Greenbrier Behavioral Health

“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: 48050 Based on record review and interview, the hospital failed to ensure the patient/patient representative’s right to participate in the development and implementation of his or her plan of care. This deficient practice is evidenced by failing to allow patient’s representative to participate in the outpatient treatment/care plan. Findings: Review of the hospital’s policy #NU207 titled “Patient and Family Rights,” last reviewed on 01/2026 revealed in part: “I Policy: Patients and families are advised of the following right upon admission to the facility: 7. The right to participate in the development and implementation of his/her plan of care. 8. Every patient or his/her representative has the right to make informed decisions regarding his or her care. 9. The patient’s rights include being informed of his/her health status, being involved in care planning and treatment, and being able to request or refuse treatment. 23. Participation in the development and implementation of patient’s care plan of care.” Review of the hospital’s policy #PM024 titled “Discharge Planning Process,” last reviewed 01/2026 revealed in part: “II. PURPOSE: To provide the most therapeutic after care plan based on patient’s individualized needs. C. Discharge Process: 8. Family teaching and involvement are also important as family support will make a big difference after discharge. The family needs to know about the illness, treatment, and accomplishments. They also must be told that the illness is not static, what changes to look for, who to call for help, what medications the patient needs, and to whom the patient is being referred. 11. When making plans, the staff should consider the patient’s living situation, the patient’s physical limitations, transportation, and finances. 12. Staff should discuss with the patient and family to find out what happened after previous discharges. This may be helpful to identify potential areas where the patient may need help. For example, if medication compliance was a problem, find out how.” Review of the form for release of information for Patient #1 revealed the first section titled, “Patient Information and Authorization,” revealed the patient authorized “exchange information with” a named family member. In the next section, “Information Requested and Purpose/ Need of Disclosure,” the form revealed “patient denied” was documented for release of psychiatric evaluation, history and physical, medication records, laboratory results, immunization records, practitioner progress notes, discharge instructions, financial account information practitioner orders, treatment/ individualized service and complete medical record. The next area contained check boxes to indicate the purpose of need for disclosure and “to inform the family” and “for discharge planning” were checked. In the next section the instructions explained that certain information related to sexually transmitted infections and treatment for alcohol and drug abuse have additional state and federal protections and asked if the patient would like this information released. The form was answered as “yes” indicating the patient would allow the release of information about alcohol, drug, or substance abuse and mental health records and the patient answered “no” to the release of HIV testing results. The section titled “Disclosure Format and Signature” revealed a format was not selected from the choices of paper, US mail, Fax, or other. The form was then signed and dated by the patient. Review of Patient #1’s medical record revealed Patient #1 was admitted on 09/14/2025 for Psychosis. A psychosocial assessment was done on 09/15/2025 at 3:15 PM and revealed in part the following: Current Living Arrangements: lives with family. Who is in household? Grandparents. Support System Involvement: Patient #1 stated his grandparents provide strong support. Date of projected family session/meeting: Social Worker to contact family upon patient agreement/ROI and initiate collateral, family meeting and discharge planning on 09/16/2025. Projected Family Meeting Topics: additional collateral info, general patient care, and discharge planning. Where will patient go upon discharge? Grandparent’s home. How will the patient be transported home? Grandparent. Specify the community resources/support systems for utilization in discharge planning? Patient lives with Grandparent’s. They will provide. Family Involvement: Grandparents provide strong support with no challenges reported. Further review of the medical record for Patient #1 revealed the patient consented to have the hospital representative speak with his family member to assist with the discharge plan and aftercare. The consent was filled out for Patient #1 by S4CI on 09/15/2025 at 1:28 PM. In interview on 03/17/2026 at 3:15 PM, S4CI verified he was the staff member who filled in the form for Patient #1. S4CI verified that Patient #1 wanted his chosen family member involved in his discharge planning, but did not want that family member to have access to his record. S4CI also verified that Patient #1 did not want his medical record disclosed to the outpatient facility where he routinely received treatment. When S4CI was asked if he discussed with the family member the specifics of the discharge plan, S4CI verified that the family member would allow Patient #1 to return to the home and discussed with the family member about securing all weapons and medications in the home. S4CI verified he did not discuss details in the discharge plan like follow up and the medications Patient #1 would need to take. S4CI verified it was not his usual routine to discuss those details with the family, but preferred to tell family members that those details would be provided in the paperwork at discharge.