway at 10:44 a.m. S55RN medicated Patient #2 with an Intramuscular injection in the hallway. S55RN then walked through Unit C while holding the syringe with a used uncapped needle pointed upward, and went into room mm where he disposed of the used needle at 10:51 a.m. During an interview on 08/05/2024 at 10:45 a.m. S1ADM confirmed that staff should not be walking around with a used uncapped needle. S1ADM also confirmed that this could be used as a weapon by a patient. 9) Failure to secure staff personal belongings Review of hospital policy titled, “Employee Lockers,” last revised January 2024, revealed in part: Policy Statement: Our facility will provide a locker to each employee for his/her personal use. Procedure: 1. Our facility provides a locker ... for safekeeping his/her personal effects. On 08/05/2024 at 10:44 a.m., S52MHT was observed having her personal belongings (cross body purse) on her person while on the unit. While S52MHT was assisting a seizing patient during this time, S52MHT was observed removing her cross body purses and setting it on the floor behind her in the hallway. Further observation of S52MHT revealed that she put her cross body purse back on after assisting the patient, at which point she continued to wear it while in patient care areas. During an interview on 08/05/2024 at 11:00 a.m. S1ADM confirmed that employees should not have their personal belongings with them while on the unit. S1ADM also confirmed that the strap from the cross body purse could a ligature risk. On 08/07/2024 at 2:50 p.m., hospital video review of Unit C on 08/03/2024, navigated by S1ADM revealed S42MHT having a computer tablet on the table in front of him in the main hallway. During an interview on 08/07/2024 at 3:15 p.m., S1ADM confirmed that employees should not have their personal belongings with them while on the unit. S1ADM also confirmed that the computer tablet could be used as a weapon. On 08/08/2024 at 11:10 a.m., hospital video review of Unit A on 08/07/2024, navigated by S1ADM revealed S43MHT having a computer tablet on her lap while playing on her cell phone in the main hallway. During an interview on 08/08/2024 at 11:35 a.m., S1ADM confirmed that employees should not have their personal belongings with them while on the unit. S1ADM also confirmed that the computer tablet could be used as a weapon. On 08/08/2024 at 12:18 p.m., hospital video review of Unit A on 08/04/2024, navigated by S1ADM revealed S38MHT having a earbuds in her ear and a backpack on the floor next to her in the main hallway. Further review of the video revealed S38MHT leaving her personal belongings unattended. During an interview on 08/08/2024 at 12:30 p.m., S1ADM confirmed that employees should not have their personal belongings with them while on the unit. S1ADM also confirmed that the backpack could contain items that may be used to harm themselves or others. During an interview on 08/12/2024 at 1:15 p.m. S2DON confirmed that staff are not supposed to have personal belongings on the unit, stating it is a safety risk for the patients. 10) ensure patients did not have access to items considered ligature risk and contraband. Review of hospital’s policy titled, “Unit Safety Rounds Checklist,” section 4.14.0 approved 06/2024, revealed in part: Policy Statement: Safety is of utmost importance. The environment of care must be safe for psychiatric patient care. At the beginning of each shift, the Registered Nurse must oversee the environmental rounds to be done by the Mental Health Technicians ...Procedure: At the beginning of each shift, Mental Health Technicians must: 1. Make environmental rounds of their unit. 2. Correct or resolve any issues immediately (ie clear hallways ...remove contraband items from patient rooms ... A review of a facility notice placed in the locked toiletry cabinets of Units A - C revealed in part: 1. Body wash: 2 tubes (no more than 2 tubes), 2. Shampoo: 2 tubes (no more than 2 tubes), 3. Toothbrush: 1 (Instruct patient not to throw away after 1 use), 4. Toothpaste: 2 tubes (no more than 2 tubes), 5. Deodorant: 1, 6. Hairbrush or comb: 1. The above mentioned items must always be kept in the bins. None of the above items are to be kept in the patient rooms. Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed patient hygiene products in the possession of patient and not securely stored when not in use. The following includes the toiletry items observed and there location: Room s: Blue toothbrush on bedside table A and comb on bedside table B; Room q: 2 tubes of Fresh Scent Body wash 30ml container in a brown paper bag; Room kk: One unlabeled patient toiletry bucket was on top of a locked cabinet and within patient reach. The contents included Fresh Scent Toothpaste 6 oz. tube x 2, Fresh Scent Stick Deodorant 0.5 oz. x 2, Toothbrush (blue) x 1, and Fresh Scent Body Wash 30 ml tube x 2; Room f: Fresh Scent Toothpaste 6 oz. tube x 1, Fresh Scent Stick Deodorant 0.5 oz. x 1, Toothbrush (blue) x 1, and Fresh Scent Body Wash 30 ml tube x 1 on bedside table A; and Room b: Toiletry bins located in the closet by Bed #A and on the bedside table of Bed #B. Both of these toiletry bin’s included the same items - Fresh Scent Toothpaste 6 oz. tube x 1, Fresh Scent Stick Deodorant 0.5 oz. x 1, Toothbrush (blue) x 1, and Fresh Scent Body Wash 30 ml tube x 1. Interview on 08/05/2024 at 9:45 a.m. S39MHT confirmed the body wash located in Room q and further confirmed patients are allowed to have toiletries as part of their allowed possessions in their rooms. In an interview on 08/05/2024 at 10:35 a.m. Patient #5 and present in his assigned room f, confirmed the toiletry items (Fresh Scent Toothpaste 6 oz. tube x 1, Fresh Scent Stick Deodorant 0.5 oz. x 1, Toothbrush (blue) x 1, and Fresh Scent Body Wash 30 ml tube x 1) at his bedside and further confirmed the items have been at his bedside his entire admission. Patient #5 also confirmed he was never instructed his toiletries could not remain at his bedside. In an interview on 08/05/2024 and present during the tour, S1ADM confirmed the above mentioned findings and further confirmed the toiletry items should be locked up and not in the possession of patients when not in use. Observation on 08/05/2024 at 9:44 a.m. of room r revealed hair extensions approximately 2 feet long on floor among Patient #3’s belongings. In an interview on 08/05/2024 at 9:45 a.m., S39MHT reported Patient #3 sometimes went into room r to be alone for quiet time. S39MHT confirmed the ligature risk and stated he would put it with her other personal belongings that are in a locked storage locker. Observation on 08/05/2024 at 11:00 a.m. of Patient #R5’s room revealed 4 batteries among patient belongings in closet. Patient #R5 stated he took the batteries out of the TV remote the other day. In an interview on 08/05/2024 at 11:02 a.m., S1ADM verified Patient #R5 was in possession of 4 batteries and stated batteries are considered contraband. S1ADM reported the batteries should have been located during environmental rounds completed by Mental Health Technicians per policy. 11) Failure to ensure maintenance cart filled with tools that could be potential weapons was covered in patient care areas Review of hospital’s policy titled, “Unit Safety Rounds Checklist,” section 4.14.0 approved 06/2024, revealed in part: Policy Statement: Safety is of utmost importance. The environment of care must be safe for psychiatric patient care. At the beginning of each shift, the Registered Nurse must oversee the environmental rounds to be done by the Mental Health Technicians ...Procedure: At the beginning of each shift, Mental Health Technicians must: 2. Correct or resolve any issues immediately (ie clear hallways ...remove contraband items from ...patient care areas ... Mental Health Tech Rounding Sheet includes access to sharps ...access to suffocants ...no doors propped open ... No Doorstops or doors are not propped open ... Observations on 08/05/2024 at 10:27 a.m. of Unit B revealed an open cart of tools propping open the door of bathroom y. Further review revealed the following items identified on the cart: Hammer Handheld screwdrivers Batteries Power pack electric drill Tray of drill bits Long drill bits Silicone gun Silicone filler In an interview on 08/05/2024 at 10:29 a.m., S23EVS confirmed the cart was not covered in order to prevent patient access to tools that could be potential weapons. In an interview on 08/05/2024 at 10:45 a.m., S1ADM stated S23EVS was in the vicinity of the cart but that the cart should still be covered. 12) Failure to properly label Embrace Pro Glucose Test Strips and Embrace Pro Control Solutions upon initial opening of new containers A review of facility policy, “Glucose Test Log,” Section 4.9.0, last revised 01/2024, revealed in part: Policy Statement: The hospital nursing staff performs capillary blood glucose levels for patients when ordered by a physician or nurse practitioner. Registered Nurses and Mental Health Technicians must be deemed competent to perform the procedure. Control tests confirm that the meter is functioning properly. The policy did not relate to the documentation of open and beyond use dates on the test strips or control solutions. A review of the Glucometer Control Testing Instructions placed in each unit’s binder containing their corresponding glucometer’s quality control testing log revealed in part: Expiration of Glucometer Control: Glucometer controls expires 6 months after opening. Both the opening date and the expiration date (beyond use date) should be written on the control solutions. Expiration of Glucometer Test Strips expire 3 months after opening (beyond use date). Both the opening date and the expiration date (beyond use date) should be written on the strips. Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed Embrace Pro Glucose Test Strips vials and Embrace Pro Control Solutions vials being opened and not properly labeled with an open date and beyond use date (expiration date). This would present a risk for harm or injury to a patient related to treatment being rendered based on the results of a capillary blood glucose reading via a glucometer that has not been properly quality control tested. The undocumented vials were as follows: Unit A: Embrace Pro Glucose Test Strip vial had an open date of 08/02/2024 marked on the vial, no beyond use date was marked on the vial. Embrace Pro Control Solution #1 vial and Embrace Pro Control Solution #2 vial had no open date or beyond use date marked on each open vial. In an interview on 08/05/2024 at 10:40 a.m., S55RN confirmed the above mentioned findings. Unit B: Embrace Pro Glucose Test Strip vial, Embrace Pro Control Solution #1 vial and Embrace Pro Control Solution #2 vial had no open date or beyond use date marked on each open vial. In an interview on 08/05/2024 at 10:30 a.m., S56RN confirmed the above mentioned findings. Unit C: Embrace Pro Glucose Test Strip vial, Embrace Pro Control Solution #1 vial and Embrace Pro Control Solution #2 vial had no open date or beyond use date marked on each open vial. In an interview on 08/05/2024 at 09:55 a.m., S48RN confirmed the above mentioned findings. 48051 50453”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficiency is evidenced by failure to ensure incidents involving serious and unexplainable injuries are investigated and reported in order to determine if abuse or neglect had occurred in 1 (#R2) of 3 (#R2, #R7, and #R24) incidents reviewed. Findings: Review of hospital’s policy titled, “Abuse and/or Neglect of Patients,” approved 06/2024, revealed in part: Policy: It is the policy of [the hospital] that ... patients will be given competent and timely medical care. A. definitions, in part: Neglect - a form of abuse. The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. B. Prevention of Abuse and Neglect 3. Unit acuity is assessed every shift to determine that the staff to patient ration is appropriate to meet the specific needs of the patient. C. Identification or Abuse and/or Neglect 1. Inadequate supervision of patients whose physical or mental condition may result in poor judgment, and who are therefore at risk of injury or illness without supervision. D. Reporting Abuse and/or Neglect of Patients. Staff are required to report any incident, which they believe, might constitute abuse or neglect of patients. Because safety of patients is our first concern, a reasonable suspicion about the observed behavior is sufficient to warrant reporting the situation so that any necessary corrections can be made to prevent or reduce harm to the patient. Review of hospital’s policy titled, “Patient Rights,” approved 06/2024, revealed in part: [the hospital] supports and protects the basic human, civil, and constitutional rights of all patients. The principle of this policy is the patient’s right to respect, dignity, and comfort. 17. The right to be free from all forms of abuse and harassment. Review of hospital’s policy titled, “Escorting Patients Off the Unit”, dated 01/2024, revealed, in part: Policy Statement: Staff members assigned to escort a patient, or a group of patients shall be responsible for the safety and well-being of the individual and/or group from the time of leaving the unit until return to the unit. Purpose: To establish guidelines for the safe transport of patients off the unit. Procedure, in part: 1 ....The staff-patient ration will be no less than two staff members for every group of up to ten patients when leaving the secured nursing unit. This will apply to meal times and smoke breaks. 6. Staff members should see that the group stays together. Review of Patient #R2’s medical record revealed an admission date of 05/14/2024 at 7:40 p.m. Diagnosis: Schizoaffective disorder and GERD. Strengths include physically healthy and communicates. Patient was verbal. Patient was on low risk suicide precautions per admit orders. Review of psychiatric Evaluation dated 05/16/2024 at 10:06 a.m. revealed patient was judicially committed and transferred to facility for further stabilization. A review of Incident Report Binder on 08/08/2024 at 11:46 a.m. revealed one incident report dated 08/02/2024 for the month of August. In an interview on 08/08/2024 at 11:47 a.m., S54LPN reported that nurses will place incident reports in a box on her door or she will collect them from the units. She then has S2DON sign the incident report before submitting to administrator. Once administrator signs the incident report she places it in a binder with the other incident reports. In an interview on 08/08/2024 at 11:52 a.m., S1ADM reported he did not know of any new incidents occurring since 08/05/2024. On 08/08/2024 at 12:00 p.m. S54LPN presented an updated incident report binder. Review of the binder revealed an incident that had occurred on 08/06/2024at 5:10 p.m involving an injury sustained in the elevator. Further review revealed Patient #R2 fell in elevator. Continued review revealed one witness, S39MHT. Comments revealed right lower leg swollen. Actions taken revealed vital signs, temperature 97.2, pulse 82, respirations 17, and blood pressure 151/74. DON notified on 08/06/2024 at 5:41 p.m. Additional review of actions taken revealed an order to transfer Patient #R2 to ER for evaluation and an order for an x-ray. Continued review failed to reveal date and time physician, psychiatrist, administrator and family were notified. Review of Patient #R2’s nursing note dated 08/06/2024 at 6:21 p.m. revealed the following: 6:11 p.m. At approximately 5:10 p.m. patient standing on elevator, returning to floor from dinner, patient dropped to ground in elevator. Staff carried off elevator on to Unit C and assisted to wheel chair. Front of right lower leg swollen, S10NP and MD. X-ray ordered. Patient placed on fall precautions. Assisted to wheel chair. Instructed patient to ask for assistant getting in/out of bed to wheel chair. Review of video footage dated 08/06/2024, navigated by S1ADM on 08/08/2024 at 12:59 p.m. revealed the following: View of area rr: 5:10 p.m. - Security guard stood in area rr with 7 patients. S39MHT and Patient #R2 not in camera view. 5:11 p.m. - S39MHT walked out of cafeteria to the elevator and with 7 patients on elevator held elevator door open. 5:12 p.m. - S39MHT held elevator open while security guard walked into cafeteria and walked out from dining room, arm-in-arm with Patient #R2 who appeared unsteady and escorted her on to elevator. 5:13 p.m.-S52MHT walked out of cafeteria with two pitchers of water. View of Unit C: 5:16 p.m. - S39MHT picked Patient #R2 from under her arms and dragged her off elevator and set her on floor outside elevator. 5:17 p.m. S53RN beside Patient #R2. Review of Patient #R2’s physician orders revealed the following: 08/06/2024 at 5:15 p.m. Okay to send to ER for fall. RBVO/ S36NP/S37RN. 08/06/2024 at 5:51 p.m. Cancel above order to send to ER. RBVO/ S36NP/S38RN. 08/06/2024 at 6:09 p.m. Place on Fall precautions. RBVO/S36NP/No RN signature. 08/06/2024 9:00 p.m. Send patient out ASAP to E.D. nearest. TO/S36NP/S39RN Review of Patient #R2’s medical record revealed the x-ray was read on 08/06/2024 at 9:00 p.m. Further review revealed a displaced fracture of the mid to lower shaft of the right tibia and a displaced fracture of proximal fibula. Review of Patient #R2’s ED records from Hospital B revealed Patient #R2 was triaged in the emergency department at 10:11 p.m. on 08/06/2024 (approximately 5 hours after the incident). Further review revealed the following ED diagnoses: 1. Closed displaced oblique fracture of shaft of right tibia 2. Closed fracture of proximal fibula. 3. Tibia/fibula fracture right closed 4. Closed displaced spiral fracture of shaft of right fibula with malunion. Continued review revealed patient was placed in splint post reduction in ED. Despite reduction, patient still appeared to have displaced right tibia fracture that needed surgical intervention. Underwent an Open Reduction Internal Fixation (ORIF) of right tibia on 08/08/2024 at 12:15 p.m. In an interview on 08/08/2024 at 1:20 p.m., S2DON stated she had started the process of investigating the incident but she did not report the incident to state. In an interview on 08/08/2024 at 2:55 p.m. S2DON reported that she had no documentation or anything else to provide related to the investigation of the incident involving #R2’s leg fracture and therefore she was unable to determine if abuse or neglect had occurred. In an interview on 08/08/2024 at 4:41 p.m., S2DON confirmed that S53RN informed her the patient fell (in an undetermined location) and her leg gave out when on the elevator. S2DON stated she did not look at footage as of time of this interview. S2DON stated she spoke with S39MHT and S52MHT on the day of the incident. S2DON stated she did not recall the time she spoke with MHT’s but remembers she spoke face-to-face with S52MHT and spoke over the phone with S39MHT. S2DON confirmed that she did not investigate the timeframe before Patient #R2 was on the elevator. S2DON stated S53RN told her Patient #R2 was her “normal self” prior to the incident. S53RN reported that both MHT’s denied Patient #R2 had injuries before the incident on the elevator. In an interview on 08/08/2024 at 4:56 p.m. S1ADM stated he was informed of the incident when the x-ray results came back and Patient #R2 was sent out. S1ADM reported that if the incident report had been brought to him he would have looked at the video, and as of this interview, he had not reviewed. S1ADM stated that when there is an incident, S54LPN will pick up the incident reports from the unit and give them to S1DON who will lead the investigation and then he will receive a copy of the incident report.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the psychiatric hospital failed to ensure restraint and seclusion was used only when less restrictive interventions had been determined to be ineffective to protect the patient from harm for 1 (#2) of 7 (#1-#6, #R1) sampled patients reviewed for restraint and seclusion. Findings: Review of hospital’s policy titled, “Patient Rights,” approved 06/2024, Section 12.1.0, revealed in part: [the hospital] supports and protects the basic human, civil, and constitutional rights of all patients. The principle of this policy is the patient’s right to respect, dignity, and comfort. Purpose: To ensure the ethical treatment of persons receiving professional health care services. Without exception, all persons in this facility are entitled to receive ethical treatment. Procedure, in part: 16. The right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff ... Review of hospital’s policy titled, “Restraint and Seclusion R/T Patient’s Rights”, Section 9.13.0, Approved 01/2024 revealed in part: Policy Statement: Use of seclusion and/or restraint may be used only after all other therapeutic interventions have been found to be ineffective to protect the patient or others from harm .... Review of hospital’s policy titled, “Safe Implementation of Restraint and Seclusion”, Section 12.6.0, Approved 01/2024 revealed in part: Policy Statement: Use of seclusion and/or restraint may be used only after all other therapeutic interventions have been found to be ineffective to protect the patient or others from harm ....Procedures: ...There must be evidence of documentation in patient’s medical record reflecting alternatives or other less restrictive interventions attempted by clinical personnel. On 08/05/2024 at 3:15 p.m., a review of video footage of Unit A for the night of 08/03/2024 at 8:26 p.m. was navigated by S1ADM. Review of footage with audio revealed the following: 8:12 p.m. Patient #2 in room ff where she was sitting at table with pen and paper writing. 8:23 p.m. Patient #2 left room ff and walked to her room then back out into hallway nn where she stopped to speak with S18MHT then walked back to her room. 8:26 p.m. S17RN was in nursing station where she was preparing medication cups. S17RN handed Patient #2 her medications and Patient #2 asked S17RN what medications were in the cup. S17RN told her that once she was finished passing medications she would let her know what medications she was taking. 8:28 p.m. Patient #2 became frustrated clapping her hands together, then Patient #2 walked away. S17RN was heard saying. “She likes to play games with people and I don’t like to play games”. 8:32 p.m. Patient #2 returned to nursing station and S17RN read her the list of medications from the computer. Patient #2 started yelling, “don’t you know I have down syndrome” while cursing and walking off. 8:36 p.m. - Patient #2 standing across from nurses’ station against the wall. 8:37 p.m. - S18MHT left to take the other patients down to smoke, while Patient #2 remained on unit and walked to her room out of camera view. Audio revealed sound of loud noises coming from the direction Patient #2 went, while S17RN was sitting at nurses’ station. Audio revealed S17RN stating aloud “she can just let out her frustration”. S17RN then stated, “OK, you’re going in restraints.” 8:39 p.m. - Audio revealed crying sounds from patient. S17RN remained in nurses’ station. 8:39:48 p.m. - S17RN walked out of view to patient room. 8:40 p.m. - S18MHT returned to Unit A. S17RN left Patient #2’s room and said, “Let’s put her down”. 8:41 p.m. - Audio revealed loud banging ceased and Patient #2 crying, stating she wanted to go downstairs with the group. S17RN replied “not with that behavior.” Patient #2 began yelling. 8:42 p.m. - S17RN left to get restraints. Audio revealed S18MHT calmed Patient #2 down while S17RN retrieved restraints. 8:44 p.m. - S17RN walked back to patient room. Audio revealed Patient #2 yelling, “Don’t you know what Down Syndrome is, you’re a nurse.” 8:45 p.m. - Another MHT arrived to unit. 8:47 p.m. - loud noises heard on audio coming from Patient #2’s room. 8:48 p.m. - staff carried Patient #2, naked, by her arms and legs towards seclusion room c. Review of Patient #2’s medical record revealed an admission date of 07/28/2024 at 7:00 a.m. and discharged on 08/06/2024 at 7:50 a.m. Further, review revealed patient diagnoses of Down’s Syndrome, Suicidal Ideation with plan to cut wrists, Major Depressive Disorder with psychosis, and pseudo seizures on Keppra. Further review of Patient #2’s medical record revealed a Restraint and Seclusion Form dated 08/03/2024 at 8:50 p.m. for Patient #2. Continued review failed to reveal less restrictive interventions had been used to protect the patient, staff members, or others from harm prior to initiating restraints and seclusion. In an interview on 08/05/2024 at 3:58 p.m., S1ADM confirmed that video/audio footage revealed less restrictive interventions had not been used to protect the patient, and staff members, or others from harm prior to initiating restraints and seclusion. In an interview on 08/06/2024 at 9:48 a.m., S2DON stated that de-escalation is a core standard of practice for a psychiatric registered nurse and should be implemented in order to prevent restraint and/or seclusion.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(ii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (ii) The use of nonphysical intervention skills. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure the hospital’s security staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) of 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) security staff personnel files reviewed. Findings: Review 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) of 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) security staff personnel files revealed no education or training for nonphysical intervention skills required for the patient population served. In an interview on 08/08/2024 at 10:11 a.m., S22HR verified S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC currently have not received education, training, or demonstrated knowledge of nonphysical intervention skills.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 47397 48050 Based on record review and interviews, the hospital failed to ensure security staff personnel records contained documentation demonstrating that Orientation was successfully completed and Patient Rights competencies had been successfully completed upon hire for 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) of 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) security staff reviewed for Orientation with Patient Rights training. Findings: Review of hospital policy titled “HR Policies and Procedures, Orientation Program 8.8”, revealed, in part: Policy Statement: An orientation program shall be conducted for all newly hired employees that will assess the competency of the employee as it relates to his or her job performance upon hire and at least every three years thereafter. Procedure, in part: 1. All newly hired personnel must attend an orientation program within their first five (5) days of employment. Then every three years thereafter. d. An introduction to our administrative structure, which includes, in part: (4) A review of resident rights. (5) A review of abuse reporting procedures. Observations of Unit B on 08/05/2024 at 10:22 a.m. revealed a visitor was allowed up to unit by security guard during non-visting hours. In an interview on 08/05/2024 at 10:23 a.m., S56RN stated visitors should not be on the unit except during visiting hours due to visitor, patient, and staff safety issues. In an interview on 08/05/2024 at 10:24 a.m., S1ADM stated the guard made a mistake. Review of S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC personnel files failed to reveal any orientation education including Patient Rights training. In an interview on 08/08/2024 at 10:11 a.m., S22HR confirmed that S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC did not go through hospital employee orientation with Patient Rights training upon hire.”

“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: 48050 Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators. Findings: In an interview on 08/07/2024 at 3:20 p.m., S1ADM stated that he was one year behind in aggregating Quality Assurance and Performance Improvement (QAPI ) data. He has not been able to collect or update Quality Assurance and Performance Improvement (QAPI) data and minutes for the last year.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failing to investigate and collect the data necessary to identify opportunities for improvement and changes that will lead to improvement. Findings: In an interview on 08/07/2024 at 2:35 p.m., S1ADM again verified that the hospital did not have Quality Assurance and Performance Improvement (QAPI ) data. He agreed that without the necessary data, the hospital is unable to identify opportunities for improvement and changes that will lead to improvement. S1ADM confirmed the QAPI program had no updated quality indicators and there were no corrective action plans because they have not identified problems.”

“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: 48050 Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program’s performance improvement program implemented preventive actions. This deficient practice is evidenced by the lack of an implemented preventive action plan following an increase in patient safety incidents and injuries. Findings: Review of hospital policy titled, “Risk Management,” last revised January 2024, revealed in part: Policy Statement: The Risk Management Plan of the hospital is designed to ensure that the standard of care provided by the staff is maintained at an acceptable level, to reduce the risk of patient injury as a consequence of that care, and to minimize financial loss to the institution. Investigation of Occurrences: The hospital Risk Management incident reports will be used to document investigation results. The event reporting system will be used to document investigation results. Risk Management Committee: Results of the investigation shall be presented to the appropriate committee for a final standard of care determination. There shall be two committees that perform Risk Management activities: 1. Safety Risk Committee 2. Medical Executive Committee (MEC). The MEC functions as the final authority in reviewing and approving all risk management standards of care decisions involving members of the medical staff. It is compromised of the officers of the medical staff, along with the Medical Director, and representatives from administration and quality management. Findings of the committees shall be forwarded to the Safety Officer, who shall have responsibility to file quarterly reports with the Governing Board. Minimizing Occurrences: 3. Data Compilation and Analysis: Data collected by the Safety Risk Committee falls into, but is not limited to, the following categories: a. Patient related: Medication error, Patient falls with or without injury, Diagnostic procedure and treatment delay or error, Blood administration/Needle stick error, Leave against medical advice, Policy and procedure not followed, Unexpected transfer to an acute care facility, Patient injury, Patient/family complaint. b. Non-Patient related: Needle stick, equipment failure, fire, theft and loss, sharps, narcotic count incorrect, employee complaint ... Data relevant to reported variances will be compiled by the DON, Safety Officer and Quality Management staff in the form of statistical summary and will be used for identifying trends and patterns in practice and patient care. Occurrence screening data regarding medical staff functions shall be analyzed so that root cause of the occurrence can be determined and corrective measures established to minimize recurrence. Active cooperation of hospital staff, medical staff, and administration of the Hospital is essential. Medical and department quality improvement findings will be presented quarterly to the Governing Board, Administration, Medical Executive Committee, Quality Improvement Committees, and other affected hospital functions ( ... infection control, safety). Review of hospital policy titled, “Safety Risk Committee,” last revised January 2024, revealed in part: The Safety Risk Committee shall ensure that all operations of the hospital will be conducted in such a manner that is consistent with the best health and safety interests of patients, visitors and staff. Procedure: 1. In order to assure constant awareness of, and response to issues of health, safety and environment, a Safety Risk Committee shall establish, periodically review, and as necessary, modify and update applicable regulations and procedures. b. Committee Meetings: The Committee shall meet quarterly, or more often as it deems necessary for the discharge of its duties and responsibilities. Meeting dates, times and places shall be established, with reasonable notice, by the Safety Officer. 2. Committee Reports: At least quarterly, the Safety Risk Committee will report identified issues and a summary of Committee activities to the Performance Improvement Committee, the Medical Executive Committee, and the Governing Board. 3. Implementation of Committee Recommendations: The Administrator or designee will be responsible for implementation of procedures designed to attain standards adopted by the Committee. Monitoring and reporting results will be the responsibility of the Performance Improvement Committee. Review of incident reports for July and August 2024 revealed, in part: Incident Reporting Log for July 2024: 07/03/2024 Self Injurious Behavior 07/03/2024 Fall 07/04/2024 Elopement 07/08/0224 Injection 07/09/2024 Fall 07/17/2024 Elopement 07/18/2024 Sexual Misconduct 07/25/2024 Contraband 07/29/2024 Fall 07/30/2024 Fall Incident Reporting Log for August 2024: 08/02/2024 Fall 08/04/2024 Elopement 08/05/2024 Elopement 08/06/2024 Fall with broken leg In an interview on 08/07/2024 at 2:40 p.m., S1ADM stated that he had not been able to collect or update Quality Assurance and Performance Improvement (QAPI) data and minutes for the last year. S1ADM reported the hospital did not have documented actions taken to prevent incidents and patient injuries on the Performance Improvement meeting minutes because the hospital has not had QAPI meetings to discuss preventive action plans and the hospital has not investigated and collected data on the incidents discussed above. In an interview on 08/12/2024 at 2:06 p.m., S1ADM stated the Risk Management Committee and Safety Committee should meet with the Medical Executive Committee at least quarterly, and they should meet immediately after incidences. 50453”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital’s Governing Body failed to ensure the QAPI program reflected the complexity of the hospital’s services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include the following contracted services: linen service, elevator service, fire systems, generator, fuel for generator, plumbing, pest control, electrician, biohazard waste, security, telephone service, and equipment, managed IT. Findings: Review of list of contracted services provided by S1ADM revealed the following services: linen service, elevator service, fire system, generator, fuel for generator, plumbing, pest control, electrician, biohazard waste, security, managed IT, telephone service, and equipment. In an interview on 08/07/2024 at 2:30 p.m., S1ADM verified the hospital is at least one year behind on collecting any QAPI data including contracted services. In an interview on 08/07/2024 at 2:30 p.m., S1ADM reported the hospital has no QAPI program at this time.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) 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: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital’s governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program. Findings: Review of hospital document provided by S1Admin, titled “Amended and Re-Statement of the By-Laws of [Hospital]”, signed and dated by Governing Body’s only member on 06/01/2021, revealed, in part: pages 2,4,6, and 8 are missing. Section 1 Page 9, revealed, in part: The Hospital will document appropriate remedial action to address deficiencies found to the quality assurance program. The Hospital will document the outcome of the remedial action. Policies and Procedures, Section 1, in part: The following policies/procedures/plans must be created and approved by the Board of Managers: Quality Assurance Plan. Review of Governing Body meeting minutes from January 2024 - July 2024 provided by S1ADM, failed to indicate an ongoing program for quality improvement and patient safety because no indicators were discussed. Review of most recent Medical Executive Meeting minutes dated 01/15/2024, provided by S1ADM, failed to indicate an ongoing program for quality improvement and patient safety because no indicators were discussed.”

“PROVIDING ADEQUATE RESOURCES CFR(s): 482.21(e)(4) [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:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients. This Standard is not met as evidenced by: 48050 Based on record review and interview, the Hospital’s Governing Body failed to ensure adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital’s performance improvement functions as evidenced by insufficient staff designated to conduct the Quality Assessment Performance Improvement (QAPI) program functions of the hospital. Findings: Review of the hospital’s organizational chart provided by S1ADM revealed the position for Quality Assurance and Infection Control Coordinator was filled by S57QAPIM. Review of the Governing Body Meeting Minutes provided by S1ADM for January 2024 through July 2024, failed to reveal S57QAPIM was appointed Quality Assurance and Infection Control Coordinator In an interview on 08/07/2024 at 2:45 p.m., S1ADM verified that S57QAPIM was the dedicated person for Quality Assurance Coordinator but had not been appointed by the Governing Body. S1ADM stated that S57QAPIM lives out of state and rarely visits the hospital, therefore is unable to complete the tasks required of the the Quality Assurance Coordinator. S1ADM also stated he has not done any QAPI data collection/analysis for this year because he has not had time to do so.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of medical care provided to patients. This deficient practice is evidenced by: 1) failure of medical staff to participate in governing body meetings; 2) failure of medical staff to participate in Infection Control Committee; 3) failure of medical staff to participate in Utilization Review Program; and 4) failure of medical staff to participate in the Quality Performance Improvement Committee. Findings: Review of the hospital medical staff bylaws reveals in part: the bylaws provide the framework for self-governance in order to permit the Medical Staff to discharge its responsibilities in matters involving the quality of medical care and patient safety. E. Duties of Officers 1. Medical Director: e) interacting with the Administrator and Governing Board in all matters of mutual concern with the Medical Staff. g) Representing the views and policies of the Medical Staff to the Governing Board and to the Administrator. j) Overseeing the medical and clinical operations of the Hospital. Section 2. Committees and Subcommittees A. The Medical Executive Committee shall be composed of the Officers of the Medical Staff ... meet as often as necessary, but not less than quarterly, maintain a record of its proceedings and actions. The function of the Medical Executive Committee shall include, but not be limited to: 2) receiving and acting upon reports and recommendations ... and reporting these activities to the Governing Board; 6) overseeing the organization of quality assurance and performance review activities and mechanisms of the Medical Staff and its committees; 11) evaluating the overall medical care rendered to patients in the Hospital. B. The Infection Control Committee shall meet at least quarterly. It shall maintain a record of its proceedings and shall submit reports of its activities and recommendations to the Medical Executive Committee. C. The Performance Improvement Committee shall ... 5) reviewing findings of quality assurance, utilization review and Performance Improvement activities performed by all Medical Staff Committees and all Hospital Services; 7) ...disclose findings to the Medical Executive Committee and Governing Board. 1) Failure of medical staff to participate in governing body meetings. Review of governing body meeting minutes dated 01/09/2024 - 07/31/2024 failed to reveal meetings with medical staff. 2) Failure of medical staff to participate in Infection Control Committee. Review of hospital documents failed to reveal an Infection Control Program. 3) Failure of medical staff to participate in Utilization Review Program. Review of hospital documents failed to reveal a Utilization Review Program. 4) Failure of medical staff to participate in the Quality Performance Improvement Committee. Review of hospital documents failed to reveal a Quality Performance Improvement Program. During an interview on 08/12/2024 at 2:06 p.m., S1ADM confirmed medical staff has not participated in meetings with the committees listed above.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure that the medical staff enforced their bylaws. This deficiency is evidenced by failing to carry out their responsibilities to meet quarterly as stated in their medical staff bylaws. Review of medical staff bylaws revealed in part: Section 2. Committees and Subcommittees. A ... The Medical Executive Committee shall meet as often as necessary, but not less than quarterly, maintain a record of its proceedings and actions. Review of the Medical Staff Meeting Minutes revealed the last Medical Executive Meeting was January 15, 2024 at 5:30 p.m. During an interview on 08/05/2024 at 2:15 p.m. S1ADM confirmed there has not been a Medical Staff Meeting since they last met on January 15, 2024 and that he has no additional medical staff meeting minutes to provide. S1ADM also confirmed that the medical staff has not been meeting quarterly as stated in the medical staff bylaws.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 47397 Based on interview and record review, the hospital failed to ensure there was a plan for administrative authority for nursing services to ensure the nursing services was under the direction of one RN employed by the hospital in the absence of the DON. This deficient practice is evidenced by failing to have coverage for nursing services provided in the absence of the DON. Findings: Review of Governing Body minutes dated 01/09/2024-07/31/2024 failed to reveal an appointed administrative authority for nursing services to ensure the nursing services was under the direction of one RN employed by the hospital in the absence of the DON. Review of Governing Body minutes dated 01/09/2024-07/31/2024 revealed on 06/03/2024, S2DON appointed Director of Nursing subject to satisfactory background check. Further review failed to review S2DON was appointed DON following receipt of background check as stated in minutes dated 06/03/2024. In an interview on 08/05/24 at 9:16 a.m., S1ADM indicated S2DON was not always available during the day because she has been working the night shifts due to short staffing. S1ADM reported that the hospital did not have an assistant director of nursing with administrative authority in the absence of S2DON. In an interview on 08/07/24 at 9:43 a.m., S1ADM indicated the hospital usually uses a nurse supervisor, S32RN, that was once the interim DON to act in the absence of S2DON. S1ADM confirmed that no RN employed at the hospital had been designated as the registered nurse in charge of nursing services at times when S2DON was unavailable and/or on leave from the hospital. In an interview on 08/12/2024 at 9:15 a.m. S2DON reported she did not know that the hospital was under a 2nd IJ since 08/07/2024 because she was not in the hospital when the IJ was called. Therefore she did not educate staff as per the hospital removal plan for the IJ. S2DON stated that she has hired an ADON to act as DON in her absence and is waiting on the results of her background check. Previously cited 06/12/2024.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 50453 Based on observations, record review and interview the hospital failed to ensure adequate numbers of licensed registered nurses and nurse support staff were available to provide nursing care to all patients as evidenced by failure to ensure a registered nurse was physically present on each unit of the hospital at all times. Findings: Review of hospital policy titled “Staffing Plans and Delivery of Care”, dated 01/2021, revealed in part: Census: 1-12 patients requires: 1 Registered Nurse and 2 Mental Health Technicians. On 08/07/2024 at 5:15 p.m., hospital video review of Unit A on 08/06/2024, navigated by S1ADM, revealed S46RN left the unit at 10:43 p.m., was gone for 17 minutes and returned at 11:00 p.m. leaving S49MHT and S50MHT alone with 7 (#5, #6, R1, R3, R4, R5, and R6) patients. During an interview on 08/07/2024 at 5:45 p.m. Greg confirmed that the S46RN should not have left the unit without an RN present. On 08/08/2024 at 11:10 a.m., hospital video review of Unit A on 08/07/2024, navigated by S1ADM, revealed S47RN left the unit at 10:41 p.m., was gone for 11 minutes and returned at 10:52 p.m. and then left a second time at 10:55 p.m., was gone for 11 minutes and returned at 11:06 p.m. This left S16MHT and S43MHT alone with 5 (#5, R1, R3, R4, and R5) patients. During an interview on 08/08/2024 at 11:32 a.m. S1ADM confirmed S47RN should not have left the unit without another RN present.”

“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: 48051 Based on observations, 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 an assessment and documentation related to Patient #R1’s transfer to and return from Hospital #B’s emergency department not being performed. A review of facility policy, “Medical Emergency Transfer to Another Facility,” Section 5.3.0, approved: 06/2024, revealed in part: Policy Statement: Patients requiring emergency medical care beyond the facility’s scope of service and capacity are transferred via ambulance to a designated emergency department. Purpose: to establish guidelines and procedure for medical emergency transfer to another facility. To provide the receiving facility with complete appropriate information to resume care of a transferred patient. Procedure: After the emergency procedures have been initiated and the physician has given transfer orders, the Registered Nurse must: 3. Complete the Emergency Transfer Sheet. On 08/08/2024 at 12:18 p.m., the video footage was reviewed with S1ADM for an incident that occurred on 08/04/2024. Review of video footage for Unit A seclusion room revealed the following: 12:10 a.m. - Patient #R1 arrived to Unit A. 12:19 a.m. - Patient #R1 to seclusion room with door remaining unlocked. Patient #R1 had not been searched since arriving to Unit A. 1:08 a.m. - S17RN and S18MHT with patient. S17RN on phone in room. 1:13 a.m. - S17RN and S18MHT standing near door, across the room from Patient #R1. Patient #R1 walks swiftly into the wall in front of him and hits his forehead on the wall. The patient then falls backward on to the floor while clutching his head in his hands. S17RN in room at time of incident. 1:15 a.m. - S18MHT walks Patient #R1 to bed. S17RN still on cell phone in doorway. S17RN had not assessed the patient. During an interview on 08/08/2024 at 1:00 p.m., S1ADM confirmed that Patient #R1 should have been searched immediately upon arrival to unit. S1ADM also confirmed that S17RN failed to perform an assessment upon arrival and following incident. A review of Patient #R1’s medical record revealed the patient involved in an incident on 08/04/2024 requiring him to be transferred to Hospital #B. A review of nursing notes did not reveal documentation of the time of the patient’s departure or return to the facility, documentation of an Emergency Transfer Sheet, or the documentation of a nurse assessment being performed upon the patient’s return to the facility. In an interview on 08/12/2024 at 3:00 p.m. S1ADM and S2DON confirmed the above mentioned information. 50453”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48051 50453 Based on observation and interview, the hospital failed to ensure that the director of nursing service provided adequate supervision and evaluation of all nursing personnel who provide services in the hospital. This deficiency is evidenced by: 1) failure to ensure staff have been properly educated and deemed competent on performing an EKG; and 2) failure to ensure staff have been properly educated and deemed competent on the appropriate monitoring of a patient placed in restraints. Findings: 1) Failure to ensure staff have been properly educated and deemed competent on performing an EKG. Review of hospital policy titled, “Electrocardiogram Machine (EKG Machine),” last revised January 2024, revealed in part: Policy Statement ... Registered Nurses, Licensed Practical Nurses, and Mental Health Technicians can operate the EKG machine when they have been observed, evaluated, and deemed competent with documentation. Purpose: To provide guidelines and procedures for use of the EKG machine. To interpret the electrical activity of the heart for Physicians and nurse Practitioners to diagnosis and treat. Procedure: 3. Turn power on. 4. Input patient’s Name, Age, and Date of Birth. To input patient’s information, push the keys. During an interview on 08/08/2024 at 1:52 p.m. S2DON confirmed all nurses are able to read an EKG or send it to the doctor to read it. S2DON stated all have been oriented, trained, and deemed competent to perform an EKG. Per S2DON, staff needs an order to perform an EKG. S2DON additionally stated that staff read what the print out of the EKG says the rhythm is at the top. S2DON confirmed the hospital does not have a company or physician that reads the EKG for them. Per S2DON, the RN working decides if the EKG is questionable or not. During an interview on 08/08/2024 at 1:57 p.m. S1ADM stated that all staff are not trained to do EKG’s. S1ADM stated EKG’s are ordered and read by S51MD. During an interview on 08/08/2024 at 2:00 p.m. S19RN stated she has not been trained to perform an EKG. During an interview on 08/08/2024 at 2:02 p.m. S44MHT, S52MHT, and S37MHT confirmed they have not received training to perform EKG’s. During an interview on 08/08/2024 at 2:06 p.m. S32RN confirmed that she has not received formal training on how to perform an EKG. S32RN stated she received an informal training and that she is not competent to perform an EKG on her own. S32RN confirmed that she also does not feel comfortable interpreting an EKG. During an interview on 08/08/2024 at 2:10 p.m. S31RN confirmed that she has been employed for 1 year and has not received education on how to perform an EKG. S31RN also confirmed EKG education was not included in her orientation. During an interview on 08/08/2024 at 2:12 p.m. S53MHT confirmed she has not received training to perform an EKG. 2) Failure to ensure staff have been properly educated and deemed competent on the appropriate monitoring of a patient placed in restraints A review of facility policy, “Safe Implementation of Restraint and Seclusion,” Section 9.13.0, approved: 01/2024, revealed in part: Purpose: To establish guidelines for the same (safe) implementation of restraint and seclusion ... To abide by state and federal guidelines for the use of restraint and seclusion. Procedures: RN and trained staff personnel must engage in the monitoring of patients in restraints to recognize changes to indicate the restraint or seclusion in no longer necessary. Restraint/Seclusion use is permitted by trained staff only ... frequencies of monitoring and assessment; assessment content (e.g., vital signs, circulation, hydration needs, elimination needs, level of distress and agitation, mental status, cognitive functioning, skin integrity, etc.); providing for nutritional needs, range of motion exercises and elimination needs; and mental status and neurological evaluation, that the use of restraint or seclusion is discontinued at the earliest possible time. Hospital policies are expected to guide staff in determining appropriate intervals for assessment and monitoring based on the individual needs of the patient, the patient’s condition and the type of restraint or seclusion used ... The patient placed in seclusion or restraints must be personally always observed by staff and documentation of the patient’s progress must occur every 15 minutes. Documentation of patient progress must include the status of the patient’s needs, such as bathing, meals, hydration, use of toilet, and behavior. Exercise of limbs and circulation checks must all be included when limb restraints are in use. All these measures ensure that the patient is not suffering undue physical discomfort, harm or paint. The patient must be given the opportunity for motion and exercise not less than 10 minutes every two hours. Documentation: Documents needed to complete restraint and seclusion procedures include Restraint and Seclusion Preprinted Orders, Restraint and Seclusion Debriefing Form, Restraint and Seclusion Flow Sheet, Restraint and Seclusion Log and the Incident Report Form. In addition to documenting patient status and staff interventions every 15 minutes on the designated seclusion and/or restraint flow sheet, the Registered Nurse must document every hour in the patient’s nursing daily progress note. The nursing care plan should be updated within 24 hours of the initiation of the restraint/seclusion. A medical record review of Patient #2 revealed the patient being placed in 4 point restraints on 08/03/2024 from 8:50 p.m. to 10:45 p.m. There was continued documentation by the MHT on the routine Patient Observation Log every 15 minutes. However, during this timeframe, there was no document of assessments being performed regarding vital signs, circulation, hydration needs, elimination needs, mental status, cognitive functioning and/or skin integrity. There was no documentation of a debriefing being performed after the patient was released. There was no documentation every hour in the patient’s nursing daily progress notes. A review of facility incident reports revealed no documentation related to an incident report being completed on 08/03/2024 for this patient being placed in restraints. In an interview on 08/12/2024 at 3:00 p.m. S2DON confirmed the above mentioned findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 44495 Based on record review, and interview the facility failed to ensure all medications and biologics were administered according to the orders of a licensed practitioner. The deficient practice is evidenced by: 1) failure of the nursing staff to contact the licensed practitioner for orders for prescribed medications at the time of admission; 2) failure to ensure medication errors related to the timing of medication administration were tracked and analyzed to determine their causes; 3) failure of the nursing staff to document the administration of an as needed medications; 4) failure of nursing staff to document the effectiveness of an as needed medication being administered; 5) failure of nursing staff to document the indication for an as needed medication to be administered; and 6) failure of the nursing staff to document the location (site) of an injectable medication. Findings: 1) Failure of the nursing staff to contact the licensed practitioner for orders for prescribed medications at the time of admission. Review of the policy, “Medication Administration,” approved January 2024, revealed in part, “Policy Statement-Only those medications ordered by physicians shall be given . . . . “ Review of the Medical Staff Bylaws, which had no documented date of last review but was presented to the surveyors as the current bylaws, revealed in part: Admissions: (a) No patient shall be admitted to the Hospital until after a provisional diagnosis has been stated and been approved by the Medical Director or his designee. All patients will be under the care of a physician while in the hospital. . . . (d) No inpatient or outpatient may be assigned to the service of any other practitioner without that practitioner’s specific authorization. . . . General Unit: (a) The admitting physician may consult the referring physician for medical management, as necessary. (b) The Medical Director or his designee must approve all admissions. . . . (d) Admitting orders shall be dated, timed and signed by the admitting or attending practitioner and shall include at least the following: a. Order for admission; b. Level of activity/ restriction; c. Vital Sign frequency; d. Medications; e. Diagnostic testing; f. Diet; g. Consultations; and h. Provisional Diagnosis (e) Verbal orders, if used, must be used infrequently. This means that the use of verbal orders must not be a common practice. Verbal orders pose an increased risk of miscommunication that could contribute to a medication or other error, resulting in a patient adverse event. Verbal orders should be used only to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to write the order or enter it into an electronic prescribing system without delaying treatment. Verbal orders are not to be used for the convenience of the ordering practitioner. (f) Verbal orders are to be signed within 48 hours of the given order. Initial admitting orders may be verbal orders, phone orders, and standing orders. Initial review of medical records during the survey revealed admission orders were a printed set of orders to be initiated as verbal orders and many were not signed by the licensed practitioner within 48 hours as required. The frequency of the unsigned verbal admission orders was concerning and the need for further review of the admission process was acknowledged. In interview on 08/08/2024 between 1:49 p.m. - 1:53 p.m., S32RN explained the admission process for Patient R8, who she was admitting. S32RN explained that she had already completed the admission and medication orders and faxed them to the pharmacy, but had not completed her admission assessment because the patient was sleeping when brought to the floor. S32RN explained that when new patients were admitted, she used the records sent from the referral source to find the current medications and then listed the on the “Home Medication History & Reconciliation” form and then faxed it to the pharmacy to be filled by the pharmacy. At the bottom of the form “Telephone Order/ VORB per Dr. ___ Date___ Time___” was printed at the bottom. The form was filled out with the name of the practitioner, 08/08/2024 and timed 1:30 p.m. S32RN explained that she checked hold on the Risperdal 2 milligrams by mouth twice a day because it was documented in the medical record that the patient had received Zyprexia 10 milligrams while in the emergency department and she felt it was not safe to give the morning dose of Risperdal. S32RN also pointed out the order for Norvasc 5 milligrams by mouth each day which she also held because his blood pressure was fine. Review of the “Physician Admit Orders,” revealed the following as needed medication orders were checked: Ativan 2 milligrams by mouth or intramuscular every 6 hours as needed for agitation; Benadryl 50 milligrams by mouth or intramuscular every 6 hours as needed for agitation; Haldol 5 milligrams by mouth or intramuscular every 6 hours as needed for agitation; Tylenol 650 milligrams by mouth every 6 hours as needed for temperature greater than 100 F; Ibuprofen 400 milligrams by mouth every 6 hours as needed for pain; Milk of Magnesia 30 cubic centimeters by mouth each day as needed for constipation; and Mylanta 30 cubic centimeters by mouth every 6 hours as needed for indigestion. S32RN was asked if she contacted the licensed practitioner for orders when each patient was admitted and she said that it was not necessary because the practitioner knew he was on call for the day and would evaluate all the patients admitted to him later when he came to the facility. The above findings were recognized as an Immediate Jeopardy situation. After communication with State Office, on 08/08/2024 at 3:35 p.m., S1ADM was notified that the practice of allowing the nursing staff to fill out the admission and medication orders without consulting the licensed practitioner was outside of the scope of practice for a registered nurse and placed all 19 admitted patients and future admitted patients at risk for serious injury, serious harm, and serious impairment or death. To verify the nursing practice of filling out admission and medication orders without consulting the licensed practitioner was not an isolated event as suggested by S1ADM, S31RN was interviewed on 08/08/2024 at 3:51 p.m. S31RN verified the admitting nurse chose which as needed medications each patient would be prescribed and fill out the admission orders without consulting the admitting licensed practitioner. On 08/12/2024 plan of correction was presented to State Office. The plan included encouraging the use of electronic or faxed orders by the licensed practitioners and discouraging the routine use of verbal admission orders. Nursing staff was immediately re-education on the verbal order policy and the medication administration policy. A final plan to ensure adherence would be developed by 08/14/2024. The Immediate Jeopardy was removed on 08/12/2024 at 3:29 p.m., but there was not enough evidence to determine sustainability of compliance for the Condition of Nursing Services to be cleared. Noncompliance remains at the Condition Level. 2) Failure to ensure medication errors related to the timing of medication administration were tracked and analyzed to determine their causes. A review of hospital’s policy, titled “Medication Variance Reporting,” Section 7.8.0, Approved 01/2024, revealed in part: All medication variances are to be reported on Medication Variance Report forms ...Purpose: To establish guidelines for reporting a medication error. To track and tend medication variances to reduce the rate of occurrence. Procedure: 3. Complete Medication Variance Report form. 4. Turn Medication Variance Report form to Director of Nursing. a. DON will monitor compliance in the documentation of medication variance through 10% concurrent review. B. DON will investigate each Medication Variance Report; provide documentation and results to administrator within 24 hours of occurrence for appraisal ... Review of hospital documents provided failed to reveal Medication Variance Reports used to track and analyze medication errors related to the timing of medication administration. In an interview on 08/08/2024 at 2:10 p.m, S2DON stated she did not know the hospital had medication variance reports. S2DON confirmed she did not keep a Medication Variance Report log. S2DON reported that she realizes that the information related to medication errors should be tracked and analyzed but she has only recently started in the DON position and has not yet addressed the medication variance reports. 3) Failure of the nursing staff to document the administration of an as needed medications A review of hospital policy, “Medication Administration,” Section 7.3.0, Approved: 01/2024, revealed in part: Policy Statement: ... All medication shall be documented on the patient’s Medication Administration Record (MAR) immediately after administration ... Purpose: To provide clinical direction for Registered Nurses (RN) and Licensed Practical Nurses (LPN) on medication administration procedures to administer medications and treatments as ordered by the physician. To ensure the safe preparation and administration of medications including dose, frequency, route, exact strength, and instructions for use and medication administration procedures as ordered by the physician ... Procedure: Medication Administration: ... Chart medications on MAR. Effects of as needed medications and the site of injection must be recorded in the progress notes as well ... Medication Administration Documentation: The RN or LPN: Documents administration of medication by recording the time of administration in the corresponding column of the proper drug column. If the medication is administered by injection, records the site of administration in the integrated progress notes. Initials the appropriate “box/slot” with corresponding medication, date and time, indicating that the medication has actually been given ... Documents the administration of as needed medication in the same manner as routine medications ... Charts all medications (scheduled, as needed and STAT) in appropriate box/slot indicating time on the patient’s MAR immediately after administered ... A medical record review of Patient #2 revealed a nursing note from 08/02/2024 at 3:25 a.m., entered by S17RN, “Patient with noted seizure activity lasting for approximately 10 minutes. Vitals assessed. S60NP notified. Ativan 2 mg IM left gluteal administered. There was no documentation related to the administration of this medicine on the MAR. A nursing note from 08/05/2024 at 11:49 a.m. and entered by S55RN revealed, “S60NP present for seizure like activity. Order for Ativan 2 mg IM x 1.” There was no documentation as to the administration of this medication in the nursing notes or the Medication Administration Record. Of note, this was the time frame the surveyors were present on this unit and did witness the patient with seizure like activity and also witnessed this nurse administer an injection to this patient. A nursing note from 08/05/2024 at 5:40 p.m. and entered by S55RN revealed in part, “1700: ... Patient had some seizure like activity in chair in hallway. MHT and RN maintained safety and supported head. VSS. S60NP with patient and ordered for one time IM Ativan dose. Patient is not postictal.” There was no documentation as to the administration of this medication in the nursing notes or the Medication Administration Record. In an interview on 08/08/2024 at 3:30 p.m. S1ADM confirmed the above mentioned findings. 4) Failure of nursing staff to document the effectiveness of an as needed medication being administered A review of hospital policy, “Medication Administration,” Section 7.3.0, Approved: 01/2024, revealed in part: Policy Statement: ... All medication shall be documented on the patient’s Medication Administration Record (MAR) immediately after administration ... Purpose: To provide clinical direction for Registered Nurses (RN) and Licensed Practical Nurses (LPN) on medication administration procedures to administer medications and treatments as ordered by the physician. To ensure the safe preparation and administration of medications including dose, frequency, route, exact strength, and instructions for use and medication administration procedures as ordered by the physician ... Procedure: Medication Administration: ... Chart medications on MAR. Effects of as needed medications and the site of injection must be recorded in the progress notes as well ... A medical record review of Patient #2 revealed a nursing note from 08/02/2024 at 3:25 a.m., entered by S17RN, “Patient with noted seizure activity lasting for approximately 10 minutes. Vitals assessed. S60NP notified. Ativan 2 mg IM left gluteal administered. There was no nursing documentation related to the follow up of the patient’s response to the effectiveness of this as needed medication administration. A nursing note from 08/05/2024 at 11:49 a.m. and entered by S55RN revealed, “S60NP present for seizure like activity. Order for Ativan 2 mg IM x 1.” There was no documentation as to the administration of this medication in the nursing notes or the Medication Administration Record. Of note, this was the time frame the surveyors were present on this unit and did witness the patient with seizure like activity and also witnessed this nurse administer an injection to this patient. There was no nursing documentation related to the follow up of the patient’s response to the effectiveness of this as needed medication administration. A nursing note from 08/05/2024 at 5:40 p.m. and entered by S55RN revealed in part, “1700: ... Patient had some seizure like activity in chair in hallway. MHT and RN maintained safety and supported head. VSS. S60NP with patient and ordered for one time IM Ativan dose. Patient is not postictal.” There was no documentation as to the administration of this medication in the nursing notes or the Medication Administration Record. Further, there was no nursing documentation related to the follow up of the patient’s response to the effectiveness of this as needed medication administration. In an interview on 08/08/2024 at 3:30 p.m. S1ADM confirmed the above mentioned findings. 5) Failure of nursing staff to document the indication for an as needed medication to be administered A review of hospital policy, “Medication Administration,” Section 7.3.0, Approved: 01/2024, revealed in part: Policy Statement: ... All medication shall be documented on the patient’s Medication Administration Record (MAR) immediately after administration ... Purpose: To provide clinical direction for Registered Nurses (RN) and Licensed Practical Nurses (LPN) on medication administration procedures to administer medications and treatments as ordered by the physician. To ensure the safe preparation and administration of medications including dose, frequency, route, exact strength, and instructions for use and medication administration procedures as ordered by the physician ... Procedure: Medication Administration: ... Chart medications on MAR. Effects of as needed medications and the site of injection must be recorded in the progress notes as well ... Medication Administration Documentation: The RN or LPN: Documents administration of medication by recording the time of administration in the corresponding column of the proper drug column. If the medication is administered by injection, records the site of administration in the integrated progress notes. Initials the appropriate “box/slot” with corresponding medication, date and time, indicating that the medication has actually been given ... Documents the administration of as needed medication in the same manner as routine medications ... Charts all medications (scheduled, as needed and STAT) in appropriate box/slot indicating time on the patient’s MAR immediately after administered ... A Review of the Medication Administration Record revealed an as needed Ativan 2 mg IM injection being administered on 08/03/2024 at 9:15 p.m. by S17RN. There was no associated nursing note as to the reason for the administration of this as needed medication. In an interview on 08/08/2024 at 3:30 p.m. S1ADM confirmed the above mentioned findings. 6) Failure of the nursing staff to document the location (site) of an injectable medication A review of hospital policy, “Medication Administration,” Section 7.3.0, Approved: 01/2024, revealed in part: Policy Statement: ... All medication shall be documented on the patient’s Medication Administration Record (MAR) immediately after administration ... Purpose: To provide clinical direction for Registered Nurses (RN) and Licensed Practical Nurses (LPN) on medication administration procedures to administer medications and treatments as ordered by the physician. To ensure the safe preparation and administration of medications including dose, frequency, route, exact strength, and instructions for use and medication administration procedures as ordered by the physician ... Procedure: Medication Administration: ... Chart medications on MAR. Effects of as needed medications and the site of injection must be recorded in the progress notes as well ... Medication Administration Documentation: The RN or LPN: Documents administration of medication by recording the time of administration in the corresponding column of the proper drug column. If the medication is administered by injection, records the site of administration in the integrated progress notes ... A Review of the Medication Administration Record revealed an as needed Ativan 2 mg IM injection being administered on 08/03/2024 at 9:15 p.m. by S17RN. This documentation failed to reveal the location the injection was administered. In an interview on 08/08/2024 at 3:30 p.m. S1ADM confirmed the above mentioned findings. 47397 48051”