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 48050 Based record reviews and interviews, the facility failed to ensure policies which restrict access to the use of patient information clearly defined the terms used by the facility to restrict or give access to medical records and patient information. The deficient practice is evidenced by failure to define the terms “release information to” and “exchange information with” used in the release of information consent. Findings: Review of the hospital’s policy #PM024 titled “Discharge Planning Process” last reviewed 01/2026 revealed in part: “II. PURPOSE: To provide the most therapeutic after care plan based on patient’s individualized needs. C. Discharge Process: 8. Family teaching and involvement are also important as family support will make a big difference after discharge. The family needs to know about the illness, treatment, and accomplishments. They also must be told that the illness is not static, what changes to look for, who to call for help, what medications the patient needs, and to whom the patient is being referred. 11. When making plans, the staff should consider the patient’s living situation, the patient’s physical limitations, transportation, and finances. 12. Staff should discuss with the patient and family to find out what happened after previous discharges. This may be helpful to identify potential areas where the patient may need help. For example, if medication compliance was a problem, find out how.” Review of the form for release of information for Patient #1 revealed the first section titled, “Patient Information and Authorization,” revealed the patient authorized “exchange information with” a named family member. In the next section, “Information Requested and Purpose/ Need of Disclosure,” the form revealed “patient denied” was documented for release of psychiatric evaluation, history and physical, medication records, laboratory results, immunization records, practitioner progress notes, discharge instructions, financial account information practitioner orders, treatment/ individualized service and complete medical record. The next area contained check boxes to indicate the purpose of need for disclosure and “to inform the family” and “for discharge planning” were checked. In the next section the instructions explained that certain information related to sexually transmitted infections and treatment for alcohol and drug abuse have additional state and federal protections and asks if the patient would like this information released. The form was answered as “yes” indicating the patient would allow the release of information about alcohol, drug, or substance abuse and mental health records and the patient answered “no” to the release of HIV testing results. The section titled “Disclosure Format and Signature” revealed a format was not selected from the choices of paper, US mail, Fax, or other. The form was then signed and dated by the patient. During the review of records on 03/17/2026 between 12:40 PM and 3:40 PM navigated by S2DOR, a discussion was initiated about what Patient #1 actually wanted released and how the facility defined the terms “release information to” and “exchange information with.” S2DOR verified that based on the information documented on the form, she was unable to determine what information Patient #1 wanted disclosed and deferred to S3DCS. In interview on 03/17/2026 at 2:56 PM, S3DCS revealed that it would have been the job of the primary social worker to discuss the discharge plan with the family if the patient wanted the family to be involved in the discharge. At the time of this interview, the surveyor requested the facility search for policy that defined the terms “release information to” and “exchange information with” or explained how the document was to be filled out. In interview on 03/17/2026 at 3:15 PM, S4CI verified he was the staff member who filled in the form for Patient #1. S4CI verified that Patient #1 wanted his chosen family member involved in his discharge planning, but did not want that family member to have access to his record. S4CI also verified that Patient #1 did not want his medical record disclosed to the outpatient facility where he routinely received treatment. When S4CI was asked if he discussed with the family member the specifics of the discharge plan, S4CI verified that the family member would allow Patient #1 to return to the home and discussed with the family member about securing all weapons and medications in the home. S4CI verified he did not discuss details in the discharge plan like follow up and the medications Patient #1 would need to take. S4CI verified it was not his usual routine to discuss those details with the family, but preferred to tell family members that those details would be provided in the paperwork at discharge. In interview on 03/18/2026 at 11:10 AM, S1CEO once again addressed the confusion surrounding the form and how it was to be filled out and verified that she could not provide a policy. S1CEO explained exchange of information with box on the form indicates verbal conversations regarding patients’ information that they select and the release of information to box is after the patient has been discharged and documented information is sent to the person/entity that the patient has chosen.”

“DISCHARGE PLANNING - PAC PROVIDER DATA CFR(s): The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use on measures. The hospital must ensure that the post-acute care data on quality measures and data on resource measures is relevant and applicable to the patient’s goals and treatment preferences. This Standard is not met as evidenced by: 48050 Based on record reviews and interviews, the facility failed to document the assistance provided to patients choosing post-acute care was based on patient treatment preference and quality data in 1 (#2) of 3 reviewed patient records. Findings: Review of Patient #2’s medical record revealed Patient #2 was admitted on 09/12/2025 for Psychosis, Bipolar Disorder, and Alcohol Abuse and discharged on 09/19/2025. On 09/17/2025 at 9:05 AM it was documented in the psychiatric progress notes that Patient #2 specifically request to go to Facility A. On 09/18/2025 10:31 AM it was documented in the psychiatric progress notes that Patient #2 continues to request Facility A upon discharge. Further review of the Patient #2’s medical record revealed Discharge Care Plan and Home Medications done by S4C1 on 09/17/2025 at 2:53 PM documented Patient #2 is being discharged to Facility B. In an interview on 03/18/2026 at 10:32 AM, S2DOR verified the above information. S2DOR also confirmed there were no social worker progress notes related to how Facility B was picked or if patient had a preference.”