“ORGANIZATION AND STAFFING CFR(s): 482.24(a) The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to have medical record services that are appropriate to the scope and complexity of the services performed and the hospital failed to employ adequate personnel to ensure prompt completion, filing, and retrieval of records. This deficient practice was evidence by the medical records department not being under the supervision of a qualified medical records practitioner. Findings: A review of S5MR personnel record revealed a signed job description on 06/27/2024 for the job title of Medical Records Technician. A review of her education background revealed a transcript for the completion of a Master of Public Health. The reviewed information does not indicate the qualifications for the position of Medical Records Practitioner. Further, the signed job description does not relate to the position of Medical Records Practitioner. In an interview on 08/06/2024 at 2:55 p.m. S1ADM confirmed S5MR does not have the qualifications for the position of Medical Records Practitioner.”

“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: 48051 Based on observation and interview, the hospital failed to maintain a system of record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This deficient practice was evidenced by the storage of medical records without protection from potential destruction by fire, water or other damage. Findings: A review of facility policy, “The Medical Record,” Section 3.1.0, last approved: 01/2024, revealed in part: Section: Responsibility for the Medical Record: It is the responsibility of the facility to provide a record for each patient and safeguard the record and its content against loss, damage, tampering and unauthorized use. Item B. CEO/Administrator: ... administrator is responsible for providing adequate direction, space, equipment, and personnel to perform these tasks effectively. Item E. Medical Staff: ... Licensure, certification and accreditation agencies all have standards requiring that the medical staff rules and regulations address certain issues regarding the medical record ... including provisions for the keeping of accurate and complete clinical records. A review of facility policy, “Retention and Destruction,” Section 3.7.0, last approved 01/2024, revealed in part: Policy Statement: The Health Information Management Department will strive to ensure that medical records and other information medium will be maintained in secure and restricted areas ... Procedures: II. Destruction: Item 3. Destruction Due to Unplanned Disaster: In anticipation of unplanned disasters, the hospital will make every attempt to safeguard health information records, documents and other storage medium in structurally sage, fire-resistant, and water resistant storage environments. Also, general safeguarding will ensure that combustible and/or hazardous chemicals and materials are maintained in a supervised environment with minimal risk for damage to hospital property. At all times, the hospital will strive to meet building and fire codes and OSHA guidelines. Item 4-a. Flooding/Water Damage: Medical records will be maintained in permanent storage filing cabinets and/or drawer units that are raised from the floor to prevent flooding and/or water damage. A review of facility policy, “Storage and Retrieval,” Section 3.8.0, last approved 01/2024, revealed in part: Policy Statement: A comprehensive, centralized system for storage and retrieval of medical records, from creation through destruction shall be established and maintained in the HIM Department. Procedure: I. Storage: A-3. Safeguard records and documents from tampering, loss and advertent destruction. III. Storage Space Specifications: A. Storage Space Specifications: Storage space shall be selected and maintained to protect records from unauthorized access, loss and destruction. Storage space shall be selected to meet the following specifications: adequate lighting, controlled environment (60º - 80º F, 50% humidity), freedom from dust, protection against fire, including the sprinkler system, and freedom from hazards, such as flooding or damage from broken water pipes. Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility’s IOP clinic location revealed 12 bankers storage boxes of medical records from 2019 to 2023 in Room #vv, 37 patient medical records laying on top of a cabinet in Room #vv and 12 bankers storage boxes of medical records from 2014 to 2018 in Room #ww being stored in a manner that lacked protection from potential destruction by fire, water or other damage. In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to remove outdated or otherwise unusable drugs and biologicals available for patient use. This deficient practice was evidenced by expired Influenza Virus Vaccine being available for patient use. Findings: Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility’s IOP clinic location revealed an open, 5ml vial of Influenza Virus Vaccine, 2016 - 2017 Formula, expired 04/2017. In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings.”

“APPLICABILITY CFR(s): 482.30(a) Standard: Applicability. The provisions of this section apply except in either of the following circumstances: (1) A Utilization and Quality Control Quality Improvement Organization (QIO) has assumed binding review for the hospital. (2) CMS has determined that the UR procedures established by the State under title XIX of the Act are superior to the procedures required in this section, and has required hospitals in that State to meet the UR plan requirements under §§456.50 through 456.245 of this chapter. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to provide a utilization review (UR) plan that provides for the review of the medical necessity of admissions, duration of stays and professional services rendered to patients furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. This deficient practice was evidenced by the facility failing to have a UR Plan that included the establishment of a UR committee to carry out the review of the medical necessity of admissions, duration of stays and professional services rendered to patients. Findings: Review of the facility’s policy and procedure manual did not reveal a policy related to a UR Plan/Policy. Review of the facility’s Governing Body Meeting Minutes dated 01/09/2024-07/31/2024 and Medical Executive Meeting Minutes dated 01/15/2024 failed to reveal documentation related to an approval of a UR plan/Policy, appointment of providers to a UR committee, or any review of Medicare and Medicaid patients related to the medical necessity of admissions, duration of stays and professional services rendered in the facility. This deficient practice had the potential to affect any current patient or future patient receiving care at the hospital. In an interview on 08/06/2024 at 2:03 p.m., S13SW confirmed the hospital did not have Utilization Review Committee. In an interview on 08/07/2024 at 11:15 a.m. S1ADM confirmed the hospital did not have Utilization Review Plan or Utilization Review Committee.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47397 48051 Based on observation and interview, the hospital failed to maintain the condition of the physical plant and hospital environment in such a manner to assure the safety and well-being of patients. This deficient practice is evidenced by: 1) Failure to maintain the security of Unit A - C nursing stations because of inoperable door latches; 2) Failure to properly secure bedside nightstands; 3) Failure to maintain the ceiling tiles of the IOP; 4) Failure to maintain the ceiling light fixtures of the IOP; and 5) Failure to maintain the physical plant in good repair. Findings: 1) Failure to maintain the security of Unit A - C nursing stations because of inoperable door latches Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed Unit A - C nursing station’s entry doors were not secure upon closure. It was noted all 3 unit’s nursing station doors had an inoperable door latch. This would allow any patient on the unit the opportunity to access the nurse’s station which could place the patient or staff at risk for harm or injury. In an interview during the tour on 08/05/2024, S1ADM confirmed the above mentioned findings. 2) Failure to properly secure bedside nightstands Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed the following bedside nightstand to be insecurely or loosely attached to the adjacent wall: Room u-Bedside table b Room s-Bedside table b Room l-Bedside table a Room k-Bedside table a and b Room f-Bedside table a and b In an interview during the tour on 08/05/2024, S1ADM confirmed the above mentioned findings. 3) Failure to maintain the ceiling tiles of the IOP Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility’s IOP clinic location revealed missing ceiling tiles in the following rooms: Room yy-2 tiles Room aaa-1 ceiling tile Room bbb-1 ceiling tile In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings. 4) Failure to maintain the ceiling light fixtures of the IOP Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility’s IOP clinic location revealed all of the clinic’s 2 ft x 4 ft fluorescent light fixture coverings were not securely attached to the light fixture and were secondarily supported by a strip placed on the exterior side of the covering and across the center. These light coverings appeared to be yellowed with cracked edges. In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings. 5) Failure to maintain the physical plant in good repair. Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed the following: A. Bathrooms v, x, and z failed to reveal a soap dispenser attached to wall. B. Bathroom w failed to reveal a functioning sink. C. Main hallway on Unit A near room g near elevator revealed a loose handrail that was not secured to the wall. D. Main hallway on Unit B near room n near elevator revealed a loose handrail that was not secured to the wall. Further observation revealed holes in the wall where the rail is only partially attached. E. Missing floor baseboard molding: Room u next to toilet, Room x next to toilet, and Room c next to door frame. F. Room q revealed a hole to the left side bottom of the door frame. G. Room x revealed a hole in the wall behind the toilet. H. Outside of Room w revealed a sagging/stained tile. I. Hallway pp with mildew noted to ceiling tiles. J. Sink in room g bathroom with non-functioning water faucet. In an interview during the tour on 08/05/2024, S1ADM confirmed the above mentioned findings. In an interview on 08/12/2024 at 11:25 a.m., S33DSS confirmed the loose handrails on Units A and B. 50453”

“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: 47397 Based on observations and interviews the hospital failed to ensure facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality. This deficient practice is evidenced by: 1) failure to ensure Vac-Assist Suction Units and Oxygen Concentrators were maintained to ensure an acceptable level of safety and quality; 2) Failure to ensure expired supplies were not available for patient use; Findings: 1) Failure to ensure Vac-Assist Suction Units and Oxygen Concentrators were maintained to ensure an acceptable level of safety and quality. Observations during a tour on 08/12/2024 at 10:40 a.m., Unit A, Unit B, and Unit C revealed the following findings: Brand C Vac-Assist Suction Unit: Unit A: ID# SU11I01036, Biomedical Inspection due date: 10/12/2021 Unit B: ID# SU11I01649, Biomedical Inspection due date: 10/12/2021 Unit C: ID# SU11I01251, Biomedical Inspection due date: 10/12/2021 Brand C Oxygen Concentrator: Unit A: ID#: N0510-22822, Biomedical Inspection due date: 10/25/2019 Unit B: ID#: 0712-11761, Biomedical Inspection due date: 10/15/2021 Unit C: ID#: 9R-021000, Biomedical Inspection due date: 10/12/2021 During an interview on 08/12/2024 at 10:50 a.m. during the tour of the Unit B, S19RN confirmed that the biomedical inspection dates are past due. During an interview on 08/12/2024 at 10:55 a.m. during the tour of the Unit C, S48RN confirmed that the biomedical inspection dates are past due. During an interview on 08/12/2024 at 11:05 a.m. during the tour of the Unit A, S33DSS confirmed that the biomedical inspection dates are past due. During an interview on 08/12/2024 at 2:00 p.m. S1ADM confirmed that the biomedical inspections did not occur when due and he was immediately calling out biomedical technician to conduct an inspection of the equipment. 2) Failure to ensure expired supplies were not available for patient use Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed BD Vacutainers (purple top) x 6 tubes, expired on 06/30/2022 in the medication room of Unit C. In an interview on 08/05/2024 at 09:55 a.m., S48RN confirmed the above mentioned findings. Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility’s offsite Intensive Outpatient Program (IOP) clinic location revealed the following expired supplies: Vacuette Safety Blood Collection Set and Luer Adapter, 21 gauge needle with expiration on 11/30/2021 - Quantity 41; Vacuette Safety Blood Collection Set and Luer Adapter, 23 gauge needle with expiration on 11/28/2021 - Quantity 22 and expiration on 04/06/2023 - Quantity 23; Terumo Sun Guard 3 Safety Hypodermic Needle (20 gauge, 2 inch needle) with expiration 04/30/2021 - Quantity 2, expiration 10/31/2021- Quantity 1, and expiration 02/23/2022 - Quantity 1; Terumo Sun Guard 3 Safety Hypodermic Needle (21 gauge, 2 inch needle) with expiration 07/31/2024 - Quantity 1; Terumo Sun Guard 3 Safety Hypodermic Needle (22 gauge, 1½ inch needle) with expiration 07/31/2024 - Quantity 2; SMP Safety Needle 22 gauge, 1½ inch needle with expirations: 08/04/2018 - Quantity 1, 11/09/2018 - Quantity 1, 11/17/2018 - Quantity 1, 09/06/2019 - Quantity 1, 02/12/2020 - Quantity 1, 10/05/2020 - Quantity 1, 11/06/2020 - Quantity 1, 11/26/2021 - Quantity 1, 04/11/2022 - Quantity 1, and 01/26/2024 - Quantity 1; SMP Safety Needle 23 gauge, 1 inch needle with expirations: 09/30/2018 - Quantity 1, 10/08/2018 - Quantity 1, 01/28/2019 - Quantity 4, 03/21/2019 - Quantity 2, 05/09/2019 - Quantity 2, 06/12/2019 - Quantity 2, 06/13/2019 - Quantity 1, 06/26/2019 - Quantity 1, 07/18/2019 - Quantity 2, 08/24/2019 - Quantity 3, 02/13/2020 - Quantity 1, 02/23/2020 - Quantity 1, 03/14/2020 - Quantity 1, 05/20/2021 - Quantity 1, 12/19/2021 - Quantity 1, 03/11/2022 - Quantity 2, 06/27/2022 - Quantity 1, and 01/26/2024 - Quantity 1; Chloraprep Single Swab Stick with expiration 02/2020. Sure Comfort Insulin Syringes (1 ml syringe with 29 gauge ½ inch needle) with expiration 05/31/2022 - Quantity 60; BD Vacutainer Eclipse Blood Collection Needle with expiration 01/31/2023 - Quantity 48; Microtainer Blood Tubes (1 ml purple top) with the expirations: 10/31/2018 - Quantity 12, 12/31/2018 - Quantity 7, 05/31/2019 - Quantity 7; BD Vacutainer Collection Tube (purple top) with expiration 07/31/2023 - Quantity 6; BD Vacutainer Collection Tube with Sodium Fluoride/Potassium Oxalate additive with expiration of 12/31/2019 - Quantity 1; BD Vacutainer Serum Tube with expiration 01/31/2019 - Quantity 60; BD Vacutainer SST Tube with expirations: 04/30/2018 - Quantity 50, 01/31/2019 - Quantity 56; BD Vacutainer C&S Transfer Straw Kit C&S Preservative Plus Urine Tube (4 ml) with expiration 05/2019 - Quantity 18; and Kendal Monojet Safety Syringe (1 ml) with expiration 07/2016 - Quantity 4. In an interview on 08/06/2024 and present during the tour, S33DSS and S4LPN confirmed the above mentioned findings 48051 50453”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to provide proper ventilation and lighting in all area of the facility. This deficient practice is evidenced by inoperable light fixtures in the facility’s IOP location. Findings: Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility’s IOP clinic location revealed non-functioning ceiling lighting in the following rooms: Room uu: 2 of 5 light fixtures; Room vv: 2 of 5 light fixtures; Room ww: 1 of 1 light fixtures; Room yy: 2 of 4 light fixtures; Room xx: 2 of 3 light fixtures; Room zz 1 of 3 light fixtures; and Room aaa: 2 of 4 light fixtures. In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital infection prevention and control program failed to employ methods for preventing and controlling the transmission of infections within the hospital. This deficient practice was evidenced by: 1) failure to sanitize a mattress between patient use; 2) failure to properly sanitize equipment after patient use; and 3) failure to store clean items separate from dirty items. Findings: 1) Failure to sanitize a mattress between patient use. Review of hospital policy titled, “Equipment Cleaning,” last revised: January 2023, revealed in part: Policy Statement: The following procedures define and establish standards for assuring that non-critical (defined by the Centers for Disease Control (CDC) as items that come into contact with skin but not mucous membranes), shared patient care equipment is clean before use and that all used or contaminated equipment is appropriately cleaned before reuse. B. Non-critical items, as defined by the CDC, come in contact with intact skin but not mucous membranes. Soiled environmental surfaces can be a source of contamination to hands or other objects that may have contact with the patient. Patient Care Equipment managed by patient care units or services must be wiped with a hospital-approved detergent/disinfectant daily and when visibly soiled. These items include but are not limited to: Commode, Wheelchair, Electronic Thermometers, Pulse Oximeters, Blood Pressure Devices. Review of hospital policy titled, “Infection Control Committee Structure,” last revised January 2023, revealed in part: 5. Procedures for infection prevention, surveillance, and control in relation to the inanimate hospital environment; including practices in disinfection, housekeeping, laundry ... and waste management. On 08/08/2024 at 12:18 p.m., hospital video review of Unit A on 08/04/2024, navigated by S1ADM revealed the following: 08/04/2024: 12:10 a.m. - R1 arrives to Unit A. 12:15 a.m. - S17RN and S38MHT walk to Room c. Patient #2 is viewed laying on a uncovered bare mattress and has no clothing on below her waist. 12:16 a.m. - Patient #2 is given green scrub pants by S38MHT. 12:17 a.m. - S38MHT escorts Patient #2 out of Room c. 12:19 a.m. - R1 is brought to Room c by S17RN and S18MHT. R1 lays on the mattress in Room c without a sheet or cover on the mattress. The mattress was not cleaned between Patient #2 and R1 being placed in Room c. During an interview on 08/08/2024 at 12:30 p.m. S1ADM confirmed that the mattress and Room c were not cleaned between patient use. S1ADM also confirmed that Patient #2 was laying on the mattress without clothing covering the bottom half of her body and that R1 laid on this same mattress. During an interview on 08/12/2024 at 3:19 p.m. S2DON confirmed that when Patient #2 was taken out of Room c, the mattress should have been cleaned prior to placing R1 in the room. 2) Failure to properly sanitize equipment after patient use Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed patient infrared thermometer on Unit C being held together by loosely wrapped tape that had become sticky. The stickiness prevented the proper sanitary cleaning of the thermometer after patient use. In an interview on 08/05/2024 at 09:55 a.m., S48RN confirmed the presence of the tape on the surfaces of the thermometer. 3) Failure to store clean items separate from dirty items Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed a brown paper bag stored in the soiled utility closet of Unit C. The bag had the writing on it “donated clothing.” The bag did appear to have items within it. In an interview during the tour on 08/05/2024, S1ADM confirmed the brown bag was being stored in the soiled utility, was not sure if the clothing in the bag was clean or dirty and should not be stored in the soiled utility. 50453”

“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: 50453 Based on observation, record review and interview, the hospital failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by failure of the Infection Control Officer to gather and/or provide data and present it to the Infection Control Committee as per policy. Findings: Review of hospital policy titled, “Infection Control Plan,” last revised January 2023, revealed in part: Infection Control Function: The principal functions of the Infection Control Officer include the following: 1. To obtain and manage critical data and information, including surveillance of infections 2. To develop and recommend policies and procedures 3. To intervene directly to prevent infections 4. To educate and train ... The infection Control Officer is responsible for carrying out all aspects of the infection control program. Environmental Considerations: b. Evaluate compliance with standards set by the infection control committee. Epidemiology: b. Investigation: Maintain adequate records ... Compile and analyze surveillance data and present deviations from baseline data to the IC Committee and to other appropriate committees, departments or services. Review of hospital policy titled, “Infection Control Committee Structure,” last revised January 2023, revealed in part: Policy Statement: The Committee will meet at least four (4) times a year. The Committee will ... make complete and accurate minutes of all meetings. In the absence of a physician, the Committee can make no policies or clinical decisions. C. The Infection Control Committee will be responsible for the initiation and supervision of an active, hospital-wide infection control program which will include: 5. Procedures for infection prevention, surveillance, and control in relation to the inanimate hospital environment; including practices in disinfection, housekeeping, laundry, engineering and maintenance, food sanitation, and waste management. These procedures will be reviewed and evaluated annually and revised as necessary. Review of hospital policy titled, “Duties of Infection Control Officer,” last revised January 2023, revealed in part: A. Duties: The Infection Control Officer works under the direction of the Infection Control Committee. 5. The Infection Control Officer prepares monthly infection surveillance reports for the Infection Control Committee. 10. The Infection Control Officer collaborates with the PI Committee to study problems and possible solutions. Review of hospital policy titled, “Surveillance Program,” last revised January 2023, revealed in part: Policy Statement: it is the policy of the hospital to have an Infection Control Surveillance Program in place. Procedure: A. Infection Control Nurse will gather data on all possible infections occurring in the hospital. From this data, he/she will prepare a surveillance report monthly. This report is presented quarterly at the Infection Control Committee Meeting. Review of hospital policy titled, “Surveillance Reports,” last revised January 2023, revealed in part: Policy Statement: Surveillance reports will be regularly prepared. Procedure: A. The Infection Control Officer shall regularly prepare a report for the Infection Control Committee that reflects the types and numbers of infections present in the hospital. C. The statistical report shall be made available to the Infection Control Committee, Hospital Administrator, CEO, and the Nursing Leadership. Review of hospital policy titled, “Control of Head or Body Lice Infestation,” last revised January 2023, revealed in part: Purpose: To establish lice infestation control measures. Procedure: B. An effective way to accomplish this is to have daily head checks with all patients and document findings in a special log designed for this purpose. C. This log is to be maintained by MHTs under the supervision of the Charge Nurse. Copies with log should be turned into the Infection Control Department Weekly. Review of hospital documents failed to reveal an active Infection Control Program. Data being collected for analysis for Infection Control was requested numerous times during the survey and the facility failed to gather or provide the requested information. During an interview on 08/07/2024 at 2:27 p.m. S1ADM confirmed that the Infection Control Committee has not had any meetings per policy. S1ADM stated he does not have any meeting minutes to provide. S1ADM also confirmed that staff are not maintaining a daily head check log to turn into Infection Control as per lice policy.”

“Social Service Records CFR(s): The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to ensure social service records included interviews with patients, family members and others, assessment of home plans, family attitudes, and community resource contacts as well as a social history and early discharge planning. This deficiency is evidenced by failure of social services to complete the psychosocial assessment as ordered by the provider for 1 (#5) of 7 (#1-#6) patient records reviewed. Findings: Review of hospital’s policy titled, “Documentation Completion Time Frames”, Section 3.9.0 approved 01/2024, revealed in part: Procedure: Psychosocial assessments. Completion time 72 hours after admission. On 08/06/2024 at 8:45 a.m. a review of Patient #5’s medical record revealed admission on 07/31/2024 at 9:55 a.m. with admitting diagnosis of psychosis and major depressive disorder. Further review failed to reveal a completed psychosocial evaluation. A review of Patient #5’s admit orders revealed consult for social services for psychosocial assessment ... In interview on 08/08/2024 at 3:30 p.m., S33DSS verified the psychosocial assessment was not in Patient #5’s medical record per provider orders. S33DSS stated the psychosocial assessment included but was not limited to interviews with patients, family members and others, assessment of home plans, family attitudes, and community resource contacts as well as a social history and early discharge planning. S33DSS confirmed the psychosocial assessment should be completed within 72 hours of admission per hospital policy.”

“Director of Nursing - Responsibilities CFR(s): The director must demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to demonstrate that the director of nursing monitored and evaluated the nursing care furnished thereby ensuring accordance with safe, acceptable standards of nursing practice. This deficient practice was evidenced by: 1) failure to ensure the registered nurse documented rounds per patient policy for (15) of (20) patients reviewed; 2) failure to ensure the mental health technician noted precaution levels per hospital policy for (13) of (20) patients reviewed; 3) failure to ensure the registered nurse completed assignment sheets per hospital policy; Findings: 1) Failure to ensure the registered nurses documented rounds per patient policy for (15) of (20) patients reviewed. Review of hospital policy titled, “Patient Observation Record,” Section 4.2.0, approved 06/2024, revealed in part: Patients must be observed at least every 15 minutes. The observation with documented location and behavior must be documented, verified by the observer’s initials, at least every 15 minutes. Purpose: To ensure that the patient’s safety and well-being are maintained and documented. To have a continuous record of patient behavior and location. Procedure: The RN is responsible for MHT assignments (Patient Observation Record) 1. A review of this record is performed every 2 hours. 2. A rounding of all patients is to be performed every 2 hours and documented on the Patient Observation Record ... Patient #1 Review of Patient #1’s observation records revealed the following: 08/05/2024-observation sheet failed to reveal RN rounding from 9:45 a.m.-12:00 p.m. Patient #2 Review of Patient #2’s observation records revealed the following: 08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. Patient #3 Review of Patient #3’s observation records revealed the following: 08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m. 08/04/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m. Patient #4 Review of Patient #4’s observation records revealed the following: 07/25/2024-observation sheet failed to reveal RN rounding from 2:00 a.m.-6:00 a.m. 07/26/2024-observation sheet failed to reveal RN rounding from 1:45 a.m.-6:00 a.m. 07/27/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-8:00 a.m. 08/05/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-8:00 a.m. Patient #5 Review of Patient #5’s observation records revealed the following: 08/04/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. or MHT observations from 5:45 a.m.-7:00 a.m. 08/05/2024-observation sheet failed to reveal RN rounding from 11:45 a.m.-8:00 a.m. 08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. Patient #6 Review of Patient #6’s observation records revealed the following: 08/03/2024-observation sheet failed to reveal RN rounding from 05:45 a.m.-8:00 a.m. 08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. Patient #R1 Review of Patient #R1’s observation records revealed the following: 08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. Patient #R2 Review of Patient #R2’s observation records revealed the following: 06/26/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m. 06/27/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m. and 8:00 p.m.-11:45 p.m. 06/28/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m. 06/29/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. 07/01/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m. 07/02/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m. 07/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. 07/05/2024-observation sheet failed to reveal RN rounding from 8:00 a.m.-2:00 p.m. 07/11/2024-observation sheet failed to reveal RN rounding from 8:00 a.m.-6:00 p.m. 07/17/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m. 07/19/2024-observation sheet failed to reveal RN rounding or MHT observations from 12:00 a.m.-7:00 a.m. 07/20/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m. 07/21/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. and 6:00 p.m.-11:45 p.m. 07/29/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m. and 8:00 p.m.-11:45 p.m. 07/31/2024-observation sheet failed to reveal RN rounding from 8:00 a.m.11:45 p.m. 08/01/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-8:00 a.m. and 8:00 p.m.-11:45 p.m. 08/02/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m. 08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m. 08/04/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m. Patient #R3 Review of Patient #R3’s observation records revealed the following: 08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. Patient #R4 Review of Patient #R4’s observation records revealed the following: 08/05/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-8:00 a.m. 08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. Patient #R5 Review of Patient #R5’s observation records revealed the following: 08/05/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-10:00 a.m. 08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. Patient #R6 Review of Patient #R6’s observation records revealed the following: 08/05/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-10:00 a.m. 08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. Patient #R10 Review of Patient #R10’s observation records revealed the following: 08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m. Patient #R15 Review of Patient #R15’s observation records revealed the following: 08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m. Patient #R23 Review of Patient #R23’s observation records revealed the following: 08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m. In an interview on 08/08/2024 at 2:10 p.m., S2DON verified the above findings. 2) Failure to ensure mental health technicians noted precaution levels per hospital policy for (13) of (20) patients reviewed. Review of hospital policy titled, “Patient Observation Record,” Section 4.2.0, approved 06/2024, revealed in part: The MHT is to note the Precaution Level ordered for each patient... Patient #1 Review of Patient #1’s admit orders dated 08/05/2024 revealed an order for Suicide Preecautions. Continued review of Patient #1’s physician orders dated 08/05/2024-08/07/2024 failed to reveal an order to discontinue suicide precautions. Review of Patient #1’s observation record dated 08/06/2024 failed to reveal “Precaution Level-Suicide” noted. Patient #2 Review of Patient #2’s admit orders dated 07/28/2024 revealed an order for Fall and Seizure Precautions. Patient #2’s observation records failed to reveal “Precaution Level-Seizures and Fall” noted on the following dates: 07/31/2024-08/03/2024, and 08/06/2024. Patient #3 Review of Patient #3’s admit orders dated 08/01/2024 revealed an order for Suicide and Assault Precautions. Patient #3’s observation records failed to reveal “Precaution Level-Suicide and Assault” noted on the following dates: 08/01/2024-08/05/2024. Patient #4 Review of Patient #4’s admit orders dated 07/24/2024 revealed an order for Suicide Precautions. Patient #4’s observation records failed to reveal “Precaution Level-Suicide” noted on the following dates: 07/28/2024-08/02/2024 and 08/05/2024. Patient #6 Review of Patient #6’s admit orders dated 08/02/2024 revealed an order for “Suicide and Fall Precautions”. Patient #6’s observation records failed to reveal “Precaution Level-Suicide and Fall” noted on the following dates: 08/03/2024, 08/04/2024, and 08/06/2024. Patient #R2 Review of Patient #R2’s admit orders dated 05/14/2024 revealed an order for suicide precautions. Continued review of Patient #R2’s physician orders dated 05/15/2024-08/06/2024 failed to reveal an order to discontinue suicide precautions. Additional review revealed Patient #R2 was discharged to Hospital B with leg fracture on 08/06/2024. Review of Patient #R2’s observation records failed to reveal Precaution Level-Suicide noted on the following dates: 06/26/2024-06/29/2024, 07/01/2024-07/03/2024, 07/05/2024, 07/11/2024, 07/12/2024, 07/17/2024, 07/19/2024-07/21/2024, 07/29/2024, 07/31/2024, and 08/01/2024-08/06/2024. Patient #R5 Review of Patient #R5’s admit orders dated 08/03/2024 revealed an order for Seizure Precautions. Review of Patient #R5’s observation records failed to reveal “Precaution Level-Seizure” noted on the following dates: 08/05/2024. Patient #R6 Review of Patient #R6’s admit orders dated 07/29/2024 revealed an order for Suicide Precautions. Review of Patient #R6’s observation records failed to reveal “Precaution Level-Suicide” noted on the following dates: 08/05/2024 and 08/06/2024 Patient #R8 Review of Patient #R8’s admit orders dated 07/27/2024 revealed an order for Suicide and Assault Precautions. Review of Patient #R8’s observation records failed to reveal “Precaution Level-Suicide and Assault” noted on the following dates: 08/03/2024-08/05/2024. Patient #R11 Review of Patient #R11’s admit orders dated 07/24/2024 revealed an order for Suicide Precautions. Review of Patient #R11’s observation records failed to reveal “Precaution Level-Suicide and Assault” noted on the following dates: 08/03/2024-08/05/2024. Patient #R14 Review of Patient #R14’s admit orders dated 07/30/2024 revealed an order for Suicide Precautions. Review of Patient #R14’s observation records failed to reveal “Precaution Level-Suicide” noted on the following dates: 08/03/2024-08/05/2024. Patient #R18 Review of Daily Nursing Assignment Sheet dated 07/28/2024 revealed Patient #R18 was on Suicide Precautions. Review of Patient #R18’s observation record dated 08/05/2024 failed to reveal “Precaution Level-Suicide” noted. Patient #R21 Review of Daily Nursing Assignment Sheet dated 08/02/2024 revealed Patient #R21 was on Homicide Precautions. Review of Patient #R21’s observation record dated 08/05/2024 failed to reveal “Precaution Level-Assault” noted. In an interview on 08/08/2024 at 2:10 p.m. S2DON verified the above findings. S2DON stated that sometimes suicide assessment may indicate the patient no longer at risk but the nurse should always notify the physician and obtain an order to discontinue suicide precautions. S2DON stated she was not sure if the hospital had a policy regarding the process of discontinuing physician ordered precautions. Previously cited on 07/24/2024 3) Failure of the Dirctor of Nursing to ensure the registered nurse completed assignment sheets per hospital policy. Review of hospital policy titled “Staffing Plans and Delivery of Care”, dated 01/2021, revealed in part: Policy: The Director of Nursing shall outline a staffing plan that shall be used to determine the personnel recommended for each shift as outlined in the units core coverage and as necessary to provide the scope of services ...Census: 1-12 patients requires: 1 Registered Nurse and 2 Mental Health Technicians. Review of Daily Nursing Assignment Sheet for Unit B dated 07/24/2024, day shift, revealed a census of 12. Continued review failed to reveal each patient was assigned a Mental Health Technician. Review of Daily Nursing Assignment Sheet for Unit B dated 07/25/2024, day shift, revealed a census of 11. Continued review failed to reveal each patient was assigned a Mental Health Technician. Review of Daily Nursing Assignment Sheet for Unit B dated 07/26/2024, day shift, revealed a census of 11. Continued review failed to reveal each patient was assigned a Mental Health Technician. Review of Daily Nursing Assignment Sheet for Unit C dated 08/01/2024, day shift, revealed a census of 11. Continued review failed to reveal each patient was assigned a Mental Health Technician. Review of Daily Nursing Assignment Sheet for Unit C dated 08/01/2024, night shift, failed to reveal a census. Continued review failed to reveal the names of the patients assigned to the Mental Health Technicians. Review of Daily Shift Assignments for Unit C dated 08/05/2024, day shift, failed to reveal a census. Continued review failed to reveal the names of the patients assigned to the Mental Health Technicians. In an interview on 08/08/2024 at 2:15 p.m. S2DON reported she had created new assignment sheets but the nurses are still using the old sheets and are not completing the assignment sheet as they should. In an interview on 08/08/2024 at 3:15 p.m., S1ADM confirmed that the assignments were not properly completed.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to provide adequate numbers of nursing staff to provide the nursing care necessary under each patient’s active treatment plan. This deficiency is evidenced by failure of the psychiatric hospital to have adequate staffing of mental health technicians (MHT) per the psychiatric hospital’s staffing matrix for 11 of 18 staffing assignments reviewed. Review of hospital’s policy titled “Staffing Plans and Delivery of Care”, Section 1.8.0 approved 01/2024 revealed in part: Policy: The director of nursing shall outline a staffing plan that shall be used to determine the personnel recommended for each shift ...Purpose: to define guidelines for the utilization of RNs and MHTs in providing delivery of patient care. Procedure, in part: Core coverage: The minimum staffing needed for each unit (RN, MHT) is set forth by the nurse-patient ratio guidelines (See table) ... Table: Census 1-12=RN-1 and MHT-2. Review of hospital policy titled “Shift Assignments”, last reviewed 01/2022, revealed, in part: Purpose: To ensure a safe, therapeutic milieu and delivery of quality patient care by designating specific duties to appropriate staff members... Procedure, in part: 1. Charge Nurse: The charge nurse will determine the nursing care assignments for that shift based on patient acuity and capabilities of available staff. On 08/05/2024 at 9:24 a.m., a request was made in writing to S1ADM for the nursing assignment sheets for each unit for June and July 2024. On 08/06/2024 at 10:48 a.m. surveyor was provided with Daily Nursing Assignment Sheets for the timeframe 07/24/2024-08/05/2024, which did not include all Units. S2DON reported she was looking for the rest and would provide them when found. A review of the Daily Nursing Assignment Sheets provided for Unit A revealed the following: 08/01/2024-day shift-Census 7 (no precautions noted on assignment sheet). Staff: 1 RN (Name not on current employee contact list) and 1 MHT (S62MHT). 08/02/2024-day shift-Census 7 (including Patient #2 with seizure and fall precautions noted on assignment sheet). Staff: 1 RN (S17RN) and 1 MHT (S40MHT). 08/02/2024-night shift-Census 7 (including Patient #2 with seizure and fall precautions noted on assignment sheet). Staff: 1 RN (S48RN) and 1 MHT (S63MHT). A review of the Daily Nursing Assignment Sheets provided for Unit B revealed the following: 07/22/2024-night shift-Census 10 (including Patient #R17 with seizure and fall precautions noted on assignment sheet). Staff: 1 RN (S64RN) and 1 MHT (S65MHT). Noted by S64RN on assignment sheet “S65MHT only tech for shift. 07/25/2024-night shift-Census 11 (no precautions noted on assignment sheet). Staff: 1 RN (Name not on current employee contact list) and 1 MHT (S53MHT). 07/27/2024-day shift-Census 7 (including Patients #R8, #R18 and #R19 with suicide precautions noted on assignment sheet). Staff: 1 RN (S66RN-Name not on current employee contact list) and 1 MHT (S39MHT). 07/28/2024-day shift-Census 7 (including Patients #R8, #R18 and #R19 with suicide precautions noted on assignment sheet). Staff: The document failed to reveal the staff RN and MHTs caring for patients on this shift. 07/29/2024-day shift-Census 8 (including Patient #R20 with suicide precautions noted on assignment sheet). Staff: 1 RN (S48RN) and 1 MHT (S39MHT). 07/30/2024-day shift-Census 8 (no precautions noted on assignment sheet). Staff: 1 RN (S32RN) and 1 MHT (S52MHT). 07/31/2024-night shift-Census 6 (no precautions noted on assignment sheet). Staff: 1 RN (S46RN) and 1 MHT (S67MHT). 08/01/2024-night shift-Census 8 (including Patients #R21 and #R22 with homicide precautions and Patient #R20 with suicide precautions noted on assignment sheet). Staff: 1 RN (S48RN) and 1 MHT (S52MHT). In an interview on 08/08/2024 at 11:15 a.m., S2DON confirmed the above findings and agreed the staffing was not adequate per the hospital staffing matrix. In an interview on 08/08/2024 at 3:15 p.m., S1ADM verified staffing was short with only 1 MHT. S1ADM confirmed the hospital policy requires 2 MHTs at all times.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 37777 Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice had the potential to affect 19 of 19 residents. Findings: During the facility tour on 8/8/2024, between the hours of 11:00 am to 5:30 pm it was observed that above the fire exit hardware on both stairs for the third, fourth, and fifth floor had double sided key deadbolts installed above the fire exit hardware. It was also observed that the smoking area had a gate that appeared to be provided with a lock that had netting installed over and attached to it. The other side had overgrown foliage preventing use of the gate. Interview with the maintenance supervisor revealed the facility was not aware that the additional lock not connected to the fire exit hardware was not allowed.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 37777 Based on visual observation the facility failed to assure that the smokeproof enclosure meets the requirements of NFPA 101:7.2.3.2 . This reduces or eliminates the potential of fire and/or smoke spreading from one floor to another. This deficiency has the potential to affect 19 of 19 residents. Findings: During the facility tour on 8/8/2024, between the hours of 11:00 am to 5:30 pm that the tops of the smoke-proof enclosures had a device with a fusible link. There was no documentation that the device had received it’s required inspection. Interview with the maintenance supervisor revealed the facility was not aware that the device required an inspection.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 37777 Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 3 of 19 residents. Findings: During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that the rooms on the opposite side from medical records had rooms converted to storage for patient records in numerous large cardboard boxes. One room was also being used for an additional maintenance/repair room. These areas are now hazardous and require separation with smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing. Interview with the maintenance supervisor revealed the facility was not aware of the hazardous areas created and that they needed self closing doors.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 37777 Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 25. NFPA 25:5.1.1.2 states, “ Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.” Findings: During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was noted that the sprinkler system was yellow tagged on 7/30/2024 due to the FDC hydro test failing. It was also observed that the sprinkler head in room 401 appeared to be damaged. It was also found that the person that performed the testing/inspection on the sprinkler system for the original yellow tag was not licensed. Interview with the maintenance supervisor revealed the facility was not aware that the sprinkler head was damaged. He was aware that the FDC hydro test had failed and that the bid had been approved for the repair.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 37777 Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 19 of 19 residents. Findings: During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that the corridor walls had gaps and numerous openings both above and below the drop ceiling. In multiple areas penetrations had been made for extension cords and/or surge protectors to be utilized in other spaces such as the nursing, med room, electrical/phone room, office, and Dr. Office on the 4th floor. Interview with the maintenance supervisor revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 37777 Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 19 of 19 residents. Findings: During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that the corridors are being used for supply/return air plenum. The HVAC closet has louvers that are open to the corridor. Interview with maintenance supervisor revealed the facility was not aware the HVAC system was using the corridors as a return/supply air plenum.”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 37777 Based on visual observation, the facility failed to assure that the policy on smoking required all smoking areas to be supplied with a metal, self-closing container. Cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion. This deficient practice could potentially affect 6 of 19 residents. Findings: During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that the smoking area on the first floor was not provided with metal containers that had self-closing cover devices into which ashtrays could be emptied into. Cigarette butts were scattered all around the smoking area in the vegetation. It appeared the previous metal container that was on or near the wall based off the signage had been removed. Interview with the maintenance supervisor revealed the facility was not aware the containers in the smoke area did not meet the requirements and/or had been removed.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 37777 Based on visual observation the facility failed to assure that installed fire doors were inspected and maintained. The fire doors restrict the movement of fire from one compartment to another. NFPA 80:5.2.3.5.2 states, “As a minimum, the following items shall be verified: (1) Labels are clearly visible and legible. (2) No open holes or breaks exist in surfaces of either the door or frame. (3) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (4) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (5) No parts are missing or broken. (6) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (7) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (8) If a coordinator is installed, the inactive leaf closes before the active leaf. (9) Latching hardware operates and secures the door when it is in the closed position. (10) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (11) No field modifications to the door assembly have been performed that void the label. (12) Meeting edge protection, gasketing and edge seals, where required, are inspected to verify their presence and integrity. (13) Signage affixed to a door meets the requirements listed in 4.1.4.” The deficient practice had the potential to affect 19 of 19 residents. Findings: During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm documentation was provided that an annual fire door inspection was performed on 5/28/2024. However on the 1st floor, the fire door between the lobby leading to the stairs and maintenance has open screw holes through the door and the label painted over. The maintenance room door is missing screws. The fire doors for the stairs on the 3rd, 4th, and 5th floor have double sided deadbolts that are not rated to be installed on fire-rated door assemblies. Room 509 had the door unable to close due to dragging the floor. Interview with the maintenance supervisor revealed the facility was not aware that the fire doors had not been properly inspected and maintained.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 37777 Based on visual observation, the facility failed to assure that all power strips are being used with general caution and that extension cords are not being used as a substitute for fixed wiring of a structure as per NFPA 99 and NFPA 70. Power strips in the patient care vicinity may not be used for non-PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms meet UL 1363. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. The deficient practice had the potential to affect of residents. Findings: During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that throughout the facility extension cords and surge protectors were being used in the place of permanent fixed wiring. Extension cords and surge protectors were going through walls and drop ceilings in numerous areas including the nursing station, med room, electrical/phone room, office, and Dr. Office on the 4th floor. Surge protectors were also being used for high voltage appliances such as microwaves, coffee appliances, and full size refrigerators. On the 5th floor a surge protector had been tapped to the receptacle due to the surge protector plug and outlet being damaged in the medicine room. Interview with the maintenance supervisor revealed the facility was not aware that extension cords are being used as a substitute for fixed wiring and that surge protectors were being used improperly.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50453 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Conditions of Participation (CoP) of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: 1) failure to prevent sexual assault of Patient #1 (See findings in A0144); 2) failure to ensure staff were rounding and monitoring patients which potentially led to patient elopement for 2 (#3, #R4) of 2 (#3, #R4) patients reviewed who eloped (See findings in A0145); 3) failure to ensure observations and precautions were implemented as ordered on 07/22/2024 for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed and on 07/23/2024 for 11 (Patient #1, #R2-#R4, #R7-#R13) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed (See findings in A0145); 4) failure to ensure all exit doors were secure (See findings in A0144); 5) failure to assess patients who were at high risk for intentional harm to self in 2 (#1 and #2) of 3 (#1-#3) patients reviewed (See findings in A0145); 6) failure to ensure the patient /patient representative was included in the development and implementation of the patient’s plan of care for 2 (#1 and #3) of 3 (#1- #3) sampled patient records reviewed (See findings in A0130).”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50453 Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Nursing Services. The deficient practice is evidenced by: 1) failure to ensure a registered nurse was physically present on each unit of the hospital at all times (See findings in A0392); 2) failure to ensure adequate numbers of nursing support staff on each unit per hospital policy (See findings in A0392); 3) failure to document patient rounding on 07/22/2024 Unit C for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients per physician orders (See findings in A0398); 4) failure of the nursing staff to monitor the therapeutic effect of PRN medications in 2 (#1-#3) of 3 (#1-#3) patients reviewed for therapeutic assessment after medication administration (See findings in A405); 5) failure of nursing staff to document provider notification following Patient #3’s elopement (See findings in A0398); 6) failure of the nursing staff to complete an Emergency Transfer Sheet in 1 (#1) of 3 (#1-#3) records reviewed (See findings in A0398).”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 47397 Based on record reviews and interview, the hospital failed to ensure compliance with State law as evidenced by having a patient admitted for treatment by physician’s emergency certificate and failing to obtain a coroners certificate or formal voluntary admission within 72 hours for 1 (#1) of 3 (#1 - #3) patient records reviewed. Findings: Review of 2024 Louisiana Law Title 28 - Mental Health RS 28:53 revealed in part: G.(1) Upon admission of any person by emergency certificate to a treatment facility, the director of the treatment facility shall immediately notify the coroner of the parish in which the treatment facility is located of the admission ...(2)(a) Within seventy-two hours of admission, the person shall be independently examined by the coroner or his deputy who shall execute an emergency certificate, pursuant to Subsection B of this Section, which shall be a necessary precondition to the person’s continued confinement. Review of Patient #1’s medical record revealed an admission date of 07/16/2024 at 4:30 p.m. after a suicide attempt in a group home. Diagnoses included intellectual disability, bipolar disorder, ADHD, and severe sexual abuse as a child. Admitted for depression and suicidal ideation. She was admitted with a physician’s emergency certificate dated 07/14/2024 at 12:40 p.m. Continued review revealed a Formal Voluntary Admission signed by Patient #1 on 07/16/2024 at 5:00 p.m. and her attending physician on 07/17/2024 at 11:00 a.m. Further review of Patient #1’s medical record revealed a readmission date of 07/19/2024 at 2:00 p.m. after returning from the emergency department following a sexual assault during prior admission. She was admitted with a physician’s emergency certificate signed by physician on 07/19/2024 at 5:45 a.m. On 07/24/2024 at 10:05 a.m., Patient #1’s medical record revealed a Formal Voluntary Admission signed by Patient #1 on 07/22/2024 at 9:05 a.m. On 07/24/24 at 10:05 a.m., Patient #1’s medical record failed to reveal a signature by her attending physician on the Formal Voluntary Admission form. On 07/24/2024 at 10:06 a.m., further review of Patient #1’s medical record failed to reveal a coroner’s emergency certificate. In an interview on 07/24/2024 at 10:06 a.m., S1Adm verified Patient #1 had not been discharged. S1Adm confirmed Patient #1’s medical record failed to reveal a coroner’s emergency certificate. S1Adm confirmed Patient #1’s medical record failed to reveal a signature by her attending physician on the Formal Voluntary Admission form indicating that he approved of a Formal Voluntary Admission. In an interview on 07/24/2024 at 5:12 p.m., S1Adm verified he was unable to locate hospital policy and procedure in regards to documentation supporting legal status pertaining to the appropriate legal circumstances under which patients are admitted and treated.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the patient /patient representative’s right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient’s plan of care for 2 (#1 and #3) of 3 (#1- #3) sampled patient records reviewed. Findings: Review of the hospital’s policy titled, “Patient Rights”, approved 06/2024, revealed in part: Procedure, in part: ...All patients have the right to ...7. The right to participate in the development and implementation of his/her plan of care. 8. Make informed decisions regarding his/her care. 9. Be informed of his/her health status, be involved in care planning and treatment, and be able to request or refuse treatment. Review of hospital policy titled, Master Treatment Plan/Weekly Update Treatment Plan”, dated 06/2021, revealed in part: Procedure, in part: B. Treatment plans will be individualized to address patient specific problems, identified through clinical assessments. Master Treatment plans cannot be initiated until all assessments are documented ...D. The patient will be involved in the treatment planning process; will provide input in developing the Master Treatment Plan/Weekly Treatment Plan, and will attend treatment team meetings when appropriate. E. Family will be involved in the treatment process if the patient gives concent, when appropriate tp facilitate family involvement. F. The delivery of effective care and services depend on the following four 94) key processes being performed well: ...4. Modifying the treatment plan sas necessary to meet the changes in progress. Patient #1 Review of Patient #1’s medical record revealed an admission date of 07/16/2024 at 4:30 p.m. after a suicide attempt in a group home. Diagnoses intellectual disability, bipolar disorder, ADHD, and severe sexual abuse as a child. Admitted for depression and suicidal ideation. Review of Patient #1’s Treatment Plan, dated 07/16/2024 at 1:16 p.m. (approximately 3 hours before her admission) failed to reveal diagnoses. Further review revealed target dates of 07/23/2024 and 07/30/2024 for long-term goals pertaining to problems, Danger to Self and GERD. Additional review failed to reveal the patient’s or patient representative’s signature indicating participation in this treatment plan. In an interview on 07/24/2024 at 3:33 p.m., S1Adm and S3DON confirmed Patient #1’s Treatment Plan was initiated before patient was admitted, was incomplete and failed to reveal the patient’s or patient representative’s signature indicating participation in this treatment plan. Patient #3 Review of Patient #3’s medical record revealed an admission date of 07/14/2024 at 1:34 a.m. after having auditory and visual hallucinations with aggressive behavior and trying to elope from the emergency department. Diagnosis schizophrenia. Review of Patient #3’s Treatment Plan, dated 07/18/2024 at 4:13 p.m. (approximately 4 days after his admission) revealed diagnosis paranoid type schizophrenia. Further review revealed target dates of 07/28/2024 and 07/29/2024 for long-term goals pertaining to problems psychotic symptoms, absent medical problems and coping skills. Further review failed to reveal the patient’s or patient representative’s signature indicating participation in this treatment plan. In an interview on 07/24/2024 at 2:20 p.m., S1Adm confirmed Patient #3’s Treatment Plan was initiated approximately 4 days following admission and failed to reveal the patient’s or patient representative’s signature indicating participation in this treatment plan.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 50453 Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by: 1) failure to prevent sexual assault of Patient #1; 2) failure to ensure all exit doors were secure. Findings: Review of hospital’s policy titled, “Patient Rights,” approved 06/2024, revealed in part: [the hospital] supports and protects the basic human, civil, and constitutional rights of all patients. The principle of this policy is the patient’s right to respect, dignity, and comfort. 18. The right to receive care in a safe setting. Review of hospital’s policy titled, “Unit Safety Rounds Checklist,” approved 06/2024, revealed in part: Policy Statement: Safety is of utmost importance. The environment of care must be safe for psychiatric patient care. At the beginning of each shift, the Registered Nurse must oversee the environmental rounds to be done by the Mental Health Technicians. Any environmental issues that cannot be resolved immediately need to be addressed with the Registered Nurse. Any staff member may fill out work order request forms if necessary. Procedure: At the beginning of each shift, Mental Health Technicians must: 1. Make environmental rounds of their unit. Mental Health Tech Rounding Sheet includes ensuring Fire doors at stairwells auto close and latch. No Doorstops or doors are not propped open. 1) Failure to prevent sexual assault in Patient #1. Review of Patient #1’s medical record revealed Patient #1 was a 19 year old female who was admitted on 07/16/2024 at 4:30 p.m. after a suicidal attempt in a group home. Diagnosis included: Intellectual Disability, Bipolar, ADHD, and severe sexual abuse as a child. Admitted for depression and suicidal ideation. Review of Patient #2’s medical record revealed Patient #2 was a 49 year old male who was admitted on 07/17/2024 at 11:00 a.m. for suicidal and homicidal ideation. Diagnosis of schizoaffective disorder. Review of Patient #2’s Psychiatric Evaluation from 07/18/2024 at 8:38 a.m. revealed Patient #2 had a previous conviction of rape with incarceration for 30 years. Further review revealed Patient #2 admit orders on 07/17/2024 at 12:00 p.m. with high suicide and high assault precautions. During an interview on 07/23/2024 at 11:15 a.m. S3DON stated she did not think Patient #2 had a previous history of a sexual crime. Review of self-report incident from 07/18/2024 revealed Patient #1 reported to S3DON that she was sexually assaulted by Patient #2. The self-report incident results revealed in part: Both patients (Patient #1 and Patient #2) were on Q15 observations prior to and during the event. The sexual assault allegation occurred on 07/18/2024 around 7:30 p.m. This incident of possible neglect is determined to be unsubstantiated. The unit was properly staffed an observation levels were consistent with the hospitals Q15 policy. On 07/23/2024 at 3:37 p.m. the video footage was reviewed for the night of the incident that occurred on 07/18/2024 with S1ADM and S3DON. Review of the video footage for Unit C revealed the following: Hallway Camera: 5:24 p.m. - Patient #2 on phone on floor in hallway a, across from room b. 5:34 p.m. - Patient #1 in hall across from Patient #2. 5:48 p.m. - S15RN left Unit C. 6:09 p.m. - S15RN returned to Unit C. (Gone 21 minutes) 6:39 p.m. - 1 oncoming MHT (S16MHT) arrives and both day MHT’s leave the Unit C. 6:44 p.m. - 1 MHT (S16MHT) on the Unit C. 6:50 p.m. - S16MHT left the Unit C. There were no MHTs and only 1 RN (S15RN). 6:54 p.m. - S13MHT on Unit C. 7:01 p.m. - S13MHT and S15RN (1 RN and 1 MHT) on Unit C in room b. 7:05 p.m. - Patient #2 and Patient #1 in hallway a together talking. 7:15 p.m. - S16MHT leaves the Unit C. 7:16 p.m. - Patient #1 in room f. 7:18 p.m. - Patient #1 in hall sitting next to Patient #2. 7:18 p.m. - S16MHT returns to Unit C. 7:19 p.m. - Patient #1 in hall with Patient #2. 7:20 p.m. - S16MHT leaves again. 7:21 p.m. - MHT’s have not made rounds since arriving on shift. 7:22 p.m. - S15RN talking to Patient #2 he wants the phone but the phone was broken by Patient #2 before shift change. S13MHT still in room b with S15RN. 7:23 p.m. - Patient #2 following Patient #1 down hallway a. 7:24 p.m. - S3DON arrives as charge nurse to relieve S15RN. 7:24 p.m. - Patient #2 talking to Patient #1 7:25 p.m. - Still no rounds. S3DON, S15RN, and S13MHT in room b. 7:26 p.m. - Patient #2 talking to Patient #1 -they are alone in hallway a. 7:26 p.m. - S16MHT back with food in room b. 7:27 p.m. - S16MHT left Unit C by back stairwell. 7:27:35 p.m. - Patient #2 exposes himself to Patient #1. 7:29 p.m. - Staff (2 RN and 1 Tech) still in room b, no rounds. 7:29 p.m. - Patient #2 walked to his room (room h). 7:29 p.m. - Patient #1 by room b looking in window. 7:30 p.m. - Patient #1 goes into room h. 7:30 p.m. - Staff still in room b. No rounds. 7:32 p.m. - Patient #2 and Patient #1 still in room h. 7:33 p.m. - Patient #1 walks out of room h into hallway a adjusting her pants and tying the waist while pulling them up. 7:33 p.m. - Patient #2 and Patient #1 in hallway a by elevator speaking. 7:36 p.m. - Staff still in room b. No rounds. 7:35 p.m. - Patient #1 pacing hallway a looking in room b. 7:36 p.m. - Staff still in room b. No rounds. 7:37 p.m. - Patient #1 in hallway a alone with Patient #3 and Patient #2. 7:39 p.m. - Staff still in room b. No rounds. 7:39 p.m. - Patient R2 walks out of room h and goes to room b. 7:40 p.m. - Patient #1 walks to room b and asking for a shower. 7:41 p.m. - S3DON walks out of room b into hallway a. 7:42 p.m. - S16MHT never returned. S13MHT still in room b. 7:43 p.m. - Patient #2 walked behind Patient #1 and S3DON. 7:44 p.m. - All staff in room b and Patient #1 and Patient #2 in the hallway a alone eating snacks. 7:46 p.m. - S15RN (day shift) leaves Unit C via elevator. 7:47 p.m. - S3DON made rounds. S13MHT in room b. 7:49 p.m. - Patient #1 sitting in hallway a. 7:50 p.m. - Staff still in room b. 7:51 p.m. - Patient #2 and Patient #1 in hallway a alone. 7:53 p.m. - S13MHT walks out of room b towards room c then back to room b. 7:54 p.m. - Patient #2 and Patient #1 in hallway a alone. 7:56 p.m. - Staff in room b. No rounds. 7:59 p.m. - S3DON out of room b. 8:00 p.m. - S13MHT takes a few patients to smoke including Patient #2. 8:01 p.m. - Patient #1 and S3DON speaking. Patient #1 tells S3DON that something happened (per S3DON). 8:05 p.m. - S3DON texting female MHT to come to Unit C. Also texting S16MHT to come up. 8:08 p.m. - Patient #1 asks to call mom. Phone is broken. 8:10 p.m. - Patient #1 sitting in chair head in hands in room b. 8:12 p.m. - S13MHT and other patients return from smoke break. 8:13 p.m. - Patient #2 leaning against wall by Patient #1 and S3DON. 8:14 p.m. - Patient #1 pulls chair closer into room b. 8:15 p.m. - S3DON taking report for another patient coming in. 8:15 p.m. - Patient #1 asks to use phone again. 8:16 p.m. - Patient #2 standing by room b. 8:17 p.m. - Patient #1 using S3DON phone. 8:18 p.m. - Patient #2 still by room b. 8:22 p.m. - Patient #2 keeps asking about a shower. Female MHT arrives to Unit C. 8:24 p.m. - Patient #2 following Patient #1 down hall. They are alone. 8:30 p.m. - Patient #1 leaning against wall outside room b. 8:34 p.m. - Patient #1 tells S3DON she was raped (per S3DON, some audio but muffled). 07/18/2024 - 8:36:14 p.m. nurses station (room b) view ends. No video available of the room b view after this point. On 07/24/2024 at 9:00 a.m. the video footage was further reviewed for the night of the incident that occurred on 07/18/2024 with S1ADM and S3DON. Review of the video footage for Unit C revealed the following: 8:36 p.m. - Patient #2 leaning against wall looking into room b as S3DON and Patient #1 talk. Audio revealed Patient #2 saying he wanted his medications early. (S3DON stated she was on the phone with the police at this time). 8:40 p.m. - S13MHT is now by Patient #2. 8:42 p.m. - Another female tech is in room b with S3DON and Patient #1. 8:50 p.m. - Patient #2 goes to room c pacing with S13MHT. 8:52 p.m. - Patient #2 still in room c. 8:54 p.m. - Patient #2 leaves room c goes to room h by himself. 8:56 p.m. - NOPD on Unit C. 8:57 p.m. - S3DON speaking with the police. Patient #1 in room c with S13MHT. 8:58 p.m. - Patient #1 in room c with police and S3DON. Patient #1 explaining to police what occurred. 9:01 p.m. - S3DON and Patient #1 leave room c with police. 9:03 p.m. - Patient #2 in room c in cuffs with S13MHT. Patient #2 Calm. 9:26 p.m. - Patient #1 leaving Unit C for hospital. Left by Ambulance. 9:58 p.m. - SVU interviewing Patient #2. Patient #2 remained in room c until he had to change his clothes for forensics. 07/19/2024 12:00 a.m. - Patient #2 had changed his clothes. His clothes went to SVU/forensics. Sitting in a chair in hallway a, with staff and SVU. 12:03 a.m. - Patient #2 and S3DON speaking. S3DON headed to put sheets on Patient #2’s bed in room h. Patient #2 in hallway a alone. S13MHT was downstairs with SVU. S1ADM on the Unit C. 12:04 a.m. - S1ADM tells Patient #2 to stay away from the female patients. Patient #2 is calm. 12:05 a.m. - Patient #2 is by himself in hallway a. 12:08 a.m. - Patient #2 wants his medication for sleep. 12:08 a.m. - Patient #2 in room h by himself. 12:15 a.m. - S3DON checks on Patient #2. 12:30 a.m. - No rounds have been done on patients. S13MHT still off Unit C. 12:45 a.m. - S16MHT looked in room h then left Unit C. 1:10 a.m. - S18MHT looked in room h. 1:21 a.m. - S13MHT back on Unit C. 1:25 a.m. - S13MHT looked in room h. 1:42 a.m. - S13MHT positioned outside of room h and S3DON looked in on Patient #2 and gave him meds. 2:15 a.m. - no rounds since 1:42 a.m. 2:31 a.m. - S13MHT makes rounds. 3:00 a.m. - No rounds. 3:10 a.m. - S13MHT has not looked into room h. 3:11 a.m. - S13MHT gets up and makes rounds. 3:30 a.m. - police arrived to arrest Patient #2. During an interview on 07/23/2024 at 3:46 p.m. S3DON confirmed RN should not have left unit before incoming RN arrived. During an interview on 07/23/2024 at 4:08 p.m. S3DON and S1ADM confirmed that no rounds have been done since arriving on shift. During an interview on 07/24/2024 at 10:05 a.m. S3DON stated she verbally put Patient #2 on 1:1. Video does not show he was on 1:1. During an interview on 07/24/2024 at 10:33 a.m. S3DON confirmed rounds were not completed per order/policy. During an interview on 07/24/2024 at 11:14 a.m. S3DON and S1ADM confirmed that rounds were not done on 07/19/2024 at 2:00 a.m., 2:15 a.m., or 3:00 a.m. Reviewed the Patient Observation Records for the night of the incident on 07/18/2024 for Patient #1, Patient #2, and Patient #3 with S1ADM and S3DON. Patient #1 Review of Patient #1’s Patient Observation Record for 07/18/2024 revealed the following: Q15 minute observations were signed by S13MHT as completed for 7:00 p.m., 7:15 p.m., 7:30 p.m., 7:45 p.m., 8:00 p.m., and 8:15 p.m. During review of video footage on 07/23/2024 at 4:08 p.m. S1ADM and S3DON confirmed that these rounds were not performed. Further review of Patient #1’s Patient Observation Record revealed there are no documented Q15 minute observations from 8:30 p.m. until the patient left the Unit C at 9:26 p.m. There was also no Precaution level marked on the Patient Observation Record for Patient #1. During an interview on 07/24/2024 at 3:15 p.m. S1ADM and S3DON confirmed there was no documentation of observations being performed and confirmed that Patient #1 should have been on Suicide Precautions. Patient #2 Review of Patient #2’s Patient Observation Record for 07/18/2024 revealed the following: Q15 minute observations were signed by S13MHT as completed for 7:00 p.m., 7:15 p.m., 7:30 p.m., and 7:45 p.m. During review of video footage on 07/23/2024 at 4:08 p.m. S1ADM and S3DON confirmed that these rounds were not performed. Patient #2’s Patient Observation Record revealed there are no documented Q15 minute observations on 07/18/2024 from 8:00 p.m. - 11:45 p.m. Patient #2’s Patient Observation Record for 07/19/2024 revealed Q15 minute observations from 12:00 a.m. - 3:30 a.m. were signed by S13MHT as being completed. Further review also revealed no Precaution level marked on the Patient Observation Record for Patient #2. Review of video footage with S1ADM and S3DON revealed that rounds were not made on Patient #2 by staff at 12:30 a.m., 1:00 a.m., 1:42 a.m. - 2:15 a.m., or at 3:00 a.m. The findings above were confirmed on 07/24/2024 during video footage review with S1ADM and S3DON. Patient #3 Review of Patient #3’s Patient Observation Record for 07/18/2024 revealed the following: Q15 minute observations were signed by S13MHT as completed for 7:00 p.m. - 9:30 p.m. Further review revealed Q15 minute observations were not documented and are blank on the Patient Observation Record from 10:00 p.m. - 11:45 p.m. During review of video footage on 07/23/2024 at 4:08 p.m. S1ADM and S3DON confirmed that these rounds were not performed. Further review of Patient #3’s Patient Observation Record for 07/19/2024 revealed Q15 minute observations from 12:00 a.m. - 3:45 a.m. were signed by S13MHT as being completed. There are no documented Q15 minute observations from 4:00 a.m. - 6:45 a.m. by staff on Patient #3. Further review also revealed no Precaution level or Level of Observation marked on the Patient Observation Record for Patient #3. During an interview on 07/24/2024 at 3:20 p.m. S1ADM and S3DON confirmed there was no documentation of observations being performed via the Patient Observation Record and also confirmed that Patient #3 did not have a documented level of observation or precautions documented. 2) Failure to ensure all exit doors were secure. On 07/24/2024 at 4:25 p.m. toured the back stairwell from floor 2 down to first floor with S1ADM. 1st floor back stairwell opens into back hallway with an exit door to front lobby and an exit door to exterior of facility. The back exit door upon inspection was found partially ajar. The door was not secured and could be opened from the outside. There was no alarm in place if door were to be opened. During an interview on 07/24/2024 at 4:32 p.m. these findings were confirmed by S1ADM.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on observations, record review, and interview the hospital failed to provide an environment free from abuse/neglect. This deficient practice is evidenced by: 1) failure to ensure staff were rounding and monitoring patients which potentially led to patient elopement for 2 (#3, #R4) of 2 (#3, #R4) patients reviewed who eloped; 2) failure to ensure observations and precautions were implemented as ordered on 07/22/2024 for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed and on 07/23/2024 for 11 (Patient #1, #R2-#R4, #R7-#R13) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed; 3) failure to assess patients who were at high risk for intentional harm to self in 2 (#1 and #2) of 3 (#1-#3) patients reviewed. Findings: Review of hospital’s policy titled, “Abuse and/or Neglect of Patients,” approved 06/2024, revealed in part: Policy: It is the policy of [the hospital] that ... patients will be given competent and timely medical care. A. definitions, in part: Neglect - a form of abuse. The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. B. Prevention of Abuse and Neglect 3. Unit acuity is assessed every shift to determine that the staff to patient ration is appropriate to meet the specific needs of the patient. C. Identification or Abuse and/or Neglect 1. Inadequate supervision of patients whose physical or mental condition may result in poor judgment, and who are therefore at risk of injury or illness without supervision. D. Reporting Abuse and/or Neglect of Patients. Staff are required to report any incident which they believe might constitute abuse or neglect of patients. Because safety of patients is our first concern, a reasonable suspicion about the observed behavior is sufficient to warrant reporting the situation so that any necessary corrections can be made to prevent or reduce harm to the patient. Review of hospital’s policy titled, “Patient Rights,” approved 06/2024, revealed in part: [the hospital] supports and protects the basic human, civil, and constitutional rights of all patients. The principle of this policy is the patient’s right to respect, dignity, and comfort. 17. The right to be free from all forms of abuse and harassment. Review of hospital policy titled, “Patient Observation Record,” revealed in part: Patients must be observed at least every 15 minutes. The observation with documented location and behavior must be documented, verified by the observer’s initials, at least every 15 minutes. Purpose: To ensure that the patient’s safety and well-being are maintained and documented. To have a continuous record of patient behavior and location. Procedure: The RN is responsible for MHT assignments (Patient Observation Record) 1. A review of this record is performed every 2 hours. 2. A rounding of all patients is to be performed every 2 hours and documented on the Patient Observation Record ... The MHT is to note the Precaution Level ordered for each patient ... The MHT is to note the Level of Observation ordered for each patient. 1) Failure to ensure staff were rounding and monitoring patients which potentially led to patient elopement for 2 (#3, #R4) of 2 (#3, #R4) patients reviewed who eloped. Review of hospital’s policy titled, “Elopement,” approved 06/2024, revealed in part: Policy Statement: Nursing personnel must report and investigate all reports of missing patients. Purpose: Establish guidelines and procedures when a patient has eloped. Procedure: Once it is confirmed that the patient has eloped the Registered Nurse must: 1. Notify the Director of Nursing who will notify the Administrator. 2. Notify the attending physician. 3. Notify law enforcement officials. 4. Notify patient’s family or legal representative. 5. Complete and file an incident report and make appropriate notations in the patient’s medical record. 6. The attending physician must give a verbal order or may write an order for discharge by elopement. Review of incident log revealed 2 patient elopements for July 2024 (Patient #3 and #R1). Patient #3: Review of the Incident Report for Patient #3 revealed the patient eloped from the smoking patio while outside on 07/19/2024 at 12:00 p.m. Review of Patient #3’s medical record revealed he was admitted on 07/14/2024 with Paranoid Type Schizophrenia. Review of the Psychiatric evaluation revealed that Patient #3 attempted to elope from the ED prior to arrival. Review of physician orders failed to reveal orders for elopement precautions. Further review of physician orders revealed orders for close observation (Q15 minute) and low suicide precautions. Further review of Patient #3’s medical record review revealed a Nursing note from 07/19/2024 at 12:15 p.m. “upon return to unit from lunch, MHT asked if I had seen patient. Patient did not return from lunch. MHT back tracked to dining room/smoking area and could not locate patient. 12:20 p.m. DON called. 1:00 p.m. NOPD notified of missing patient. 1:32 p.m. unable to reach caregiver to notify of elopement. 1:35 p.m. spoke with grandmother. Note signed by RN at 2:18 p.m. on 07/19/2024. During an interview on 07/24/2024 at 11:27 a.m. with S1ADM and S3DON confirmed the MHT who was observing the patient’s smoking on the patio at the time of the incident, came inside from the patio and turned her back towards the patient’s outside when Patient #3 eloped over the fence. S1ADM and S3DON confirmed that they immediately terminated employment with the MHT who was supposed to be observing Patient #3 at the time of his elopement. Patient #R1: Review of the Incident Report for #R1 revealed the patient eloped via the elevator on 07/04/2024. Census for Unit B on 07/04/2024 was 9 patients (including #R1) with 1 RN and 1 MHT. On 07/24/2024 at 11:45 a.m. the video footage was reviewed for the incident involving #R1 that occurred on 07/04/2024 with S1ADM and S3DON. Video footage review on elopement that occurred at 5:19 p.m. (per incident report) actually occurred at 4:02 p.m. on 07/04/2024. Review of the video footage for Unit B revealed the following: 3:26 p.m. - S17MHT leaves Unit B per elevator. (Leaving 1 RN only on unit) 3:36 p.m. - S17MHT returns. 3:44 p.m. - #R1 pacing back and forth and lingering by elevator. 3:48 p.m. - No observations per RN or MHT for 15 minutes 3:49 p.m. - #R1 walking around in his underwear coming back from shower. No one is around. 3:55 p.m. - S17MHT leaving per elevator and glanced into #R1’s room. 4:00 p.m. - #R1 is in regular clothes and socks on feet. No tech on unit. 4:02 p.m. - S17MHT comes back to Unit B. S17MHT does not wait for elevator door to close before turning the corner and #R1 enters elevator before the elevator doors close. During an interview on 07/24/2024 at 11:55 a.m. S1ADM confirmed video not available for the 1st and 2nd floor for 07/04/2024. During an interview on 07/24/2024 at 11:57 a.m. S3DON verified that S17MHT was the only MHT on the unit and left without having replacement to observe the patients. Reports the nurse should have come out of the nurses’ station to perform observations. During an interview on 07/24/2024 at 12:00 p.m. S1ADM reported he looked at video on the 07/04/2024 and did not see patient #R1 get off the elevator and exit facility. During an interview on 07/24/2024 at 12:08 p.m. S1ADM confirmed that the RN signed the Patient Observation Record for RN rounding on 07/04/2024 indicating that rounds were completed on #R1 at 4:00 p.m. S1ADM confirmed that the video footage failed to reveal that the RN completed the 4:00 p.m. nursing observation and the documentation was falsified on the Patient Observation Record. 2) Failure to ensure observations and precautions were implemented as ordered on 07/22/2024 for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed and on 07/23/2024 for 11 (Patient #1, #R2-#R4, #R7-#R13) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed. Review of Unit C census for 07/22/2024 revealed 11 patients (Patient #1, #R2-#R4, #R7-#R13) Review of Patient Observation Record for Unit C on 07/22/2024 failed to reveal 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients with documented levels of Precautions or levels of Observations per physician orders. Patient #1 Review of Patient #1’s medical record revealed admit orders dated 07/19/2024 at 2:00 p.m. Further review revealed an order for Visual Contact and High Suicide precautions. Review of Patient #1’s Patient Observation Record for 07/22/2024 failed to reveal high suicide precautions or visual contact documented as per physician order. Patient #R2: Review of Patient #R2’s Patient Observation Record for 07/22/2024 failed to reveal a documented level of precautions as per physician order. Patient #R3: Review of Patient #R3’s Patient Observation Record for 07/22/2024 failed to reveal a documented level of observations or level of precautions as per physician order. Patient #R4: Review of Patient #R4’s Patient Observation Record for 07/22/2024 failed to reveal a documented level of observations or level of precautions as per physician order. Patient #R7: Review of Patient #R2’s Patient Observation Record for 07/22/2024 failed to reveal a documented level of precautions as per physician order. During an interview on 07/24/2024 at 12:15 p.m., S1ADM and S3DON confirmed the findings above. Review of Unit C census for 07/23/2024 revealed 11 patients (Patient #1, #R2-#R4, #R7-#R13) Review of Patient Observation Record for Unit C on 07/23/2024 failed to reveal 11 (Patient #1, #R2-#R4, #R7-#R13) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients with documented levels of Precautions or levels of Observations per physician orders. During an interview on 07/24/2024 at 12:15 p.m., S1ADM and S3DON confirmed the findings above. 3) Failure to assess patients who were at high risk for intentional harm to self in 2 (#1 and #2) of 3 (#1-#3) patients reviewed. Review of hospital policy titled, “Suicide Risk Assessment”, approved 06/2024, revealed in part: Policy: All patients admitted to [hospital] will receive a Suicide Risk Screening. Patients who have a history of sucide attempts and/or have suicidal ideations, plans, or intent will receive a Suicide Risk Assessment and treatment plan interventions as described. Purpose in part: To provide guidelines for screening and assessment of suicide risk and initiation of interventions to maximize safety for patients. Procedure in part: 1. the admitting Registered Nurse (RN) will initiate the Suicide Risk Screening which will determine the need for completion of the Suicide Risk Assessment ...4. ...If [high risk] positive indicators are noted, 1:1 is recommended and the RN will notify the attending physician to assess need and order the 1:1 observation level. Patient #1 Review of Patient #1’s medical record revealed an admission date of 07/16/2024 at 4:30 p.m. after a suicide attempt in a group home. Diagnoses intellectual disability, bipolar disorder, ADHD, and severe sexual abuse as a child. Admitted for depression and suicidal ideation. Review of Patient #1’s History and Physical dated 07/17/2024 at 11:00 a.m., revealed patient with intellectual disability drank baby shampoo and attempted to choke herself with rubber band and a towel. Review of Columbia Risk and Protective Factors screening tool dated 07/16/2024 at 5:00 p.m. revealed a score of 12 indicating patient was considered a high suicide risk. The screening revealed Patient #1 was a high suicide risk. Review of Patient #1’s Columbia-Suicide Severity Rating scale frequent screener document dated 07/16/2024 at 9:00 p.m. revealed Patient #1 remained depressed and continued to be a high suicide risk. Review of Patient #1’s Columbia-Suicide Severity Rating scale frequent screener document dated 07/17/2024 at 8:00 a.m. revealed Patient #1 continued to be a high suicide risk. Continued review of Patient #1’s medical record failed to reveal a Columbia-Suicide Severity Rating scale frequent screener document after 07/17/2024 at 8:00 a.m. Review of Patient #1’s admit orders dated 07/16/2024 and signed by the attending physician on 07/17/2024 at 11:00 a.m., revealed orders for Patient #1 to be placed on high risk suicide precautions. Further review of Patient #1’s medical record failed to reveal the recommended 1:1 observation level or suicide precautions noted on any of her observation sheets. In an interview on 07/24/2024 at 3:15 p.m., S1Adm and S3DON confirmed the suicide risk assessment was not completed per hospital policy. S1Adm and S3DON verified Patient #1’s medical record failed to reveal suicide precautions noted on any of the observation sheets. S3DON stated Patient #1 was not on 1:1 level of observation. Patient #2 Review of Patient #2’s medical record revealed an admission date of 07/17/2024 at 11:00 a.m. after having been released from another psychiatric hospital 2 days prior and endorsing suicidal and homicidal ideations. Diagnoses Schizoaffective Disorder, Bipolar type, Stimulant Use Disorder. Admitted for suicidal and homicidal ideations. Seeing shadows and hearing whispers. Review of Patient #2’s Psychiatric Evaluation dated 07/18/2024 at 8:38 a.m. revealed patient reported having thoughts of hurting himself with a plan to jump in the Mississippi River. Review of Columbia Risk and Protective Factors screening tool dated 07/17/2024 at 1:00 p.m. revealed a score of 12 indicating patient was considered a high suicide risk. Patient #2 stated he would go into traffic. The screening revealed Patient #2 was a high suicide risk. Continued review of Patient #2’s medical record failed to reveal a Columbia-Suicide Severity Rating scale frequent screener document after 07/17/2024 at 1:00 p.m. Review of Patient #2’s Admission orders dated 07/17/2024 at 12:00 p.m. revealed orders for high-risk suicide precautions. Further review of Patient #2’s medical record failed to reveal the recommended 1:1 observation level or suicide precautions noted on any of his observation sheets. In an interview on 07/24/2024 at 4:14 p.m., S1Adm confirmed the suicide risk assessment was not completed per hospital policy. S1Adm verified Patient #2’s medical record failed to reveal suicide precautions and 1:1 observations noted on any of the observation sheets. 50453”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47397 Based on observations, record review and interview the hospital failed to ensure adequate numbers of licensed registered nurses and nurse support staff were available to provide nursing care to all patients as evidenced by: 1) failure to ensure a registered nurse was physically present on each unit of the hospital at all times; 2) failure to ensure adequate numbers of nursing support staff on each unit per hospital policy. Findings: Review of hospital policy titled “Staffing Plans and Delivery of Care”, dated 01/2021, revealed in part: Census: 1-12 patients requires: 1 Registered Nurse and 2 Mental Health Technicians. 1) Failure to ensure a registered nurse was physically present on each unit of the hospital at all times. On 07/23/2024 at 2:58 p.m., hospital video review of Unit C, area gg, on 07/18/2024, navigated by S1Adm, revealed S15RN left the unit at 5:48 p.m., was gone for 21 minutes and returned at 6:09 p.m. leaving S17MHT alone with 10 (#1, #2, #3, #R2, #R3, #R4, #R5, #R6, #R14, and #R15) patients. Review of Patient #1’s medical record revealed Patient #1 was assessed as a high suicide risk. Review of Patient #2’s medical record revealed Patient #2 had a previous conviction of rape with incarceration. Further review revealed Patient #2 was a high suicide risk and high assault risk. Review of Census revealed Patient #R8 was on detoxification precautions. Review of Patient #R2’s medical record revealed a high assault risk with orders to block the other bed in his room for the safety of the unit. In an interview on 07/23/2024 at 3:46 p.m., S3DON confirmed S15RN should not have left unit leaving one MHT to care for 10 patients potentially creating an unsafe environment. In an interview on 07/24/2024 at 3:15 p.m., S1Adm and S3DON confirmed Patient #1’s high suicide risk assessment. In an interview on 07/23/2024 at 11:15 a.m., S3DON stated she did not think Patient #2 had a previous history of a sex crime. In an interview on 07/24/2024 at 4:14 p.m., S1Adm confirmed Patient #2’s high suicide risk assessment. In an interview on 07/23/2024 at 9:45 a.m., S7MHT stated Patient #R10’s room was blocked because Patient #R10 did not know where he was and had been acting out, going in other patient’s rooms and getting naked in the dayroom. In an interview on 07/24/2024 at 1:00 p.m., S2DHR verified she personally trained S15RN. S2DHR stated the training included instructions not to leave the unit without first making sure another RN was present on the unit. 2) Failure to ensure adequate numbers of nursing support staff on each unit per hospital policy. Review of Unit C census dated 07/18/2024, AM shift, revealed 10 patients. Staff included S15RN, S7MHT and S17MHT. On 07/23/2024 at 2:58 p.m., a review of Hospital video dated 07/18/2024, navigated by S1Adm and S3DON, revealed Unit C, area gg. Continued review revealed S7MHT left unit at 5:18 p.m. leaving only 1 MHT (S17MHT) on the unit. In an interview on 07/23/2024 at 12:30 p.m., S3DON reported there should always be 2 MHTs on the units. Review of Unit C’s staff assignment sheet dated 07/23/2024 for the AM shift, revealed S7MHT and S8MHT assigned to the 11 patients on the census. On 07/23/2024 at 9:51 a.m., observation of Unit C failed to reveal S7MHT. In an interview on 07/23/2024 at 9:52 a.m., S6RN confirmed she did not know if S7MHT was currently on Unit C and stated she did not know where he had gone. On 07/23/2024 at 12:15 p.m., a review of hospital video of Unit C, area gg, navigated by S1Adm, dated 07/23/2024, revealed S7MHT walked out of Unit C into stairwell o at 9:27 a.m. Observations failed to reveal he spoke to S6RN or S8MHT before leaving. Continued review revealed S7MHT came back in from stairwell o, sat down for a minute in area d, then proceeded back down stairwell o at 9:36 a.m. Further review revealed S7MHT returned by elevator r at 9:54 a.m. In an interview on 07/23/2024 at 12:30 p.m., S1Adm and S3DON confirmed S7MHT left the unit without notifying S6RN. S3DON stated S7MHT should not have left the unit without notifying S6RN and having someone to relieve his post. In an interview on 7/24/24 at 1:19 p.m., S2DHR verified she personally trained S7MHT to let the RN know where he is. S2HDR stated the nurse should know where MHTs are at all times.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47397 50453 Based on observations, record review and interview, the Director of Nursing failed to ensure all nursing staff adhered to the policies and procedures of the hospital. This deficient practice is evidenced by: 1) failure to document patient rounding on 07/22/2024 Unit C for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients per hospital policy; 2) failure of the nursing staff to complete an Emergency Transfer Sheet in 1 (#1) of 3 (#1-#3) records reviewed; 3) failure of nursing staff to document provider notification following Patient #3’s elopement. Findings: 1) Failure to document patient rounding on 07/22/2024 Unit C for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients per hospital policy. Review of hospital policy titled, “Patient Observation Record,” revealed in part: Patients must be observed at least every 15 minutes. The observation with documented location and behavior must be documented, verified by the observer’s initials, at least every 15 minutes. Purpose: To ensure that the patient’s safety and well-being are maintained and documented. To have a continuous record of patient behavior and location. Procedure: The RN is responsible for MHT assignments (Patient Observation Record) 1. A review of this record is performed every 2 hours. 2. A rounding of all patients is to be performed every 2 hours and documented on the Patient Observation Record ... The MHT is to note the Precaution Level ordered for each patient ... The MHT is to note the Level of Observation ordered for each patient. Patient #1 Review of Patient #1’s Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 8:00 p.m., or 10:00 p.m. and no Q15 minute observations at 7:15 a.m., 7:30 a.m., or 7:45 a.m. Patient #R2: Review of Patient #R2’s Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., or 6:00 a.m. Patient #R3: Review of Patient #R3’s Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., or 6:00 a.m. and no Q15 minute observations at 7:15 a.m., 7:30 a.m., or 7:45 a.m. Patient #R4: Review of Patient #R4’s Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., or 6:00 a.m. and no Q15 minute observations at 7:15 a.m., 7:30 a.m., or 7:45 a.m. Patient #R7: Review of Patient #R2’s Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., or 6:00 a.m. During an interview on 07/24/2024 at 12:15 p.m., S1ADM and S3DON confirmed the findings above. 2) Failure of the nursing staff to complete an Emergency Transfer Sheet in 1 (#1) of 3 (#1-#3) records reviewed. Review of hospital policy titled, “Medical Emergency Transfer to Another Facility”, dated 01/2024, revealed in part: Purpose: ...To provide the receiving facility with complete appropriate information to resume care of a transferred patient. Procedure, ...the Registered Nurse must: 3. Complete the Emergency Transfer Sheet ... Review of Patient #1’s medical record revealed a physician’s RBVO order dated 07/18/2024 at 9:00 p.m. The order stated Transport to Hospital D for evaluation. Observation of video dated 07/18/2024, navigated by S1Adm, revealed Patient #1 left Unit C at 9:26 p.m. Review of Patient #1’s medical record failed to reveal the nurse completed an Emergency Transfer Sheet per hospital policy regarding emergency transfers. In an interview on 07/24/2024 at 3:45 p.m., S3DON verified that an Emergency Transfer Sheet was not completed for Patient #1 as per hospital policy. 3) Failure of nursing staff to document provider notification following Patient #3’s elopement. Review of hospital’s policy titled, “Elopement,” approved 06/2024, revealed in part: Policy Statement: Nursing personnel must report and investigate all reports of missing patients. Purpose: Establish guidelines and procedures when a patient has eloped. Procedure: Once it is confirmed that the patient has eloped the Registered Nurse must: 1. Notify the Director of Nursing who will notify the Administrator. 2. Notify the attending physician. 3. Notify law enforcement officials. 4. Notify patient’s family or legal representative. 5. Complete and file an incident report and make appropriate notations in the patient’s medical record. 6. The attending physician must give a verbal order or may write an order for discharge by elopement. Review of Patient #3’s medical record revealed no note documented in the medical record of nurse notification to provider. During an interview on 07/24/2024 at 2:15 p.m. with S1ADM and S3DON confirmed there was no documentation in Patient #3’s medical record that the provider was notified.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47397 Based on record review and interview, nursing staff failed to administer PRN medications in accordance with accepted standards of practice. This deficiency is evidenced by failure of the nursing staff to monitor the therapeutic effect of PRN medications in 2 (#1-#3) of 3 (#1-#3) patients reviewed for therapeutic assessment after medication administration. Findings: Review of hospital policy titled “Nursing Shift Assessment & Nursing Daily Progress Note”, dated 06/2024, revealed in part: Procedure: Nursing Daily Progress Note: ... F. PRN medication given with reason and follow-up results to medication. Patient #1 Review of the electronic medical record for Patient #1, navigated by S1Adm, revealed an order for Ativan 2 mg PO q 6 hours PRN agitation. Review of the electronic medication administration record revealed on 07/17/2024 at 10:15 p.m., Ativan 2 mg by mouth was administered to Patient #1. Further review failed to reveal the reason why the Ativan was administered. Continued review failed to reveal documentation of the therapeutic effectiveness of the medication administered. In an interview on 07/24/2024 at 2:53 p.m., S1Adm verified there was no documented indication for the administration of Ativan and there was no documented follow-up for therapeutic effectiveness of the Ativan administered to Patient #1. Continued review of the electronic medical record for Patient #1 revealed an order for Benadryl 50 mg PO q 6 hours PRN agitation. Review of the electronic medication administration record revealed on 07/23/2024 at 12:47 p.m., Ativan 2 mg by mouth was administered and at 12:48 p.m., Benadryl 50 mg by mouth was administered to Patient #1. Further review failed to reveal documentation of the therapeutic effectiveness of either medications administered. In an interview on 07/24/2024 at 3:36 p.m., S1Adm verified there was no follow-up documented for the therapeutic effectiveness of the Ativan and Benadryl administered to Patient #1. Patient #3 Review of the electronic medical record for Patient #3, navigated by S1Adm, revealed an order for Ativan 2 mg PO q 6 hours PRN agitation. Review of the electronic medication administration record revealed on 07/14/2024 at 8:12 p.m., Ativan 2 mg by mouth was administered because Patient #3 was responding to internal stimuli with need for redirection. Further review failed to reveal documentation of the therapeutic effectiveness of the medication administered. In an interview on 07/24/2024 at 2:01 p.m., S1Adm verified there was no follow-up documented for therapeutic effectiveness of the Ativan administered to Patient #3.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to meet the Condition of Participation for Governing Body. The hospital’s governing body failed to effectively carry out its responsibilities for the conduct of the hospital for the hospital’s compliance not only with the specific standards of the governing body CoP, but also with the following CoPs. This deficient practice was evidenced by: 1) Failure of the governing body to assure that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice. (See Findings in A-0115, A-0263, A-0385, and A-0747); 2) Failure of the governing body to protect and promote each patient’s rights. (See Findings in A-0115); 3) Failure of the governing body to implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. Failure to ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. Failure to maintain and demonstrate evidence of its QAPI program for review by CMS. (See Findings in A-0263); 4) Failure of the governing body to ensure the hospital has an organized nursing service. As a result of this noncompliance, on 06/10/2024 at 5:11 p.m., S13Admin was informed of the Immediate Jeopardy situation that existed. The hospital failed to have a director of nursing and an assistant director of nursing responsible for the operation of the nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care to all areas of the hospital. (See findings in A-0385). 5) Failure of the governing body to ensure an active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. Failure to ensure programs that demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Failure to ensure infection prevention and control problems and antibiotic use issues identified in the programs are addressed in collaboration with a hospital-wide quality assessment and performance improvement (QAPI) program. This deficient practice resulted in an Immediate Jeopardy situation. As a result of this noncompliance, on 06/10/2024 at 3:00 p.m., S13Admin was informed of the Immediate Jeopardy situation that existed. The hospital failed to ensure patient safety by failing to adhere to nationally recognized guidelines when sanitizing patient glucometers and failing to perform glucometer control testing per hospital policy. (See Findings in A-0747).”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47397 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: 1) failure to ensure patients were observed per physician orders resulting in patient harm (See findings at A-0145); 2) failure to ensure glucometer controls were tested per hospital policy resulted in an Immediate Jeopardy Situation and S13Admin was notified on 06/10/2024 at 3:00 p.m. The hospital provided the following plan of removal for the Immediate Jeopardy situation at 4:40 p.m.: A. Administrator will immediately implement the training of the three (3) RNs in-house at the time of the finding. S15HS will conduct one-to-one training of S5RN and S18RN before end of shift on 06/10/2024. B. A step by step written training will be placed in the Communication Binders on each floor to be reviewed by subsequent shift RN’s. C. This written training will include a signature page that will be audited daily by the Administrator for compliance and understanding of the information in the training. D. Each RN will demonstrate their understanding of the training to the Administrator or Director of Nursing until all full-time and PRN RNs are compliant. E. The hospital’s Policy and Procedures regarding Glucometers (Section 11.4.0) will be updated to include the latest standards in disinfection and control testing, including the specific hospital approved disinfection wipes. F. The Administrator and/or the Director of Nursing will inspect the Glucometer Logs daily (Monday through Friday) to ensure compliance with disinfection and control testing. The results of this daily rounding will be reported monthly to the CEO and quarterly in the MEC meeting. G. A currency with dates of completion for each full-time and PRN RN will be maintained, and compliance placed in the employees personnel file. H. An online training course through will be assigned to all Clinical staff, RNs and MHTs. I. Hospital’s Policy and Procedures regarding Glucometers (Section 11.4.0) will be updated to include the latest standards in disinfection and control testing, including the specific hospital approved disinfection wipes. J. The Administrator and/or the Director of Nursing will inspect the Glucometer Logs daily (Monday through Friday) to ensure compliance with disinfection and control testing. K. Data will be collected on compliance of identified Infection Control standards and reported in Quality and Improvement measures. L. The data will be reported to Administrator monthly, and the Medical Executive Committee and Governing Body quarterly. M. Corrective Actions Completed: 06/17/2024-Including the online training of current clinical staff On 06/11/2023 at 12:14 p.m., the Immediate Jeopardy Situation was lifted and the deficiencies remain at Condition levels. (See findings at A-0144); 3) failure to ensure appropriate staffing to meet the safety needs of the patients (See findings at A-0144); 4) failure to ensure staff personnel records contained documentation that demonstrated Patient Rights competencies had been successfully completed (See findings at A-0208); 5) failure to ensure the patient /patient representative’s right to participate in the development and implementation of his or her plan of care was met (See findings at A-0130); 6) failure to inform patient/patient’s representative of the patient’s rights (See findings at A-0117); and 7) failure to obtain informed consent (See findings at A-0131).”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 47397 Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. This deficient practice is evidenced by: 1) the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators (see findings in A-0273); 2) the hospital’s Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement, implement effective action, measure success and track performance related to not having quality improvement activities (see findings in A-0283); 3) the hospital failed to track and analyze all events involving abuse and neglect. The deficient practice is evidenced by failure to investigate several patient-to-patient, patient-to-staff, and staff-to-patient incidents. (see findings in A-0286); 4) the hospital’s governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program (see findings in A-0309) and 5) the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital’s performance by having insufficient staff designated to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital. (see findings in A-0315).”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47397 Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Nursing Services. The deficient practice is evidenced by: 1) failure of the nursing service to be under the direction of a registered nurse resulted in an Immediate Jeopardy situation called on 06/10/2024. S13Admin was informed of the Immediate Jeopardy situation that existed at 5:11 p.m.. The hospital failed to have a director of nursing and an assistant director of nursing responsible for the operation of the nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care to all areas of the hospital. On 06/11/2024 at 2:16 p.m., the hospital provided a plan of removal for the Immediate Jeopardy situation. This plan included: A. Administrator will present minutes of the Governing Body to the surveyor June 11,2024. B. CEO who is the Governing Body will be updated on the DON orientation progress regularly. C. Administrator will orient S14DON to administrative duties. D. Commencing today, June 11, 2024 and June 12, 2024, S14DON will orient in the milieu with House Supervisor S15HS in regard to nursing duties. E. Commencing Tuesday, June 18, 2024 orientation to the duties of Director of Nursing will be provided by S16DON. F. Following the Director of Nursing initial orientation, the key position form will be submitted to the Health Standards Section. G. Administrator will meet with S14DON on a daily basis, followed by weekly meetings and as needed attention and assistance. H. Corrective Actions to be Completed: 06/19/2024 On 06/11/2023 at 3:51 p.m., the Immediate Jeopardy Situation was lifted and the deficiencies remain at Condition levels. (See Findings in A-0386); 2) failure to ensure the nurse assigns 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 (see findings in A-397). 3) failure to implement physician orders and evaluate clinical activities (See findings in A-0398); 4) failure to ensure observation checks are being performed by RN on all patients (See findings in A-0395); 5) failure to implement a plan of care consistent with the plan for medical care of the practitioner responsible for the care of the patient (See findings in A-0396)”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47397 Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Infection Control by failure to have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. This was evidenced by: 1) failure to adhere to nationally recognized guidelines when sanitizing patient glucometers which led to an Immediate Jeopardy Situation. As a result of this noncompliance, on 06/10/2024 at 3:00 p.m., S13Admin was informed of the Immediate Jeopardy situation that existed. The hospital failed to ensure patient safety by failing to adhere to nationally recognized guidelines when sanitizing patient glucometers and failing to perform glucometer control testing per hospital policy. The hospital was utilizing a mulitpatient glucometer on 1 (#R1) patient receiving insulin injections per sliding scale. Staff were not cleaning the glucometer per the nationally recognized guidelines recommendations by using alcohol wipes to sanitize the glucometer. Staff were not performing control testing per hospital policy. On 06/10/2024 at 4:40 p.m., the hospital provided a plan of removal for the Immediate Jeopardy situation. This plan included: A. Administrator will immediately implement the training of the three (3) RNs in-house at the time of the finding. S15HS will conduct one-to-one training of S5RN and S18RN before end of shift on 06/10/2024. B. A step by step written training will be placed in the Communication Binders on each floor to be reviewed by subsequent shift RN’s. C. This written training will include a signature page that will be audited daily by the Administrator for compliance and understanding of the information in the training. D. Each RN will demonstrate their understanding of the training to the Administrator or Director of Nursing until all full-time and PRN RNs are compliant. E. The hospital’s Policy and Procedures regarding Glucometers (Section 11.4.0) will be updated to include the latest standards in disinfection and control testing, including the specific hospital approved disinfection wipes. F. The Administrator and/or the Director of Nursing will inspect the Glucometer Logs daily (Monday through Friday) to ensure compliance with disinfection and control testing. The results of this daily rounding will be reported monthly to the CEO and quarterly in the MEC meeting. G. A currency with dates of completion for each full-time and PRN RN will be maintained, and compliance placed in the employees personnel file. H. An online training course through will be assigned to all Clinical staff, RNs and MHTs. I. Hospital’s Policy and Procedures regarding Glucometers (Section 11.4.0) will be updated to include the latest standards in disinfection and control testing, including the specific hospital approved disinfection wipes. J. The Administrator and/or the Director of Nursing will inspect the Glucometer Logs daily (Monday through Friday) to ensure compliance with disinfection and control testing. K. Data will be collected on compliance of identified Infection Control standards and reported in Quality and Improvement measures. L. The data will be reported to Administrator monthly, and the Medical Executive Committee and Governing Body quarterly. M. Corrective Actions Completed: 06/17/2024-Including the online training of current clinical staff On 06/11/2023 at 12:14 p.m., the Immediate Jeopardy Situation was lifted and the deficiencies remain at Condition levels. (See Findings in A-0748, A-0749, and A-0750). 2) failure to demonstrate an individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership (See findings in A-0748); 3) failure to implement an infection prevention and control program that 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 (See Findings Tag A0750).”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure patients and staff were free from abuse and neglect and failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital’s failure to report and investigate cases of possible abuse or neglect in 7 of 7 reviewed incidents. Findings: Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. Review of hospital policy approved January 2021, titled “Abuse and/Or Neglect of Patients” revealed, in part: Policy Statement, in part: [The hospital] implements the Louisiana State mandated report law, which states that, any professional having contact with children, disabled persons, senior citizens or other identified vulnerable populations, are required to report ...when there is evidence of neglect, knowledge of an incident or an imminent risk of serious harm. D. Reporting Abuse And/Or Neglect of Patients, in part: 5. in part: Director of Nursing or Administrator will notify the appropriate authorities. These authorities may include in part: h. Department of Health and Hospitals. Review of incident reports for April, May and June 2024 revealed, in part: 06/10/2024 at 8:00 p.m.: Patient #1 with unwitnessed fall after choking on a sandwich. Hit head hard and required Heimlich maneuver, patient sent to ER (Patient was on 1:1 observation). 06/06/2024 at 3:25 p.m.: MHT observed another MHT pulling Patient #R1 out of a chair in the hallway and shoving the patient in the back. 05/19/2024 at 8:15 a.m.: Patient #R2 came out of her room at 8:00 a.m. clutching her arm saying she had purposely ripped out the metal sutures to the laceration on her left arm. It was seeping blood, pressure put on her left arm until bleeding stooped. Patient was sent to ER. 05/11/2024 at 10:30 a.m.: Patient #R3 stated, “yeah I hit her, she ate my breakfast”. Patient very hostile becomes easily agitated and aggressive. 05/11/2024 at 10:30 a.m.: Patient #R4 was hit on the back of the head from behind by Patient #R3, stated “All I did was eat a piece of her sausage”. Patient #R4 sustained a lump to the back of the left side of her head. 05/06/24 at 11:00 a.m.: Patient #R5 gave his PRN Ativan that he took out of his mouth and gave it to another patient. 05/06/2024 at 12:30 p.m.: Patient #R6 gave his PRN Ativan to another patient (the same patient that was given Ativan by #R5). 04/09/2024 at 12:15 p.m.: Upon attempting rounds on Patient #R7, #R7 punched S5RN with his right hand and hit her right jaw. Review of the ACTS database revealed the last self-report received from the provider was in December 2022. In an interview on 06/12/2024 at 11:05 a.m, S13Admin reported he did not investigate, analyze or submit a self-report to the Louisiana Department of Health as per state rules and regulations for any of the above incidents involving negect, patient-to-patient abuse, patient-to-staff abuse, and staff-to-patient abuse. Hospital was cited on 01/04/2024 for failure to self-report to the Louisiana Department of Health as per state rules and regulations”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure that each patient (or when appropriate, the patient’s representative) was informed of their rights, in advance of furnishing or discontinuing patient care whenever possible. This deficient practice is evidenced by: 1) failure to have all of the required patient rights included in the patient rights policy and Patient Handbook; 2) failure to have evidence that 1 ( #1) of 4 ( #1-#4) patients (or their representatives) reviewed for patient rights were informed of their patient rights. Findings: Review of hospital policy titled “Patient Rights”, last reviewed 01/2021, failed to reveal the following patient rights: 1. The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. 2. The patient has the right to participate in the development and implementation of his or her plan of care. 3. The patient has the right to receive care in a safe setting. 4. The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual. Review of hospital policy titled “Patient Handbook”, last reviewed 01/2021, revealed, in part: A Patient and Family Handbook will be given to each patient upon admission to hospital. The acknowledgment of receipt of the Handbook is noted on the Conditions of Admission and Consents Form. Procedure, in part: The handbook shall include: h. Patient Rights. Review of hospital document provided by S13Admin, titled “Patient and Family Handbook “, undated, failed to reveal the following patient rights: 1. The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. 2. The patient has the right to participate in the development and implementation of his or her plan of care. 3. The patient has the right to receive care in a safe setting. 4. The patient has the right to be free from all forms of abuse or harassment. 5. The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual. Review of Patient #1’s medical record revealed admission date of 06/01/2024. Diagnoses included Mental Retardation, Autism and Schizophrenia. Continued review revealed a Physician’s Emergency Certificate dated 05/31/2024. The certificate included the name and phone number of Patient #1’s guardian. Further review revealed a document titled “Conditions of Admissions & Consents”. The document failed to reveal evidence Patient #1 or his guardian was informed of Patient #1’s rights. In an interview on 06/12/2024 at 8:45 a.m., S13Admin reviewed the medical records for Patient #1 and acknowledged there was no documented evidence that the patient/representative was notified of the patient’s rights prior to furnishing care.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the patient/patient representative’s right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure 2 (#1 and #4) of 4 (#1-#4) patients/patient representatives reviewed participated in the development and implementation of his or her plan of care. Findings: Review of hospital policy titled “Patient Rights”, last reviewed 01/2021, failed to reveal, in part: All patients have the right to participate in the development and implementation of his or her plan of care. Review of hospital policy titled “Standards of Nursing Practice: Patient Care, Treatment & Services”, last reviewed on 01/2021, revealed, in part: Procedure, in part: The plan is developed with the patient. Review of Patient #1’s medical record revealed admission date of 06/01/2024. Diagnoses included Mental Retardation, Autism and Schizophrenia. Continued review revealed a document titled “Treatment Plan” dated 06/10/2024 at 9:44 a.m. Further review failed to reveal Patient #1’s/representative’s signature indicating participation in the decision making process of his treatment plan. Additional review failed to reveal documentation that the family/caregiver was notified or given the opportunity to be included in the patient’s plan of care. In an interview on 06/12/2024 at 9:15 a.m., S13Admin confirmed the treatment plan failed to reveal Patient #1’s/representative’s signature indicating participation in the decision making process of his treatment plan and failed to reveal documentation verifying family/caregiver was notified or given the opportunity to be included in the patient’s plan of care. Review of Patient #4’s medical record revealed admission date of 06/04/2024. Diagnoses included Major Depression, SI with plan to inject herself with insulin with intentions to harm herself after a sexual assault. Continued review revealed a document titled “Treatment Plan” dated 06/12/2024 at 9:41 a.m. Further review failed to reveal Patient #4’s/representative’s signature indicating participation in the decision making process of her treatment plan. Additional review failed to reveal documentation that the family/caregiver was notified or given the opportunity to be included in the patient’s plan of care. In an interview on 06/12/2024 at 11:10 a.m., S13Admin confirmed the treatment plan failed to reveal Patient #4’s/representative’s signature indicating participation in the decision making process of her treatment plan and failed to reveal documentation family/caregiver was notified or given the opportunity to be included in the patient’s plan of care.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure proper documentation of informed consent. The deficient practice is evidenced by failure of the person obtaining the consent to sign the document in 1 (#1) of 4 (#1-#4) patient records reviewed. Findings: Review of hospital policy titled “Patient Rights”, last reviewed 01/2021, revealed the following patient rights, in part: Procedure, in part: All patients have the right to a written, signed “Informed Consent” form obtained from all patients/representative... Review of Patient #1’s medical record revealed admission date of 06/01/2024. Diagnoses included Mental Retardation, Autism and Schizophrenia. Further review revealed a four page document which pertained to consent for the following: treatment, medical procedures, medications, nursing care, restraint and confinement, audio/video surveillance, to not use nor keep any drug not prescribed, transport release, personal valuables, patient rights, assignment of benefits, notice of advance directives, privacy practices, release of information, notification of emergency services when a physician is not present at the facility, and financial responsibility. The form was unsigned by the patient/representative. The form was not dated, and did not have the signature of the person obtaining the consent. In interview on 06/12/2024 at 9:20 a.m., S13Admin verified the document was unsigned by the patient/representative, was not dated, and did not have the signature of the person obtaining the consent.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 Based on observation, record review, and interview, the hospital failed to ensure care in a safe setting. The deficient practice is evidenced by: 1) failure to ensure staffing to meet the safety needs of the patients; 2) failure to test glucometer controls per hospital policy to meet the safety needs of the patients. Findings: 1) Failure to ensure staffing to meet the safety needs of the patients. Review of hospital policy titled “Staffing Plans and Delivery of Care”, last reviewed 01/2021, revealed, in part: Policy: The Director of Nursing shall outline a staffing plan that shall be used to determine the personnel recommended for each shift as outlined in the units core coverage and as necessary to provide the scope of services ... Scheduling Limitations: The goal of staffing each nursing unit is to ensure patient safety in healthcare delivery ...Staffing Assessment: Staffing levels are assessed daily (by shift) and adjustments are made for staff assignments based on the needs of the patient. The charge nurse, Director of nursing or designee does this assessment prior to the beginning of each shift and staffing adjustments are made accordingly to accommodate patient needs ... Review of Staffing Matrix as part of the “Staffing Plans and Delivery of Care” policy, revealed, each unit should be staffed with at least 1 RN and 2 MHTs for a census of 1-12 patients. Observations on 06/11/2024 at 9:42 a.m. revealed 1 (S21MHT) mental health technician (MHT) and 1 registered nurse (RN) on Unit C caring for 8 (#1, R8-R14) patients. Further observations revealed Patient #1 was alone in his room and was not being observed. Continued observations revealed S21MHT was making rounds on patients R8-R14. S24RN was in room hh. Review of Patient #1’s medical record revealed physician orders dated 06/04/2024. The orders read “Place patient on 1:1”. Further review revealed Patient #1 sustained an unwitnessed fall on the night of 06/10/2024 and was sent to the emergency room at 9:45 p.m. Patient #1 returned to Unit C on 06/11/2024 at 9:15 a.m. In an interview on 06/11/2024 at 9:43 a.m., S24RN stated that S22MHT called in and S21MHT was the only MHT on Unit C. S24RN confirmed that there should be another MHT to assist S21MHT since Patient #1 is 1:1. In an interview on 06/11/2024 at 10:30 a.m., S13Admin confirmed the Unit C was not staffed per hospital policy and patient safety needs. 2) Failure to test glucometer controls per hospital policy. Review of hospital policy titled “Glucose Test Log”, approved 01/2024, revealed, in part: Policy Statement: The night shift Registered Nurse is to perform control tests, every 24 hours and anytime there is a question about the blood glucose results and document control test results on the Glucose Test Log. Control tests confirm that the meter is functioning properly. Review of June’s Glucometer Log with S13Admin for Unit C on 06/10/2024 at 10:00 a.m. revealed the most recent controls test was completed on 06/08/2024 at 12:00 a.m. Review of patient census for Unit C revealed 1 patient (#3) with a diagnosis of Diabetes. Review of Patient #3’s medical record revealed glucose checks were not performed. In an interview on 06/10/2024 at 10:00 a.m., S13Admin verified the control testing on Unit C was not completed per hospital policy and could be a potential patient safety issue. Review of June’s Glucometer Log with S13Admin for Unit B on 06/10/2024 at 10:10 a.m. revealed the most recent controls test was completed on 06/06/2024 at 12:00 a.m. Review of patient census for Unit B revealed Patient #4 with a diagnosis of Diabetes. In an interview on 06/10/2024 at 10:12 a.m., Patient #4 reported she had her blood sugar checked earlier this morning and was given 6 units of insulin for a reading of 286. Patient #4 reported she felt her blood sugar was high. Review of Patient #4’s medical record on 06/10/2024 at 10:25 a.m., revealed patient blood glucose level per glucometer registered 268 mg/dl on 06/10/2024 at 8:00 a.m. Patient was given 6 units of insulin. The patient complained of drowsiness. The patient was rechecked at 10:15 a.m. and found to have a blood glucose level of 548 mg/dl. Patient #4 was administered another 2 units of insulin per physician orders. In an interview on 06/10/2024 at 10:30 a.m., S13Admin verified the control testing on Unit B was not completed per hospital policy and could be a potential patient safety issue.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on record review and interview, the facility failed to ensure all patients were protected and free from neglect. The deficient practice is evidenced by failure to provide the ordered level of observations in 1 (#1) of 4 (#1-#4) patients reviewed, potentially resulting in patient harm. Findings: Review of hospital policy titled “Shift Assignments”, last reviewed 01/2022, revealed, in part: Purpose: To ensure a safe, therapeutic milieu and delivery of quality patient care by designating specific duties to appropriate staff members ...2., in part: ...Mental Health Technicians will: Perform 1:1 observation level of patients if ordered. Review of hospital policy titled “Patient Observation Record”, last reviewed 01/2021, revealed, in part: The MHT is to note the Level of Observation ordered for each patient: 4. 1:1 Observations on 06/10/2024 at 9:55 a.m. on Unit C in room hh revealed a white board with Patient #1 noted to be on observation level 1:1. Observations on 06/10/2024 at 10:50 a.m. on Unit C revealed Patient #1 wandering the unit alone and proceeding into room ff. Further observations revealed S20MHT in hallway gg. Review of Patient #1’s observation sheet revealed level of observation “close observation without unit restriction”. The observation sheet failed to reveal Patient #1 was on observation level 1:1. Review of Patient #1’s medical record revealed physician orders dated 06/04/2024. The orders read, “Place patient on 1:1”. In an interview on 06/10/2024 at 10:51 a.m., S20MHT stated that he was assigned to Patient #1 and was not aware that Patient #1 was on 1:1 observations. In an interview on 06/10/2024 at 10:51 a.m., S13Admin and S18RN confirmed patient #1 was on 1:1 and should be observed on a 1:1 level per hospital policy. On 06/11/2024 at 10:30 a.m., a review of incident report dated 06/10/2024 at 8:00 p.m. revealed Patient #1 had an unwitnessed fall. The incident report stated the patient started choking, hit head hard. Heimlich maneuver performed by S25MHT, patient coughed out food. Patient became stable but continued to touch and grab the back of his head. Orders to send out for neurological exam due to complaints of head injury. Review of nursing note dated 06/10/2024 at 9:34 p.m. revealed at 8:00 p.m. patient had an unwitnessed fall in the hallway. He landed supine and assuming hit back of head. He appeared to be choking was sat up immediately and Heimlich maneuver was performed. He coughed up several pieces of sandwich. Then sat upright in chair and became stable. Verbal orders to send to emergency room for neurological testing. Review of Hospital Transfer Sheet dated 06/10/2024 revealed Patient #1 had an unwitnessed fall; landed supine; hit head hard; maneuver performed; coughed out food items, patient stable but continued to touch / grab back of head. Review of Patient #1 observation sheet dated 06/10/2024 revealed level of observation noted 1:1. Further noted that Patient #1 was in a hallway pacing from 5:00 p.m.-8:00 p.m. At 8:15 p.m. and 8:30 p.m., it was noted that Patient #1 was in his room resting quietly. On 06/12/2024 at 9:14 a.m. with S13Admin, reviewed hospital video of Unit C, dated 06/10/2024 from 7:43 p.m.-9:44 p.m.. The video revealed the following: 7:43 p.m.-8:30 p.m.: observation failed to reveal evidence that Patient #1 was observed on a 1:1 basis as per orders and observation sheets. The video revealed Patient #1 was in and out of room q and room ff. Both rooms not within line-of-sight of nurse’s station. Patient #1 was seen pacing the hallways between going in and out of rooms q and ff. 7:52 p.m.: Patient #1 left room q, went to room hh where S26MHT gave him a sandwich. Patient #1 went back to room q. 7:53 p.m.: S26MHT was seen going into room q to give Patient #1 a cup of what appeared to be water and then leaving and going back to room hh. 7:53 p.m.-7:56 p.m.: Patient finished eating his sandwich and then walked into room ff and obtained a cookie and then went back into room q where he ate the cookie. 7:57 p.m.-8:05 p.m.: S25MHT and S26MHT entered into room q and stripped the bed as Patient #1 left and walked alone to his own room u. 8:14 p.m.: S25MHT proceeded into elevator and left Unit C after looking in Patient #1’s room u. 8:15 p.m.-8:21 p.m.: Patient #1 left his room, paced back and forth between hallway gg and his room and then went back into his room. 8:23 p.m.: S25MHT returned to Unit C and went into room hh. 8:25 p.m-8:26 p.m: Patient #1 left his room and spoke to S26MHT in the hallway by room hh. 8:26-8:28 p.m.: Patient #1 entered room ff alone except for another patient who was watching tv with his back to Patient #1. Patient #1 noticed another patient’s sandwich sitting on the table in the dayroom and preceded to sit down and eat it. 8:29 p.m.: While eating the sandwich Patient #1 began to show signs of distress. He threw his sandwich down, stumbled out of the dayroom, and fell in hallway ii where he was alone. 8:29 p.m.: S25MHT, S26MHT and S23RN were all in room hh. 8:29 p.m.: S25MHT walked out of room hh, looked to the right and noticed Patient #1 on the floor in hallway ii. S26MHT and S23RN came out of room hh and assisted S25MHT in helping Patient #1 into a standing position where S25MHT proceeded to give Patient #1 the Heimlich maneuver. The video shows food-like object projecting out of Patient #1’s mouth. 8:30 p.m. Patient #1 assisted to a chair in hallway gg where he proceeded to fall on the floor again. He was lifted up by S25MHT and S26MHT. 8:31 p.m.-9:19 p.m.: S25MHT and S26MHT stayed with Patient #1 in chair in hallway gg while S23RN intermittently checked on him. 9:20 p.m.-9:44 p.m.: S25MHT and S26MHT walked patient to room u. S26MHT stayed with him until EMS arrived at 9:44 p.m. In an interview on 06/12/2024 at 10:35 a.m., S13Admin verified that nursing staff failed to provide the level of observation that was ordered by the physician and documented on the observation sheet, potentially causing patient neglect and harm.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure staff personnel records contained documentation that demonstrated Patient Rights competencies had been successfully completed during orientation upon hire for 1 (S4RN) of 6 (S1RN-S6RN) hospital registered nurses reviewed for Patient Rights training. Findings: Review of hospital policy titled “Nursing Staff Orientation”, last reviewed 01/2021, revealed, in part: Procedure, in part: Each new employee reviews and is oriented to the following core areas: Online courses, in part: Patient Rights. Review of S4RN’s personnel record revealed hire date of 01/31/2024. Further review failed to reveal Patient Rights training and competency was successfully completed during orientation upon hire. In an interview on 06/12/2024 at 12:30 p.m., S17HR confirmed that S4RN was not oriented to hospital Patient Rights policies upon hire.”