“Treatment Plan - Adequate Documentation CFR(s): [The written plan must include] Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out. This Standard is not met as evidenced by: 48050 Based on record reviews and interviews, the facility failed to ensure nursing staff provided documentation to verify rehabilitation activities were carried out and treatment goals were met in 3 of 3 (#1-#3) reviewed records of discharged patients. Findings: Review of the hospital’s policy #PM032 titled, “Interdisciplinary Treated Process” revealed in part: “POLICY: Each patient’s treatment shall be guided by the Interdisciplinary Treatment Plan (ITP). The treatment plan is the tool used by the physician and interdisciplinary treatment team to implement the physician ordered services and move the patient toward the expected outcomes and goals. 4. Guidelines of the Interdisciplinary Treatment Plans: a. The Interdisciplinary Treatment Plan shall be an accurate and functional representation of the patient’s treatment experience. c. The Interdisciplinary Treatment Plan shall identify goals related to each problem. i. Goals are based upon the assessments and are realistic, relevant, measurable, individualized, and consistent with the therapy prescribed by the psychiatrist and medical practitioner. ii. Goals identify what the patient is expected to accomplish in treatment. iii. Treatment plan goals shall be modified and resolved as treatment progresses. iv. Interventions shall be modified by responsible staff throughout the course of treatment. e. Treatment plan updates shall be documented at least weekly, as the physician and treatment team assess the patient’s current clinical status, review progress toward treatment goals, and make necessary modifications. G. A review of the patient’s Interdisciplinary Treatment Plan following any major clinical change shall be conducted, and appropriate modifications made.” Review of Patient #1’s medical record revealed plan of care initiated on 09/15/2025 with the following problems identified: disturbed thought as evidenced by AEB, altered comfort/activity intolerance related to acute pain as evidenced by medication regimen of Motrin, and altered sleep pattern related to difficulty falling asleep as evidence by medication regimen of Trazadone. Patient #1’s plan of care also consisted of short-term/long-term goals and interventions. Further review of Patient #1’s plan of care revealed all short-term goals, and long-term goals were met on Patient #1’s discharge date of 09/21/2025. Review of Patient #1’s medical record revealed psychiatric progress notes dated 09/20/2025 revealed response to treatment: has achieved some treatment goals, but still in process and reason for continued hospitalization/treatment: discharge may exacerbate illness, medication stabilization, and behavior requires 24 hour supervision. In an interview on 03/18/2025 at 1:20 PM, S9NP verified Patient #1’s thoughts were fixed, but not harmful. S9NP states Patient #1 was improving, but not all goals were met at discharge. S9NP also confirmed that she wrote the discharge order for Patient #1, but did not participate in Patient #1’s IDT meetings. Review of Patient #2’s medical record revealed plan of care initiated on 09/13/2025 with the following problems identified: disturbed thought related to paranoia, auditory hallucinations, substance abuse related to alcohol, altered tissue perfusion related to hypertension, impaired skin integrity related to abrasion head, potential for injury related to fall, risk for altered psychological wellbeing related to acute withdrawals, and altered nutrition related nausea, vomiting. Patient #2’s plan of care also consisted of short-term/long-term goals with interventions. Further review of Patient #2’s plan of care revealed all short-term goals, and long-term goals were met on Patient #2’s discharge date of 09/19/2025. Review of Patient #2’s medical record revealed psychiatric progress notes dated 09/18/2025 revealed response to treatment: has achieved some treatment goals, but still in process and reason for continued hospitalization/treatment: discharge may exacerbate illness, severely impaired disorder-thoughts/perception, danger to self and others, post-acute detox symptoms, medication stabilization, and behavior requires 24 hour supervision. Review of Patient #3’s medical record revealed plan of care initiated on 09/16/2025 with the following problems identified: depressed mood with psychosis, altered nutrition related to vitamin deficiency, altered sleep pattern related to insomnia, and risk for altered psychological wellbeing related to acute withdrawals. Patient #3’s also consisted of short-term/long-term goals with interventions. Further review of Patient #3’s plan of care revealed all short-term goals, and long-term goals were met on Patient #3’s discharge date of 09/23/2025. Review of Patient #3’s medical record revealed psychiatric progress notes dated 09/22/2025 revealed response to treatment: has achieved some treatment goals, but still in process and reason for continued hospitalization/treatment: discharge may exacerbate illness, severe depression/anxiety, medication stabilization, and behavior requires 24 hour supervision. In interview on 03/18/2026 at 11:35 AM, S3DOR verified the above mentioned information. An interview on 03/18/2025 at 11:50 AM, S6CNRN verified normal practice related to patients’ plan of care is to document short-term/long-term goals are met when patients are discharged. S6CNRN further stated that patients’ charts are not reviewed to verify if the goals are actually met at discharge.”

“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: 48050 Based on record review and interviews, the hospital failed to ensure a patient complaint of alleged sexual harassment was recognized as a grievance. This deficient practice was evidenced by failing to correctly identify a patient grievance for 1 (#1) of 3 (#1-#3) patients reviewed for complaints/grievances. Findings: Review of the hospital’s policy number RM-038 titled “Patient Grievance” last reviewed on 02/2024 revealed in part: POLICY: the facility will provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to our patients. All patient grievances will be investigated and the results of the investigation reported back to the complainant. DEFINITION: A patient grievance (as defined by Centers of Medicare & Medicaid Services, ref. 482.13(a)(2)) is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), Medicare beneficiary billing complaint related to rights and limitations by 42CRF489. Any reported grievance by patients, families, staff and/or visitors that directly relate to patient neglect or abuse will be forwarded to the Administrator On-Call IMMEDIATELY for review. Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: “11. Facility Investigation (Administrative Review) and Final Investigative Report: In accordance with regulations, facilities are directed to process an allegation of abuse or neglect as a grievance in accordance with facility Grievance Processes and Abuse/Neglect policies. In accordance with §482.13, an allegation of abuse/neglect is to be treated as a grievance even if the complainant recants or indicates that the issue is resolved. A written response must be issued to the reporting patient or patient’s representative. In many cases, the presentation of an abuse investigation handled in this manner will satisfy surveyor reviews related to the manner in which a facility processes grievances.” Review of Patient #1’s medical record revealed Patient #1 was admitted on 11/22/2024 Major Depressive Disorder. On 11/28/2024 the nurse documents the following: “Patient compliant with meds; participates with group. Patient stated that she was being sexually harassed by other male patients and this is the reason she was so anxious and uncomfortable because she is a rape survivor. I informed the nurse supervisor of her complaint”. In an interview on 08/05/2025 at 3:25 PM, S1ADM stated that the facility has not had any documented grievances/complaints logged since November 2024 regarding Patient #1. S1ADM also reported when the facility became aware of possible sexual harassment of Patient #1, is was not treated as a grievance and was not self-reported to LDH.”