“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: 47397 Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators. Findings: In an interview on 06/10/2024 at 9:20 a.m., S13Admin stated that he was one year behind in aggregating Quality Assurance and Performance Improvement (QAPI ) data. He has not been able to collect or update Quality Assurance and Performance Improvement (QAPI) data and minutes for the last year.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failing to investigate and collect the data necessary to identify opportunities for improvement and changes that will lead to improvement. Findings: In an interview on 06/12/2024 at 12:10 p.m., S13Admin again verified that the hospital did not have Quality Assurance and Performance Improvement (QAPI ) data. He agreed that without the necessary data, the hospital is unable to identify opportunities for improvement and changes that will lead to improvement. S13Admin confirmed the QAPI program had no updated quality indicators and there were no corrective action plans because they have not identified problems.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program’s performance improvement program implemented preventive actions. This deficient practice is evidenced by the lack of an implemented preventive action plan following an increase in patient safety incidents and injuries. Findings: Review of incident reports for April, May and June 2024 revealed, in part: 06/10/2024 at 8:00 p.m.: Patient #1 with unwitnessed fall after choking on a sandwich. Hit head hard and required Heimlich maneuver, patient sent to ER (Patient was on 1:1 observation). 06/06/2024 at 3:25 p.m.: MHT observed another MHT pulling Patient #R1 out of a chair in the hallway and shoving the patient in the back. 05/19/2024 at 8:15 a.m.: Patient #R2 came out of her room at 8:00 a.m. clutching her arm saying she had purposely ripped out the metal sutures to the laceration on her left arm. It was seeping blood, pressure put on her left arm until bleeding stooped. Patient was sent to ER. 05/11/2024 at 10:30 a.m.: Patient #R3 stated, “yeah I hit her, she ate my breakfast”. Patient very hostile becomes easily agitated and aggressive. 05/11/2024 at 10:30 a.m.: Patient #R4 was hit on the back of the head from behind by Patient #R3, stated “All I did was eat a piece of her sausage”. Patient #R4 sustained a lump to the back of the left side of her head. 05/06/24 at 11:00 a.m.: Patient #R5 gave his PRN Ativan that he took out of his mouth and gave it to another patient. 05/06/2024 at 12:30 p.m.: Patient #R6 gave his PRN Ativan to another patient (the same patient that was given Ativan by #R5). 04/09/2024 at 12:15 p.m.: Upon attempting rounds on Patient #R7, #R7 punched S5RN with his right hand and hit her right jaw. In an interview on 06/12/2024 at 12:10 p.m., S13Admin stated that he had not been able to collect or update Quality Assurance and Performance Improvement (QAPI) data and minutes for the last year. S13Admin reported the hospital did not have documented actions taken to prevent incidents and patient injuries on the Performance Improvement meeting minutes because the hospital has not had QAPI meetings to discuss preventive action plans and the hospital has not investigated and collected data on the incidents discussed above.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital’s Governing Body failed to ensure the QAPI program reflected the complexity of the hospital’s services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include the following contracted services: linen service, elevator service, fire systems, generator, fuel for generator, plumbing, pest control, electrician, biohazard waste, security, telephone service, and equipment, managed IT. Findings: Review of list of contracted services provided by S13Admin revealed the following services: linen service, elevator service, fire system, generator, fuel for generator, plumbing, pest control, electrician, biohazard waste, security, managed IT, telephone service, and equipment. In an interview on 06/10/2024 at 9:20 a.m., S13Admin verified the hospital is at least one year behind on collecting any QAPI data including contracted services. In an interview on 06/10/2024 at 11:30 a.m., S13Admin reported the hospital has no QAPI program at this time.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) 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: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital’s governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program. Findings: Review of hospital document provided by S13Admin, titled “Amended and Re-Statement of the By-Laws of [Hospital]”, signed and dated by Governing Body’s only member on 06/01/2021, revealed, in part: pages 2,4,6, and 8 are missing. Section 1 Page 9, revealed, in part: The Hospital will document appropriate remedial action to address deficiencies found to the quality assurance program. The Hospital will document the outcome of the remedial action. Policies and Procedures, Section 1, in part: The following policies/procedures/plans must be created and approved by the Board of Managers: Quality Assurance Plan. Review of Governing Body meeting minutes from January 2024 - June 2024 provided by S13Admin, failed to indicate an ongoing program for quality improvement and patient safety because no indicators were discussed. Review of most recent Medical Executive Meeting minutes dated 01/15/2024, provided by S13Admin, failed to indicate an ongoing program for quality improvement and patient safety because no indicators were discussed.”