“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 recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to identify and investigate potential allegations of abuse by a patient. Findings: Review of the hospital’s policy number NU207 titled “Patient and Family Rights” last reviewed on 02/2025 revealed in part: I. POLICY: The facility protects and promotes each patient’s rights according to LAC 48:1 Chapter 9319 Patient Rights and Privacy. Every patient shall have the following rights, none of which shall be abridged by the hospital or any of its staff. The hospital administrator shall be responsible for developing and implementing policies to protect patient rights and to respond to questions and grievances pertaining to patient rights. Patients and families area advised of the following rights upon admission to the facility: 17. The right to be free from all forms of abuse and harassment. 18. The right to receive care in a safe setting. Review of the hospital’s policy number HR.014 titled “Sexual and Unlawful Harassment” last reviewed on 02/2025 revealed in part: III. PROCEDURE: A. the hospital is committed to maintaining an environment that is free of sexual and unlawful harassment and has zero tolerance for this type of behavior. F. Management’s responsibility will be as follows: 1. All management personnel are expected to be alert to the possible presence of sexual harassment in the work place, to take appropriate measures to prevent incidents from occurring, and to initiate action immediately in the event incidents occur. G. General Guidelines: 2. All complaints, incidents, or practices will be investigated promptly examined impartially and resolved by the hospital as promptly as possible. The events surrounding the investigation and the outcome will be documented and kept confidential. Review of Patient #1’s medical record revealed Patient #1 was admitted on 11/22/2024 Major Depressive Disorder. On 11/28/2024 the nurse documents the following: “Patient compliant with meds; participates with group. Patient stated that she was being sexually harassed by other male patients and this is the reason she was so anxious and uncomfortable because she is a rape survivor. I informed the nurse supervisor of her complaint”. S1ADM presented a letter from Sexual Trauma Awareness & Response (STAR) dated 02/24/2025 and received by the facility on 03/2025 which revealed in part the following: This letter is in behalf of Patient #1 regarding the sexual harassment incident experienced during her hospitalization in November 2024. We have already received Patient #1’s medical records; however, the records include only one brief notation that the incident was reported by Patient #1 to the nurse on duty, who subsequently reported to the supervising nurse on duty. In order to fully understand the hospital’s response and any subsequent actions taken, we respectfully request copies of any and all internal documentation related to the this incident. On 08/05/2025 between 3:25 PM to 3:45 PM, an interview was conducted with S1ADM. S1ADM revealed the hospital became aware Patient #1’s allegations of sexual harassment when the hospital received the letter from STAR. Further review of Patient #1’s medical record revealed a nurse note dated 11/28/2025 that documented Patient #1’s complaint and that it was reported to the nursing supervisor. S1ADM reported she interviewed the supervisor who stated she didn’t remember being told about patient #1’s complaint. S1ADM admits to not interviewing the nurse who documented Patient #1’s complaint of sexual harassment, but educated the nursing staff in a team meeting on 04/07/2025 regarding incidents that should be reported immediately to nursing supervisors. S1ADM verified the facility had no documentation to prove a thorough investigation was performed after learning of the allegation. On 08/07/2025 between 8:35 AM to 8:40 AM an interview was conducted with S5RN who stated that she doesn’t remember the incident with Patient #1, but stands by her documentation in Patient #1’s medical record dated 11/28/2024. On 08/07/2025 between 9:35 AM to 9:45 AM an interview was conducted with S4SRN who stated that she doesn’t remember the incident with Patient #1 on 11/28/2025. On 08/07/2025 between 10:55 AM to 11:05 AM an interview was conducted with S6NP who stated that she remembers Patient #1, but doesn’t remember any complaints by Patient #1 that she experienced any sexual harassment while hospitalized.”

“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 each patient’s right to receive care in a safe setting. The deficient practice was evidenced by: 1) failure to ensure hypersexual Patient #1 was in a safe setting by failure to ensure Patient #2 was unable enter her room unseen by staff; and 2) failure to maintain a safe outdoor recreation environment as evidenced by a detached picket fence from its stringer with two nails partially removed exposing the sharp ends posing a potential risk of injury. Findings: Review of psychiatric hospital’s policy# NU 207, titled “Patient and Family Rights”, revised on 05/17/2017, revealed in part: Policy, in part: “18. The right to receive care in a safe setting.” 1) Failure to ensure hypersexual Patient #1 was in a safe setting by failure to ensure Patient #2 was unable enter her room unseen by staff. Review of psychiatric policy# NU 432 titled, “Levels of Observation”, revised on 11/2024, revealed in part: “66. Q 15 Minute Observations, in part: iii. Remain vigilant for specific risks for patients on Special Precautions.” BHA Conducting Observations, in part: Staff completing observations will not be responsible for other duties but may assist with patient needs as long as it doesn’t delay observations. Monitoring, in part: 2. Monitoring for compliance with observations will be a continuous, ongoing process. For safety and quality improvement purposes, this will be conducted In-Person and/or via Video Review. It is preferable that Video Review be done at least monthly for ALL shifts. Review of psychiatric policy# NU 432A titled, “Precautions: Fall, Seizure, Elopement, Suicide, Aggression, Withdrawal, Cheeking, and Sexual”, revised on 11/2024, revealed in part: E. Sexually Acting out Precautions (SAO)2. Factors that may indicate a risk of sexually acting out, inpart: Prior sexual acting out. 4. Staff interventions may include, in part: Increase level of observation for severe or repeated behaviors to reduce impulsivity. Review of Patient #1’s medical record revealed and admission date of 01/30/2025, with a history of depression and anxiety. Patient ran away from school and got into trouble for hypersexual behaviors, attempting to give oral sex to multiple peers at school. Has a history of cutting herself around twice a month. Patient #1 with a history of being bullied at school and PTSD due to suffering a gunshot wound less than 30 days ago during a drive by shooting. Review of document titled “Hospital / Licensed Provider Abuse/Neglect Initial Report” dated 02/11/2025 revealed an incident that occurred on 02/04/2025 at 9:40 PM. S11BHA entered Patient #1’s room while performing Q 5 minute rounds. S11BHA’s electronic observation tablet detected a signal from 2 beacons coming from the bathroom. S11BHA heard noises in the bathroom. She opened the bathroom door to find Patient #2 (12 y/o) lying on the ground with his pants down and Patient #1 (14 y/o) on top of him with her pants down and her bra open. The two appeared to be attempting to have intercourse. S11BHA immediately separated the patients. Further review revealed Patient #2 had been restless around 9:25 PM after having punched a wall earlier in the night (7:00 PM). Around 9:35 PM, he was allowed to help the technicians clean and reset the day room after bedtime to help him calm down. The report indicated Patient #2 did not have a history of sexually acting out. Patient #1 had a history of sexually acting out prior to admission to the facility, therefore was placed on Sexually Acting Out Precautions and Q5 minute observations upon admission. Review of nursing note dated 02/05/2025 at 3:46 AM revealed around 9:35 PM Patient #2 was allowed to help the technicians clean and reset the day room after bedtime to help him calm down. According to Patient #2’s own statement, he was helping to sweep the floor. He walked across the unit to empty the dustpan. His path took him past Patient #1’s room and he entered the room after which Patient #2 asked Patient #1 to go in the bathroom with him. Review of Patient #1’s observation sheets dated 02/04/2025 revealed observation level from 12:00 AM to 10:42 PM was every 5 minutes. Precautions: assault, blocked room, elopement, restrict to unit, sexually acting out and moderate suicide risk/precaution. Continued review revealed the following: 9:30 PM-S12BHA-documented patient was in her bedroom asleep. 9:34 PM-S11BHA-documented patient was in her bedroom asleep. 9:40 PM-S11BHA-documented patient was in her bedroom asleep. 9:46 PM-S11BHA-documented patient was in her bedroom asleep. 9:50 PM-S11BHA-documented patient was in her bedroom asleep. 9:54 PM-S11BHA-documented patient was in her bedroom asleep. 9:55 PM-S11BHA-documented patient was in her bedroom asleep. 10:00 PM-11:56 PM-S11BHA, S12BHA, and S16BHA. Review of Patient #2’s observation sheets dated 02/04/2025 revealed observation level from 12:00 AM to 11:48 PM was every 15 minutes. Precautions: Suicide Precautions, Suicide Risk-Low. Continued review revealed the following: 9:21 PM-S12BHA-documented patient was in the dayroom Assaultive / Destructive. 9:31 PM-S12BHA-documented patient was in the dayroom Assaultive / Destructive. 9:46 PM-S11BHA-documented patient was in the dayroom Assaultive / Destructive. 10:00 PM-S11BHA-documented patient was in the dayroom Assaultive / Destructive. 10:13 PM- S11BHA-documented patient was in the dayroom Assaultive / Destructive. 