“PROVIDING ADEQUATE RESOURCES CFR(s): 482.21(e)(4) [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:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients. This Standard is not met as evidenced by: 47397 Based on record review and interview, the Hospital’s Governing Body failed to ensure adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital’s performance improvement functions as evidenced by insufficient staff designated to conduct the Quality Assessment Performance Improvement (QAPI) program functions of the hospital. Findings: Review of the hospital’s organizational chart provided by S13Admin, failed to reveal a position for Quality Assurance or Infection Control Coordinator. Review of the list of hospital department heads provided by S13Admin, failed to reveal a position for Quality Assurance or Infection Control Coordinator. In an interview on 06/10/2024 at 9:05 a.m., S13Admin verified that the hospital does not have a dedicated position for Quality Assurance Coordinator. He has not done any QAPI data collection for this year because he has not had time to do so. S13Admin confirmed the hospital has not had an infection control coordinator since the last Director of Nursing (DON) resigned over 4 months ago. S13Admin stated that the interim DON is not the Infection Control Coordinator, and further reported she is on a cruise since 06/07/2024. S13Admin stated that the hospital does not have an Assistant Director of Nursing and he is not sure if they need one.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the operation of the nursing service would include the quality of the patient care provided by the nursing service. This deficiency is evidenced by: 1) failure of the nursing service to be under the direction of a registered nurse responsible for the operation of the nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care to all areas of the hospital; 2) failure to adhere to nursing policies and procedures requiring the patient or the patient’s representative to be notified of a transfer. Findings: 1) Failure of the nursing service to be under the direction of a registered nurse responsible for the operation of the nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care to all areas of the hospital. Review of hospital document titled “Competency-based Job Description, Director of Nursing”, revealed, in part: III. Summary: This position is responsible for being the senior level provider of leadership to nursing services and coordinates the delivery of nursing serves, treatment and care ...this position is responsible for nursing services that include training, staffing, education and development, communications and documentation in order to maintain quality patient care ...V. Essential Duties and Responsibilities, in part: 1. Serves as the leader of nursing services at the hospital. 3. Support the staffing coordinator with staffing needs that meet standards. 6. Maintains quality care standards that admissions and transfers are appropriate considering the patients level of acuity, the hospitals capacity and staff, and and whether the patient has proper consent. 13. Assures, measures, assesses and improves patient outcomes by properly education and directing clinical staff. 15. Provides access and guidance to all staff in relation to nursing policy and procedures. 16. Serves as final authority for all nursing staff. 19. Assures that the highest quality of nursing care is given. 21. Assures that all patients are treated with respect and that all patient rights and regulations governing them are followed. 22. Serves as the hospital’s Infection Control Officer. The Infection Control Officer will be qualified by education and experience and competent in infection control practices. The Infection Control Officer will be required to complete 10 CEU’s in infection control related topics. Review of hospital policy titled “Staffing Plans and Delivery of Care”, last reviewed 01/2021, revealed, in part: Policy: The Director of Nursing shall outline a staffing plan that shall be used to determine the personnel recommended for each shift as outlined in the units core coverage and as necessary to provide the scope of services ... Scheduling Limitations: The goal of staffing each nursing unit is to ensure patient safety in healthcare delivery ...Staffing Assessment: Staffing levels are assessed daily (by shift) and adjustments are made for staff assignments based on the needs of the patient. The charge nurse, Director of nursing or designee does this assessment prior to the beginning of each shift and staffing adjustments are made accordingly to accommodate patient needs.... Review of the hospital’s organizational chart provided by S13Admin, revealed S16DON as Director of Nursing. Review of the hospital’s organizational chart provided by S13Admin, failed to reveal an Assistant Director of Nursing. Review of the list of hospital department heads provided by S13Admin, revealed S16DON as Director of Nursing. Review of the list of hospital department heads provided by S13Admin, failed to reveal an Assistant Director of Nursing. Review of the hospital’s organizational chart provided by S13Admin, failed to reveal a position for Infection Control Coordinator. Review of the list of hospital department heads provided by S13Admin, failed to reveal a position for Infection Control Coordinator. In an interview on 06/12/2024 at 12:38, S17HR confirmed that 2 nurses (S4RN and S6RN) were unable to have Performance Evaluations due to the previous DON resigning 4 months ago (See findings in A-0398). In an interview on 06/11/2024 at 10:30 a.m., S13Admin confirmed the Unit C was not staffed per hospital policy and patient safety needs (See findings in A-0144). In an interview on 06/10/2024 at 9:48 a.m., S13Admin confirmed the MHTs were assigning their own patients (See findings in A-397). In an interview on 06/10/2024 at 10:20 a.m., S13Admin confirmed that the registered nurses are not signing observation sheets, which indicates the nurses are not rounding and observing the patients (See findings in A-395). In an interview on 06/10/2024 at 9:54 a.m., S13Admin confirmed the registered nurses are not using the correct disinfecting solution when cleaning the glucometers (See findings in A-0043 and A-0749). In an interview on 06/10/2024 at 10:00 a.m., S13Admin confirmed the registered nurses are not testing the controls for the glucometer per hospital policy (See findings in A-0043 and A-0144). In an interview on 06/11/2024 at 1:18 p.m., S24RN verified that nurses are not implementing physician orders. (See findings in A-0398). In an interview on 06/10/2024 at 9:05 a.m., S13Admin stated that the previous Director of Nursing (DON) resigned approximately 4 months prior. The interim DON, S16DON, was on a cruise since 06/07/2024. The previous Assistant Director of Nursing (ADON) resigned last week. S13Admin reported that the hospital is waiting on the receipt of a criminal background check before the new DON, S14DON, will start. S13Admin verified the hospital currently has no qualified person to cover the DON responsibilities while S16DON is out. 2) Failure to adhere to nursing policies and procedures requiring the patient or the patient’s representative to be notified of a transfer or discharge. Review of hospital policy titled “Medical Emergency Transfer to Another Facility”, last reviewed 01/2021, revealed, in part: Procedure: After emergency procedures have been initiated and the physician has given transfer orders, the Registered Nurse must: 2. Notify patient’s family/significant other of patient’s transfer. 3. Complete the Emergency Transfer Sheet with the following contents, in part: Receiving Hospital and phone number, Family/Caregiver’s name and phone number and time contacted. Review of Patient #1’s medical record revealed admission date of 06/01/2024. Diagnoses included Mental Retardation, Autism and Schizophrenia. Continued review revealed a Physician’s Emergency Certificate dated 05/31/2024. The certificate included the name and phone number of Patient #1’s guardian. Review of Patient #1’s nursing note dated 06/10/2024 at 9:34 p.m. revealed at 8:00 p.m. Patient #1 had an unwitnessed fall in the hallway. He landed supine and assuming hit back of head. He appeared to be choking was sat up immediately and Heimlich maneuver was performed. He coughed up several pieces of sandwich. Then sat upright in chair and became stable. Verbal orders to send to emergency room for neurological testing. Continued review failed to reveal the nurse contacted Patient #1’s guardian as per hospital Emergency Transfer policy. Review of Patient #1’s transfer sheet dated 06/10/2024 failed to reveal the name of the receiving hospital or phone number. Further review failed to reveal the Family/Caregiver’s name and phone number and time contacted. In an interview on 06/12/2024 at 8:45 a.m., S13Admin confirmed there was no evidence the guardian of Patient #1 was notified of the emergency transfer.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the registered nurse supervised the care of each patient. The deficient practice is evidenced by failure of the nurse to review and sign the observation sheet for 46 out of 46 observation sheets reviewed. Findings: Review of the hospital policy “Patient Observation Record,” last reviewed, 01/2021, revealed in part, Procedure, in part: The RN is responsible for MHT assignments re: Patient Observation Records. 1. A review of this record is performed every 2 hours. 2. A rounding of all patients is to be performed every 2 hours and documented on the Patient Observation Record. Review of the Patient Observation Record for Patient #1 revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below: 06/06/2024 between 4:00 p.m. - 11:00 p.m. In interview on 06/12/2024 at 9:05 a.m., S13Admin verified nurses did not supervise Patient #1’s care according to the hospital’s policy. Review of the Patient Observation record for Patient #2 revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below: 05/04/2024 between 11:00 p.m. - 4:00 a.m. N.D. between 11:00 p.m. - 4:00 a.m. 04/24/2024 between 2:00 a.m. - 8:00 a.m. 04/25/2024 between 4:00 a.m. - 8:00 a.m. 04/26/2024 between 2:00 p.m. - 8:00 p.m. In interview on 06/12/2024 at 10:38 a.m., S13Admin verified nurses did not supervise Patient #2’s care according to the hospital’s policy. Review of the Patient Observation record for Patient #4 revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below: 06/08/2024, 06/09/2024 and 06/10/2024 between 2:00 a.m. - 6:00 a.m.; 8:00 a.m. - 2:00 p.m.; 8:00 p.m. - 6:00 a.m.; 8:00 p.m. - 8:00 a.m.; and 8:00 p.m.-12:00 a.m. In interview on 06/11/2024 at 11:55 a.m., S13Admin verified nurses did not supervise Patient #4’s care according to the hospital’s policy. Review of the Patient Observation records on 06/10/2024 at 10:38 a.m., for Unit A, dated 06/10/2024, revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below: Patients R15 - R25 between 6:00 a.m. - 10:38 a.m. In interview on 06/10/2024 at 10:38 a.m., S13Admin verified nurses did not document supervised care according to the hospital’s policy in 11 (R15 - R25) out of 11 (R15 - R25) patient observations sheets reviewed. Review of the Patient Observation records on 06/10/2024 at 10:16 a.m., for Unit B, dated 06/10/2024, revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below: Patients R26 - R29 between 12:00 a.m. - 8:00 a.m. Patients #4 and R30 - R34 between 11:00 p.m. - 10:16 a.m. In interview on 06/10/2024 at 10:16 a.m., S13Admin verified nurses did not document supervised care according to the hospital’s policy in 10 (#4, and R26 - R34) out of 10 (#4, and R26 - R34) patient observations sheets reviewed. Review of the Patient Observation records on 06/10/2024 at 9:50 a.m., for Unit C, dated 06/10/2024, revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below: Patients #1, #3 and R8 - R13 between 6:00 a.m. - 9:50 a.m. In interview on 06/10/2024 at 9:50 a.m., S13Admin verified nurses did not document supervised care according to the hospital’s policy in 8 (#1, #3 and R8 - R13) out of 8 (#1, #3 and R8 - R13) patient observations sheets reviewed. Review of the Patient Observation records on 06/11/2024 at 9:42 a.m., for Unit C, dated 06/11/2024, revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below: Patients #1, #3 and R8 - R13 between 6:00 a.m. - 9:42 a.m. In interview on 06/11/2024 at 9:42 a.m., S27SS verified nurses did not document supervised care according to the hospital’s policy in 8 (#1, #3 and R8 - R13) out of 8 (#1, #3 and R8 - R13) patient observations sheets reviewed.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47397 Based on record review and interview, the nursing staff failed to update the plan of care after a significant event. The deficient practice is evidenced by failure to update the nursing plan of care for Patient #1 after having an unwitnessed fall involving a head injury and Heimlich maneuver and sent to emergency room. Findings: Review of hospital policy titled “Standards of Nursing Practice”, last reviewed 01/2021, revealed, in part: Procedure, in part: Treatment plan goals and expected outcomes are derived from an analysis of the physical and mental health status data. The treatment plan for nursing care must include individualized nursing actions to achieve the established outcomes. The plan is developed with the patient. The treatment plan for nursing care is systematic, ongoing, and must be updated regarding whether or not the patient is making progress toward established goals. Review of Patient #1’s medical record revealed an incident report. Further review revealed Patient #1 had an unwitnessed fall involving a head injury and Heimlich maneuver on the night of 06/10/2024 at 8:00 p.m. and was transferred to the emergency room for neurological workup at 9:45 p.m. The patient returned to Unit C on 06/11/2024 at 9:15 a.m. Review of Patient #1’s Treatment Plan dated 06/11/2024 at 10:05 a.m., revealed Hypothyroidism was addressed. Further review failed to reveal the treatment plan was updated to address the unwitnessed fall involving a head injury, heimlich maneuver or transfer to emergency room. In interview on 06/12/2024 at 9:15 a.m., S13Admin verified the plan of care was not updated to address the unwitnessed fall involving a head injury, Heimlich maneuver or transfer to emergency room.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 47397 Based on observation and interview the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with Hospital policy and the patient’s needs. This deficiency is evidenced by failing to ensure a Registered Nurse completed all patient care assignments at the beginning of each shift. Findings: Review of hospital policy titled “Shift Assignments”, last reviewed 01/2022, revealed, in part: Purpose: To ensure a safe, therapeutic milieu and delivery of quality patient care by designating specific duties to appropriate staff members ...Procedure, in part: 1. Charge Nurse: The charge nurse will determine the nursing care assignments for that shift based on patient acuity and capabilities of available staff. In an interview on 06/10/2024 at 9:48 a.m., when asked to produce Unit C assignment sheets, S18RN stated that she did not prepare an assignment sheet because the Mental Health Technicians assign themselves the patients they will care for on each shift. In an interview on 06/10/2024 at 9:48 a.m., S13Admin verified the Mental Health Technicians assign to themselves the patients they will care for on each shift. In an interview on 06/10/2024 at 10:07 a.m., when asked to produce Unit B assignment sheets, S5RN stated that she did not have an assignment sheet because the Mental Health Technicians pick their patients and make their assignments. In an interview on 06/10/2024 at 10:07 a.m., S13Admin verified the Mental Health Technicians assign their own patients and stated “we have been doing that for years”. In an interview on 06/10/2024 at 10:35 a.m. when asked to produce Unit A assignment sheets, S15HS stated that she did not have an assignment sheet because the Mental Health Technicians make their own patient assignments. In an interview on 06/10/2024 at 10:35 a.m., S13Admin verified the Mental Health Technicians assign to themselves the patients they will care for on each shift.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to have a Director of Nursing ensure adequate supervision and evaluation of the nursing personnel and nursing staff adherence to policies and procedure. This deficient practice was evidenced by: 1) failure of the nurses to implement physician orders per hospital policy; 2) failure of the hospital to have documentation of Performance Evaluations for 3 (S4RN, S5RN, and S10MHT) of 12 (S1RN - S6RN and S7MHT - S12MHT) nursing staff personnel records reviewed. Findings: 1) Failure of the nurses to implement physician orders. Review of hospital policy titled “Receiving and Recording Verbal Orders”, last reviewed, 01/2021, revealed, in part: Procedure, in part: The Charge RN is responsible for implementing the orders and indication as such on the physician’s order by bracketing off the entire order and signing his/her name. Review of Patient #1’s medical record revealed an order written on 06/04/2024 reading “Place Patient on 1:1”. Review of Patient #1’s Observation record failed to reveal patient was placed on observation level 1:1 from 06/04/2024-06/10/2024 as per physician order. In an interview on 06/10/2024 at 10:51 a.m., S13Admin and S18RN confirmed patient #1 was on 1:1 observation per physician order but the order was not implemented. Review of Patient #3’s medical record on 06/11/2024 at 1:18 p.m., revealed admission date of 06/06/2024. Diagnoses include Depression with SI and Diabetes on Metformin 500 mg once in the morning. Review of Patient #3’s Treatment Plan dated 06/06/2024 at 4:30 p.m. revealed Diabetes included in the problem list. Continued review revealed the following intervention: Nurse will monitor and record blood glucose levels regularly and report values outside normal parameters specified by physician. This will occur daily per shift and will last as needed. Review of Patient #3’s History and Physical dated 06/06/2024 at 7:13 a.m., revealed a Diagnosis of Diabetes with plan of care for Metformin and Insulin sliding scale coverage per protocol. Review of Patient #3’s physician orders revealed a verbal order for Accuchecks twice a day with sliding scale protocol dated 06/06/2024 at 10:12 a.m. and signed by nurse. Review of Patient #3’s medical record dated 06/06/2024-06/11/2024 failed to reveal a record of blood glucose levels or a record of insulin administration per sliding scale protocol. In an interview on 06/11/2024 at 1:18 p.m., S24RN confirmed that the Accuchecks and sliding scale protocol were ordered but the orders were not implemented. 2) Failure of the hospital to have documentation of Performance Evaluations for 3 (S4RN, S5RN, and S10MHT) of 12 (S1RN - S6RN and S7MHT - S12MHT) nursing staff personnel records reviewed. Review of hospital policy titled “Staff Development/Continuing Education”, last reviewed on 01/2021, revealed, in part: Policy Statement: It is the policy of [Hospital] to establish minimum training requirements and to provide ongoing education specific to areas of responsibility to promote skill development, maintain skills, increase knowledge, provide job enrichment, support desired competencies and comply with regulatory requirements. Procedure, in part: DON or designee, in part: Assesses nursing areas of staff’s need for education by outcomes of ... staff evaluations. A review of S4RN’s personnel record with S17HR revealed a hire date of 01/31/2024. Further review failed to reveal a completed Performance Evaluation on file. In an interview on 06/12/2024 at 12:33 p.m., S17HR verified that S4RN did not have a completed Performance Evaluation on file. S17HR reported the first evaluation should be completed within the first 90 days of hire. S17HR stated that the Performance Evaluations have not been completed since the last DON resigned approximately 4 months ago. A review of S5RN’s personnel record with S17HR revealed a hire date of 02/16/2024. Further review failed to reveal a completed Performance Evaluation on file. In an interview on 06/12/2024 at 12:33 p.m., S17HR verified that S5RN did not have a completed Performance Evaluation on file. A review of S10MHT’s personnel record with S17HR revealed a hire date of 11/21/2023. Further review failed to reveal a completed Performance Evaluation on file. In an interview on 06/12/2024 at 12:33 p.m., S17HR verified that S10MHT did not have a completed Performance Evaluation on file.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47397 Based on observation, record review and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment were maintained in such a manner that the safety and well-being of patients were assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair. Findings: Review of hospital policy titled “Environmental Services Policy & Procedure, Environmental Safety”, last reviewed 01/2023, revealed, in part: Policy Statement. It is the policy to operate and maintain a safe environment, which minimizes risk and promotes safety. Review of hospital policy titled “Environmental Services Policy & Procedure, Maintenance Rounding”, last reviewed 01/2023, revealed, in part: Purpose: to ensure thoroughness and consistency in providing a safe and functional environment, the Environmental Services department will conduct environmental tours to maintain compliance. Procedure, in part: Maintenance Rounding checklist ...of the following items, in part: Shower/bath cleanliness and functionality; Patient bed cleanliness and functionality. Observations during a tour of Unit C 06/10/2024 from 9:25 a.m. to 10:00 a.m. revealed the following: 9:25 a.m.- Observations of Room o revealed trash with a pair of strappy sandals noted under mattress of bed by door. 9:29 a.m.- Observations of Room p revealed trash under mattress near door. 9:33 a.m.- Observations of Room r revealed trash under mattress by door. 9:36 a.m.- Observations of wall to the left of Room hh revealed a hole in wall approximately 4 inches in diameter. 9:37 a.m.- Observations of Room q revealed trash under mattress. 9:39 a.m.- Observation of Room u revealed mal-functioning overhead lights. 9:40 a.m.- Observations of Room aa revealed non-functioning shower head, no water. 9:41 a.m.- Observations of shower curtain in Room z partially hanging off the shower curtain rod in disarray and missing hooks.. 9:44 a.m.- Observations of Room ff with windowsill noted to be cracked and broken cement falling to the floor. In an interview on 06/10/2024 at 10:00 a.m., S13Admin and S19EVS verified the above-mentioned findings In Unit C during the hospital tour. Observations during a tour of Unit B on 06/10/2024 from 10:04 a.m. to 10:20 a.m. revealed the following: 10:20 a.m.- Observations of Room k revealed the over-head lights malfunctioning. 10:21 a.m.-Observation of Room m revealed broken latch on door. In an interview on 06/10/2024 at 10:25 a.m., S13Admin and S19EVS verified the above-mentioned findings In Unit B during the hospital tour. Observations during a tour of Unit A on 06/10/2024 from 10:29 a.m. to 10:38 a.m. revealed the following: 10:29 a.m.- Observations of Room e revealed overhead light malfunctioning. 10:30 a.m.- Observations of Room g with trash noted under mattress by door. In an interview on 06/10/2024 at 10:40 a.m., S13Admin and S19EVS verified the above-mentioned findings In Unit B during the hospital tour. In an interview on 06/10/2024 at 1:00 p.m., S13Admin confirmed there is no maintanenance log. There is an online system for staff to report maintenance issues, but no one utilizes the system. In an interview on 06/10/2024 at 3:00 p.m. S19EVS reported he did not have a log of maintenance rounding but presented a sheet titled “[Hospital] Rounding dated 06/10/2024. The documented revealed the following: Unit C Room u lights not working, baseboard missing next to toilet. Room t clean restroom floor, missing paper towel dispenser, room door drags, baseboard repair in closet. Room r strip and wax floor. Room s strip and wax floor, chipped wood on closet door, baseboard repair behind desk. Room o baseboard missing under window, strip and wax floor. Room p strip and wax floor. Room aa shower faucet has no water coming out. Room z shower curtain missing hooks. Room ff floor repair needed by wall chairs sit against. Hallway gg hand rail off wall, finish wall repair between Rooms r and s. Unit B Room n restroom wall and baseboard repair, paint room door. Room m door broke at latch, latch is missing. Room l floor tile broke next to toilet. Room k lights not working. Room h missing baseboard under window. Room i missing baseboard behind door. Room jj broken counter top in med room, strip and wax med room floor. Room kk wall repair around window frame. Room x wall repair above toilet. Hallway ll replace baseboard left of Room k. Unit A Room g soap dispenser not working. Room f soap dispenser not working. Room d missing door stopper, light switch not working. Room a reattach blind behind plexiglass. Room b clean entrance floor around threshold. Room x shower faucet has a trickle, paint wall next to toilet, strip and wax floor Hallway nn schedule with Company B to repair west stairwell lock Unit D Room oo strip and wax floor, update lights to led bulbs. Hallway pp replace missing baseboard, strip and wax floor. Area qq tighten net against wall. Room rr replace internet wire to security desk. Common 1. Paint west stairwell. 2. Install generator timer. 3. Install Brand ss switch on driveway lights.”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 47397 Based on record review and interview the hospital failed to demonstrate an individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership. Findings: Review of hospital document titled “Competency-based Job Description, Director of Nursing”, revealed, in part: V. Essential Duties and Responsibilities, in part: 22. Serves as the hospital’s Infection Control Officer. The Infection Control Officer will be qualified by education and experience and competent in infection control practices. The Infection Control Officer will be required to complete 10 CEU’s in infection control related topics. Review of the hospital’s organizational chart provided by S13Admin, failed to reveal a position for Infection Control Coordinator. Review of the list of hospital department heads provided by S13Admin, failed to reveal a position for Infection Control Coordinator. A review of Governing Body minutes failed to reveal evidence that the governing body appointed an Infection Control Professional to be responsible for the infection prevention and control program within the timeframe of 01/2024 to 06/2024. In an interview on 06/10/2024 at 9:05 a.m., S13Admin verified the hospital has not had an Infection Control Coordinator since March of 2024 when S28RDON resigned. This hospital was cited for same deficiency in 2011.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47397 Based on observations, record review and interview the hospital failed to employ methods for preventing and controlling the transmission of infections. This deficient practice was evidenced by failure to adhere to nationally recognized guidelines when sanitizing patient glucometers, which led to an Immediate Jeopardy Situation. (See findings in A-0747) Findings: Review of hospital policy titled “Cleaning and Disinfecting Medical Equipment”, last reviewed, 01/2024, revealed, in part: Policy Statement: ...shared patient care equipment is clean before use and that all used or contaminated equipment is appropriately cleaned before reuse. Purpose: To decrease the incidence of nosocomial infections by maintaining clean equipment ... Review of hospital policy titled “Glucometer”, last reviewed 01/2024, revealed, in part: Care of the Meter ..., in part: Clean the meter monthly; using the hospital approved disinfecting solution. Review of hospital policy titled “Glucometer”, revised 06/2024 as part of the Immediate Jeopardy Removal Plan, revealed, in part: Care of the Meter ..., in part: Clean the meter between each patient use; using the hospital approved purple top sanitizer. In an interview on 06/10/2024 at 9:54 a.m., S18RN reported she uses alcohol wipes to clean the glucometer between patient uses. S13Admin confirmed. In an interview on 06/10/2024 at 10:11 a.m., S5RN stated she located the appropriate wipes for cleaning the multi- use glucometer and cleaned it per manufacturer’s guidelines. S13Admin confirmed. In an interview on 06/10/2024 at 10:33 a.m., S15HS reported she cleans the glucometer with alcohol wipe between patients. S13Admin confirmed.”