10:25 PM-11:48 PM-S11BHA and S12BHA-documented patient was in his bedroom calm. Review of psychiatric hospital’s document titled “Shift Assignment Sheet” dated 02/04/2025 for Unit a, 7 PM shift, revealed D11BHA, S13BHA, S20BHA, S21BHA and S22BHA. The assignment sheet listed only Patient #R1 who was on 1:1 assigned to S21BHA and S13BHA. Review of untitled psychiatric document dated 02/04/2025 for Unit a, 7P-7A shift, revealed S10BHA, S11BHA, S12BHA, and S16BHA (orientation). The document listed S10BHA on a 1:1 with Patient #R2 starting at 11:00 PM; D11BHA on a 1:1 with Patient #R2 until 11:00 PM; S16BHA on a 1:1 with Patient #1 at 10:30 PM. Observation of Unit a on 03/10/2025 at 9:00 AM revealed an open floor plan where all of the patient rooms opened up into the large dayroom from each side. The nurses station was centrally located overlooking the dayroom. During an interview on 03/12/2024 at 12:34 PM, S1ADM stated there was no policy on separating the boys and girls on the adolescent units. During an interview on 03/12/2025 at 2:45 PM, S2DOR stated that S12BHA was cleaning up the dayroom after dinner around 9:30 PM and gave Patient #2 a broom and dust pan to help with the cleanup. He did not see Patient #2 put down the broom and go into Patient #1’s room. S2DOR did not know why the nurse did not notice Patient #2 go into Patient #1’s room but thought the nurse could not view Patient #1’s room from the nursing station. S2DOR did not know why S11BHA was rounding when, according to the assignment sheet, she was supposed to be on 1:1 with Patient #R2. S2DOR was unable to say why S11BHA documented Patient #1 was sleeping in her bedroom at the time of the incident when the incident report stated she was in her bathroom with Patient #2. She was unable to say why S12BHA documented Patient #2 was in the dayroom “Assaultive/destructive” and was not being observed when he walked into patient #1’s room at around 9:40 PM. During an interview on 03/12/2025 at 12:34 PM, S1ADM stated the psychiatric hospital began using electronic monitoring system in December 2023. S1ADM verified the hospital did not have policies and procedures regarding the use of electronic monitoring system A and staff expectations for the following: -hand-offs of tablet/assignments between technicians using electronic monitoring system A. -when staff are unable to sign-in to the electronic monitoring system A to prevent delay in observations. - signal loss or beacon loss. - logging in to the electronic monitoring system using another staff’s name. -“forced” entries and the process to prevent them. -compliance rate -proximity of electronic monitoring system A to patient. -Registered Nurse observation rounds using electronic monitoring system A. -process for the assignment of patients to staff using the electronic monitoring system A. During an interview on 03/10/2025 at 12:15 PM, S1ADM confirmed the Shift Assignment Sheets did not list the names of the patients that are on 1:1 observations with an assigned BHA. She indicated the patients on 1:1 should be listed next to the asigned BHA on the assignment sheet. S1ADM verified that none of the patients were listed on the Shift Assignment Sheets because all of the staff monitor all of the patients. During an interview on 03/12/2025 at 3:07 PM S18RNS indicated the assignment sheets did not agree with the observation sheets. S18RNS confirmed she was unable to determine the staff who were on 1:1 and the staff who were doing rounds. During an interview on 03/12/2025 at 3:35 PM, S1ADM confirmed there is no video footage available to review because there are no cameras in the hospital except in the seclusion rooms. 2) Failure to maintain a safe outdoor recreation environment as evidenced by a detached picket fence from its stringer with two nails partially removed exposing the sharp ends posing a potential risk of injury. On 03/12/2025 at 4:39 PM, observations of the outdoor recreation area located near Units a and b revealed a detached picket fence from its stringer with two nails partially removed exposing the sharp ends posing a potential risk of injury. During an interview on 03/12/2025 at 4:39 PM, S15 confirmed the detached picket fence from its stringer with two nails partially removed exposing the sharp ends posed a potential risk of injury to any patients that were in the recreation area and stated she would take a picture and have it repaired as soon as possible.”

“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 48050 Based on record review and interview the hospital failed to protect patients from abuse and neglect. The deficient practice is evidenced by: 1) failure implement disciplinary actions per hospital policy regarding observations; 2) failure of Registered Nurses to make observation rounds per psychiatric hospital policy 5 (#1,#2,#4, #5, and #6) of 6 (#1-#6) patient records reviewed.; and 3) failure of staff to follow physician orders for observation levels in 3 (#2, #4, #5) of 6 (#1-#6) patient observation sheets reviewed. Findings: 1) Failure implement disciplinary actions per hospital policy regarding observations Review of hospital policy titled “Progressive Discipline” last reviewed 01/2024 revealed in part: POLICY: It is the expectation that employees conduct themselves in a professional manner at all times adhering to all standards and polices set forth by the company. Employees should act with due regard to the facility, fellow employees, and patients. If the need arises for management to address an employee’s performance, conduct, or attendance issues; management may choose a disciplinary action plan. Disciplinary action may include one of more of the following: Counseling, verbal or written warnings, suspension or termination. The course of action taken may depend on the number and frequency of past violations and the seriousness of the offense. COACHING: Supervisors are expected to regularly communicate with their employees regarding work expectations and performance matters. This may include coaching with an employee when a specific performance or conduct issue is identified in order to provide direction for necessary and successful correction. STEP 1: VERBAL COUNSELING: A verbal counseling should be given for minor infractions or to address performance deficiencies when coaching has not resolved the issue. STEP 2: WRITTEN WARNING: Written warnings will be issued for repeated conduct and performance issues that persist after a verbal counseling or if the behavior involves a more serious violation of policy or deficiency in performance. Review of S11BHA personnel file revealed the following coaching forms: 1) A coaching form dated 11/15/2024 indicated S11BHA didn’t start observation rounds on a patient that was admitted on 11/13/2024 at 9:50 PM until 10:48 PM. 2) A coaching form dated 12/10/2024 indicated S11BHA is below expectations on compliance with Q5 minute observations being done to over 7 minute intervals on the ObservSmart report. 3) A coaching form dated 2/13/2025 indicated S11BHA conducted rounds on a patient, but failed to change the behavior and location within ObservSmart system. On 03/11/2025 at 11:30 AM S19HR verified S11BHA three coaching forms were all related to the same issues and should have been advanced per hospital disciplinary policy. 2) Failure of the registered nurses to make observations rounds per psychiatric hospital policy in 5 (#1,#2, #4, #5, and #6) of 6 (#1-#6) patient records reviewed. Review of psychiatric policy# NU 432 titled, “Levels of Observation”, revised on 11/2024, revealed in part: “Charge RN/RN Designee, in part: The Charge RN/RN Designee should observation at least once per 8-hour shift (twice per 12-hour shift) to assess the general safety of the unit/milieu and to check in with the team member assigned to observations to provide an additional opportunity for the assigned team member to report on safety concerns. Each RN is responsible for general oversight of the safety observations on his/her assigned patients. Patient #1 Review of medical record revealed admission date of 01/30/2025 and discharge date 02/05/2025. Review of observation sheets dated 01/31/2025-02/05/2025 revealed a registered nurse made observation rounds on Patient #1 on the following dates and times: -02/02/2025 at 1:14 PM, 1:15 PM, 1:20 PM, 1:27 PM, 1:32 PM, 1:45 PM, 3:03 PM, 3:17 PM, 3:22 PM, 3:26 PM, 3:35 PM, 3:40 PM and 3:49 PM. -02/05/2025 at 1:00 PM. Review of observations sheets dated 01/31/2025-02/05/2025 failed to reveal a registered nurse made observation rounds on Patient #1 on the following dates: 01/31/2025, 02/01/2025, 02/03/2025/ and 02/04/2025. Patient #2 Review of medical record revealed admission date of 01/29/2025 and discharge date of 02/07/2025. Review of observation sheets dated 01/29/2025-02/07/2025 revealed a registered nurse made observation rounds on Patient #2 on the following dates and times: -02/02/2025 at 1:15 PM Patient #3 Review of medical record revealed admission date of 10/24/2024 and discharge date 11/13/2024. Review of observation sheets dated 11/05/2024-11/13/2024 revealed a registered nurse made observation rounds on Patient #3 on the following dates and times: -11/05/2024 at 6:30 PM -11/06/2024 at 3:00 PM and 4:00 PM. -11/11/2024 at 7:15 AM Review of observations sheets dated 11/05/2024-11/13/2024 failed to reveal a registered nurse made observation rounds on Patient #3 on the following dates: 11/07/2024, 11/08/2024, 11/09/2024, 11/10/2024, 11/12/2024 and 11/13/2024. Patient #4 Review of medical record revealed Patient #4 was admitted on 11/06/2024 and discharged on 11/12/2024. Review of observation sheets dated 11/06/2024-11/12/2024 revealed a registered nurse made observation rounds on Patient #4 on the following dates and times: -11/08/2024 at 7:20 PM, 7:45 PM, 8:00 PM, 8:05 PM, 8:30 PM, 8:35, 8:45 PM, 11:10 PM, 11:25 PM, 11:345 PM, and 11:50 PM -11/09/2024 at 1:10 AM, 1:20 AM, 1:35 AM, 3:10 AM, 3:30 AM, 3:45 AM, 5:00 AM, 5:30 AM, 6:00 AM, 6:15AM, 6:40 AM, 8:10 PM, 8:45 PM, and 9:15 PM -11/10/2024 at 2:10 AM, 2:25 AM, 2:35 AM, 2:50 AM, and 3:05 AM -11/11/2024 at 7:25 AM, 7:40 AM, 7:50 AM, 8:15 AM, 8:55 AM, and 9:05 AM Patient #5 Review of medical record revealed admission date of 10/24/2024 and discharge date 11/15/2025. Review of observation sheets dated 10/26/2024-11/15/2024 revealed a registered nurse made observation rounds on Patient #5 on the following dates and times: -10/26/2024 at 8:00 PM -10/27/2024 at 6:15 PM and 6:30 PM -10/30/2024 at 10:15 AM and 10:30 AM -11/01/2024 at 2:45 PM, 4:45 PM, 5:00 PM, and 5:15 PM -11/10/2024 at 2:30 AM, 2:45 AM, and 3:00 AM -11/11/2024 at 7:30 AM, 7:45 AM, and 8:15 AM Review of observations sheets dated 11/05/2024-11/13/2024 failed to reveal a registered nurse made observation rounds on Patient #5 on the following dates: 10/28/2024, 10/29/2024, 