“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: 47397 Based on observation, record review, and interview, the hospital failed to ensure the infection prevention program included surveillance of the facility to identify and mitigate identified sources with potential for transmission of infection. The deficient practice is evidenced by: 1) failure to provide hand sanitizer for staff use; 2) failure to provide and maintain equipment to prevent the spread of infection; 3) failure to ensure the hospital maintained a sanitary environment to prevent infections. Findings: 1) Failure to provide hand sanitizer for staff use. On 06/10/2024 at 9:32 a.m., observations of Unit C failed to reveal hand sanitizer in the locked Room hh available for staff use. In an interview on 06/10/2024, R18RN and S13Admin confirmed that hand sanitizer was not available for staff use in room hh on Unit C. S13Admin stated they did not have hand sanitizer because the patients were ingesting the hand sanitizer. S13Admin agreed that the hand sanitizer should be available to the nurses in the locked nurses’ station. 2) Failure to provide and maintain equipment to prevent the spread of infection. Review of hospital policy titled “Environmental Services Policy & Procedure, Maintenance Rounding”, last reviewed 01/2023, revealed, in part: Purpose: to ensure thoroughness and consistency in providing a safe and functional environment, the Environmental Services department will conduct environmental tours to maintain compliance. Procedure, in part: Maintenance Rounding checklist ...of the following items, in part: Shower/bath cleanliness and functionality; Patient bed cleanliness and functionality. Observations during a tour of Unit C 06/10/2024 from 9:25 a.m. to 10:00 a.m. revealed the following: 9:39 a.m.-Observations of Room t revealed missing paper towel holder. 9:40 a.m.- Observations of Room aa revealed non-functioning shower head. When the faucet lever was turned to the on position, water did not run from the faucet. In an interview on 06/10/2024 at 10:00 a.m., S13Admin verified the above-mentioned findings on Unit C during the hospital tour. Observations during a tour of Unit A on 06/10/2024 from 10:29 a.m. to 10:38 a.m. revealed the following: 10:30 a.m.- Observations of Room g with malfunctioning soap dispenser. 10:31 a.m.- Observations of Room f with malfunctioning soap dispenser. In an interview on 06/10/2024 at 3:00 p.m., S19EVS confirmed the malfunctioning soap dispensers. 3) Failure to ensure the hospital maintained a sanitary environment to prevent infections. Observations during a tour of Unit C 06/10/2024 from 9:25 a.m. to 10:00 a.m. revealed the following: 9:25 a.m.-Observations of Room o revealed torn mattress noted to bed by window. In an interview on 06/10/2024 at 10:00 a.m., S13Admin verified the above-mentioned findings on Unit C during the hospital tour. Observations during a tour of Unit B on 06/10/2024 from 10:05 a.m. to 10:20 a.m. revealed the following: 10:05 a.m.- Observations of Room l revealed torn mattress by door. 10:20 a.m.- Observations of Room k revealed a mold-like substance noted to the middle portion on the under part of the mattress located in the bed by the door. In an interview on 06/10/2024 at 10:00 a.m., S13Admin verified the above-mentioned findings In Unit B during the hospital tour. Observations during a tour of Unit A on 06/10/2024 from 10:29 a.m. to 10:38 a.m. revealed the following: 10:29 a.m.- Observations of Room e revealed a mold-like substance noted to the middle portion on the under part of the mattress located in the bed by the door. In an interview on 06/10/2024 at 10:40 a.m., S13Admin verified the above-mentioned findings In Unit A during the hospital tour.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for psychiatric patients admitted for being a danger to self or others. Findings: Observations on 01/03/2024 beginning 9:42 a.m. revealed the toilets used by patients in rooms a, b, (shared) d, e (shared) f (single use), g (single use), h, i, (shared) k, l, (shared) m (single use), n (single use), o, p (shared), r, s (shared), t (single use), and u (single use) with unsecured seats presenting ligature risks. Continued observations revealed the toilets available to patients at locations v, w, x, y, z, aa, and ee with unsecured seats presenting ligature risks. In an interview on 01/03/2024 at 11:10 a.m., S10DON verified the findings of the observations.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on interview and record review, the hospital failed to submit critical incident reports to the Louisiana Department of Health regarding the elopement of patients R2, R3, R4, R5 and R6. This deficient practice had the potential to affect the safety of any patients admitted to the hospital who have eloped. Findings: Review of document titled, “Louisiana Department of Health, Health Standards Section Self-Reporting Process for Hospitals - Abuse/Neglect”, (Revised 12/01/2021) revealed the following, in part: Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report (abuse/neglect) within 24 hours of receiving knowledge of the (incident) to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable). Review of the hospital incident log revealed 5 elopements occurring on the dates 07/11/2023, 07/20/2023, 07/23/2023, 09/16/2023 and 11/18/2023. Review of incident report dated 07/11/2023 revealed R2 was outside in the smoking area at 4:30 p.m. and while the MHT was watching R2 jumped over the fence and eloped. S10Admin and S12DON were notified. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health. Review of incident report dated 07/20/2023 revealed R3 was outside in the smoking area at 8:55 p.m. and walked out the cafeteria into the lobby and out the front door. Staff called after R3 but to no avail. S12DON was notified. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health. Review of incident report dated 07/23/2023 revealed R4 was outside in the smoking area at 6:15 p.m. and R4 climbed the fence and ran. Several people thought they saw him get it a car after he jumped the fence. S6MHT was outside with patient and stated he was lighting other patients’ cigarettes and his back was turned away from R4. The second MHT was inside the cafeteria when the event occurred. S10Admin and S12DON were notified. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health. Review of incident report dated 09/16/2023 revealed R5 went down for breakfast at 9:00 a.m. with S6MHT and ran out the front door. M6MHT reported the door in cafeteria (patio door) was unlocked. S12DON was notified. Police were called. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health. Review of incident report dated 11/18/2023 revealed R6 ran from staff after breakfast. R6 exited building through main door and staff pursued him but were not able to catch R6. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health. In an interview on 01/04/2024 at 12:30 p.m., S11Admin and S12DON indicated the hospital did not submit self-reports to the Louisiana Department of Health regarding the elopements as per state rules and regulations.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 47397 Based on record review and interviews, the hospital failed to ensure staff personnel records contained documentation that demonstrated Patient Rights competencies had been successfully completed during orientation upon hire for 3 (S4NP, S5PMHNP, and S13PA) of 3 (S4NP, S5PMHNP, and S13PA) hospital midlevel providers reviewed for Orientation with Patient Rights training. Findings: Review of hospital policy titled “HR Policies and Procedures, Orientation Program 8.8”, revealed, in part: Policy Statement: An orientation program shall be conducted for all newly hired employees that will assess the competency of the employee as it relates to his or her job performance upon hire and at least every three years thereafter. Procedure, in part: 1. All newly hired personnel must attend an orientation program within their first five (5) days of employment. Then every three years thereafter. d. An introduction to our administrative structure, which includes, in part: (4) A review of resident rights. (5) A review of abuse reporting procedures. Review of S4NP’s personnel record revealed hire date of 03/27/2021. Further review failed to reveal Patient Rights training and competency was successfully completed during orientation upon hire. Review of S5PMHNP’s personnel record revealed hire date of 05/25/2021. Further review failed to reveal Patient Rights training and competency was successfully completed during orientation upon hire. Review of S13PA’s personnel record revealed hire date of 07/13/2022. Further review failed to reveal Patient Rights training and competency was successfully completed during orientation upon hire. In an interview on 01/04/2024 at 9:20 a.m., S14HR confirmed that S4NP, S5PMHNP, and S13PA did not go through hospital employee orientation and Patient Rights training upon hire.”

“CONTROLLED DRUGS KEPT LOCKED CFR(s): 482.25(b)(2)(ii) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 must be kept locked within a secure area. This Standard is not met as evidenced by: 47397 Based on observations and interviews, the hospital failed to ensure schedule IV medications were locked within a secure area. This deficient practice was evidenced by failure to ensure vials of Lorazepam were stored securely under double lock. Findings: Review of hospital policy titled “Narcotic Count and Documentation” dated January 2023, revealed, in part: Policy Statement, in part: Narcotic medication (referred to as narcotics) is located in the locked narcotic box and in the locked medication refrigerator in each medication room on each unit. On 01/03/2024 at 9:24 a.m., an observation with S10DON was conducted of the Nurses’ Station Medication Refrigerator located on floor ff. During the observation, 39 vials of 2mg/ml Lorazepam were noted to be located in an unsecured cardboard box in an unlocked refrigerator. In an interview on 01/03/2024 at 9:25 a.m., S10DON verified 39 vials of 2mg/ml Lorazepam were stored in an unsecured cardboard box in an unlocked refrigerator on floor ff.”

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 47397 Based on observation and interview the hospital failed to have an approved therapeutic diet manual with a publication or revision date of not more than 5 years old. Findings: Review of hospital therapeutic diet manual titled, “Adult Nutrition Care Manual (NCM)”, revealed the manual was published in 2018. In an interview on 01/04/2024 at 11:13 a.m., S15DM verified the hospital therapeutic diet manual titled, “Adult Nutrition Care Manual (NCM)” was published in 2018 and was more than 5 years old.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47397 Based on observations and interviews, 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. This deficient practice was evidenced by failure to maintain the physical plant in good repair and failure to maintain a safe patient care environment. Findings: Review of hospital policy titled “Environmental Services Policy & Procedure, Environmental Safety”, dated January 2023, revealed, in part: Policy Statement. It is the policy to operate and maintain a safe environment, which minimizes risk and promotes safety. Review of hospital policy titled “Environmental Services Policy & Procedure, Maintenance Rounding”, dated January 2023, revealed, in part: Purpose: to ensure thoroughness and consistency in providing a safe and functional environment, the Environmental Services department will conduct environmental tours to maintain compliance. Procedure, in part: Maintenance Rounding checklist ...of the following items, in part: Shower/bath cleanliness and functionality; Patient bed cleanliness and functionality. Review of hospital policy titled “Environmental Services Policy & Procedure, Scope of Services”, dated January 2023, revealed, in part: Policy Statement, in part: The Environmental Services Department ...will provide housekeeping services, seven days per week 24 hours a day. Observations on 01/03/2024 beginning 9:42 a.m. with S10DON the following was observed: Unit C: Temperature on Unit C was noted to be markedly cold at 9:45 a.m. Observation of temperature gauge read 66 degrees. Patients were observed to be in sweaters, jackets and wrapped in blankets. In an interview on 01/03/2024 at 10:21 a.m. Patient R1, who was wrapped in a blanket stated, “It is freezing in here”. In an interview on 01/03/2024 at 9:50 a.m., S10DON confirmed the temperature on Unit C was 66 degrees. Observation of bathroom aa noted to have approximately 2-3 inches of white cloudy water on shower floor. Water was noted puddled on the floor near the sink. In an interview on 01/03/2024 at 10:15 a.m., S10DON and S9EVS confirmed white cloudy water collected on the shower floor and the puddles of water on the floor near the sink of bathroom aa and agreed the condition of bathroom aa was not sanitary. Observation bathroom z noted to have strips of dirty paper wrinkled up on shower floor. Continued observation revealed used wet wash clothes tucked into crevices of the shower. Hairbrush with hair in it stuck in shower crevice. Clothes and paper cups in chair in bathroom z. No soap by sink for patients to wash hands. In an interview on 01/03/2024 at 10:23 a.m., S10DON and S9EVS confirmed the condition of the bathroom z was not sanitary. Observation of room u revealed ripped and torn mattress creating unsanitary conditions. In an interview on 1/03/2024 at 10:27 a.m., S12DON confirmed the torn mattress in room u and agreed this was not sanitary. Unit B: Observation of the shower in bathroom y revealed the water was cold. After letting the water run for approximately 20 mintues, the water rose to barely luke-warm. In an interview on 01/03/2024 at 10:55 a.m. S10DON reported the temperature of the water in the shower of bathroom y was barely luke-warm because of the pipes. Observation of room j noted to have 2 ripped mattresses creating unsanitary conditions. In an interview on 1/03/2024 at 10:36 a.m., S10DON and S9EVS confirmed the torn mattresses in room j and agreed this was not sanitary. Unit A: Observation of room e noted to have ripped mattress with food wrappers located under the mattress creating unsanitary conditions. In an interview on 1/03/2024 at 11:00 a.m., S10DON and S9EVS confirmed the torn mattresses and food wrappers under the mattress of room e and agreed this was unsanitary. Observation of room c revealed the bed under the mattress with brown, dried, fluid-like substance and food crumbs noted. In an interview on 1/03/2024 at 11:06 a.m., S10DON and S9EVS confirmed that under the mattress of the bed in room c there contained a brown, dried, fluid-like substance and food crumbs. Both agreed this was unsanitary. S10DON stated that the hospital policy is to clean every bed at discharge and on admit.”

“Psychiatric Evaluation CFR(s): Standard: Psychiatric Evaluation. Each patient must receive a psychiatric evaluation that must-- This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the Psychiatric Evaluation described the information necessary to justify the diagnosis and treatment of each patient. This is evidenced by failure to include the physician certification for admission, the estimated length of stay, the treatment goals, criteria for discharge and the required signature of the evaluating licensed practitioner on Psychiatric Evaluation for 1 (#3) of 3 (#1-#3) psychiatric evaluations reviewed. Findings: Review of Patient #3’s medical record revealed an admit date of 12/03/2023 and date of birth 07/22/1954. Further review revealed a document titled “Psychiatric Evaluation” dated 12/03/2023. Continued review failed to reveal the provider, S16PMHNP, completed the “Physician Certification for Admission”, “Estimated Length of Stay”, “Treatment Goals”, and the “Criteria for Discharge”. Further review failed to reveal S16PMHNP’s signature. In an interview on 01/03/2024 at 3:30 p.m., S10DON confirmed that Patient #3’s Psychiatric Evaluation did not reveal documentation containing the “Physician Certification for Admission”, the “Estimated Length of Stay”, the “Treatment Goals”, the “Criteria for Discharge” and the evaluating licensed practitioner’s signature.”

“Psych Eval - Medical History CFR(s): [Each patient must receive a psychiatric evaluation that must--] Include a medical history; This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure a complete medical history was documented on the Psychiatric Evaluation for each patient admitted to the psychiatric hospital. This deficiency is evidenced by failure to obtain a complete medical history for 1 (#1) of 3 (#1-#3) reviewed records. Findings: Review of the History and Physical completed by S4NP on 11/17/2023 for Patient #1, revealed in part, Medical History: “Autism”, “Drug Addiction”, “Mixed Hyperlipidemia”, and “Hypertension”. Review of the Psychiatric Evaluation completed by S16PMHNP on 11/18/2023 for Patient #1, revealed in part, Medical History: “0”; Disease/Illness: “0”; Surgical history: “0”; PCP: “0”; Last Appointment: “NA”. In interview on 01/03/2024 at 3:40 p.m., S10DON verified the evaluating licensed psychiatric practitioner did not document an accurate nor complete medical history on the Psychiatric Evaluation.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure each patient had an individualized, comprehensive treatment plan for 1 (#3) of 3 (#1-#3) patients. This deficiency is evidenced by failure to include all medical and nursing diagnoses as part of an individualized, comprehensive treatment plan. Findings: A review of hospital document titled “Patient Rights”, revealed, in part: All patients have the right to ...in part: Individualized treatment plans ... A review of hospital document titled “Master Treatment Plan/Weekly Update Treatment Plan”, revealed, in part: Purpose, in part: To provide comprehensive, individualized plan of treatment for each patient ...Procedure, in part: B. Treatment plans will be individualized to address patient specific problems, identified through clinical assessments ... A review of Patient #3’s list of psychiatric diagnoses included Major Depressive Disorder. Review of incident report dated 12/15/2023 revealed Patient #3 had a fall when she got up to use the restroom. She had no socks or shoes on. She fell and landed on her bottom. Patient reported pain to the right upper posterior arm. Review of Patient #3’s medical record revealed a document titled “Treatment Plan”. Further review failed to reveal evidence of the following: 1) Identified diagnoses (the diagnosis section was blank). 2) Updated physical problems that included pain to the right upper posterior arm. 3) Target dates for short-term goals (this section was blank). 4) The specific therapies Patient #3 would attend (this section was blank). 5) Discharge or Transition plan (this section was blank). 6) A signature that indicated the Treatment plan had been reviewed and approved (this section was blank).7) A signature the treatment plan was given to patient/family or declined by the patient/family (this section was blank). In an interview on 01/03/2024 at 4:02 p.m., S10DON confirmed the Treatment Plan failed to reveal evidence that the treatment plan was individualized, comprehensive and complete.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure all patients treatments were within compliance of particular aspects of the patients’ individualized treatment program as evidenced by failure to have documentation that a treatment team conference was held since patient’s admission in 1 (#2) of 3 (#1-#3) patient records reviewed. Review of hospital policy titled “Master Treatment Plan/Weekly Update Treatment Plan”, dated January 2023, revealed, in part: Policy Statement: It is the policy of this hospital to utilize a multi-disciplinary approach in the development and implementation of an individualized Master Treatment Plan and Weekly Treatment Plan for each patient. Procedure, in part: A. The multi-disciplinary team is headed by the physician and consists of Nursing, Social Services, and Activity/Recreational Therapy and other health professionals as indicted. 5. The Master Treatment Plan will be developed in the first team meeting ... Review of Patient #2’s medical record revealed an admission date of 12/16/2023. Further review failed to reveal documented evidence of a treatment team conference held since admission. In an interview on 01/03/2024 at 4:20 p.m., S10DON verified that there was evidence that a treatment team conference was held for patient #2 since admission on 12/16/2023.”

“Discharge Summary CFR(s): The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient’s hospitalization… This Standard is not met as evidenced by: 47397 Based on record review and interviews, the hospital failed to ensure each patient who had been discharged had a discharge summary that included a recapitulation of the patient’s hospitalization. This deficiency is evidenced by failure to have a documented discharge summary in 1 (#1) of 3 (#1-#3) patient records reviewed. Findings: Review of hospital policy titled “Discharge Summary” revealed, in part: Discharge Summary. A. A discharge summary shall be recorded at the time of discharge ...3 ....the Discharge Summary must be completed within thirty (30) days of discharge. Review of Patient #1’s medical record revealed an admission date of 11/17/2023 and a discharge date of 11/24/2023. Further review failed to reveal a discharge summary. In an interview on 01/03/2024 at 3:15 p.m., S10DON confirmed that the medical record revealed no evidence of a discharge summary and that the discharge summary should have been completed within 30 days of discharge.”