10/31/2024, 11/02/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/12/2024, 11/13/2024, 11/14/2024, and 11/15/2024. Patient #6 Review of medical record revealed admission date of 02/15/2025 and was still admitted as of 03/12/2025. Review of observation sheets dated 02/15/2025-03/12/2025 revealed a registered nurse made observation rounds on Patient #6 on the following dates and times: -02/19/2025 at 3:13 PM, 3:14 PM, and 3:19 PM -02/21/2025 at 1:06 AM -02/22/2025 at 08:00 AM- 08:10 AM, 9:41 AM, 12:36 PM-1:24 PM -02/23/2025 at 10:40 PM-10:51 PM -02/28/2025 at 1:41 PM-2:11 PM -03/01/2025 at 11:19 PM -03/02/2025 at 11:38 AM-12:20 PM, 9:13 PM -03/03/2025 at 12:55 AM-12:59 AM. -03/04/2025 at 7:19 AM and 5:09 PM-5:18 PM. -03/05/2025 at 2:03 AM and 3:50 PM -03/09/2025 at 2:30 PM-2:35 PM -03/10/2025 at 7:28 AM and 2:01 PM -03/11/2025 at 10:30 PM -03/12/2025 at 12:08 AM-12:45 AM, 8:52 AM, 3:17 PM, 3:19 PM, 3:20 PM, 3:43 PM, and 3:49 PM. Review of observations sheets dated 02/15/2025-03/12/2025 failed to reveal a registered nurse made observation rounds on Patient #6 on the following dates: 02/15/2025, 02/16/2025, 02/17/2025, 02/18/2025, 02/20/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, 03/06/2025, 03/07/2025, and 03/08/2025 During an interview on 03/11/2025 at 4:28 PM., S23DON verified the observation sheets fail to reveal the registered nurses are making observation rounds per hospital policy. During an interview on 3/12/2025 at 12:24 PM, S1ADM verified the hospital did not have policies and procedures regarding Registered Nurse observation rounds using electronic monitoring system A. During an interview on 03/12/2025 at 1:25 PM, S2DOR reported S23DON was concerned that the registered nurses were not documenting nursing rounds in the patients’ medical records. 3) Failure of staff to follow physician orders for observation levels in 3 (#2, #4, #5) of 6 (#1-#6) patient observation sheets reviewed. Patient #2 Review of medical record revealed Patient #2 was admtted on 01/29/2025 and discharged on 02/07/2025. Orders entered on 01/29/2025 at 12:50 PM revealed observtions every 15 minutes. Further review of Patient #2’s observation sheetsp revealed greater than every 15 minutes rounding on the following dates and times: -01/31/2025 rounding was done at 5:44 PM then agian at 6:03 PM -02/02/2025 rounding was done at 5:27 AM then again at 5:43 AM -02/02/2025 rounding was done at 9:56 AM then again at 10:12 AM -02/02/2025 rounding was done at 11:52 AM then again at 12:09 PM -02/02/2025 rounding was done at 1:38 PM then again at 1:55 PM -02/02/2025 rounding was done at 7:34 PM then again at 8:00 PM -02/03/2025 rounding was done at 7:18 AM then again at 7:37 AM -02/04/2025 rounding was done at 3:45 PM then again at 4:03 PM -02/04/2025 rounding was done at 5:17 PM then again at 5:34 PM Orders entered on 02/04/2025 at 10:30 PM revealed observations were to be performed every 5 minutes. Further review on Patient #2’s observation sheets revealed rounding was done in intervals greater than every 5 minutes on 02/06/2025, with rounding performed at 5:08 PM then again at 7:27 PM Patient #4 Review of medical record revealed Patient #4 was admitted on 11/06/2024 and discharged on 11/12/2024. Orders entered on 11/06/2024 revealed observations were to be performed every 5 minutes. Review of observation sheet dated 11/06/2024 failed to reveal observations occured every 5 minutes between 1:30 PM and 10:15 PM as ordered. Further review of the observation sheet dated 11/06/2025 revealed rounding occured every 15 minutes between 1:30 PM and 10:15 PM. During an interview on 03/12/2024 at 1:45 PM, S17CD confirmed the above findings. Patient #5 Review of medical record revealed Patient #5 was admitted on 10/24/2024 and discharged 11/15/2024. Orders entered on 10/24/2024 revealed observations were to be performed every 15 minutes. Review of observation sheet dated 11/03/2025 failed to reveal observations occurred between 5:30 PM and 6:30 PM. During an interview on 03/12/2025 at 10:35 AM, S2DOR confirmed the above findings.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to measure, analyze, track and report adverse patient events in 2 (#3 and #4) of 6 (#1-#6) patients involved in patient-to-patient physical and sexual abuse involving adolescents. Findings: Review of psychiatric hospital’s policy# NU 206, titled “Patient Abuse and/or Neglect”, reviewed on 02/2024, revealed in part: “I. A. It is the policy of Covington Behavioral Health, in accordance with state and federal law, that suspected cases of abuse and/or neglect will be reported to the appropriate protective services agency.” Patient #3 Review of medical record revealed Patient #3 was admitted on 11/05/2024 with a long history of anxiety, depression and ADHD and attempted suicide by bashing her head into the wall 10 times in an attempt to kill herself. Patient reported having suicidal thoughts of drowning and cutting herself. Patient struggled with her sexual identity and was bullied in school. Review of document titled “Incident Report Form”, dated 11/11/2024, revealed on 11/11/2024 at 7:50 PM Patient #3 notified the nurses that during rest time she was napping in her room when she felt her roommate, Patient #4, touch her side and then reach for her pelvic area. Patient #3 then fully awakened and sat up, stopping the incident. Patient #3 was moved to another room with a peer she identified as supportive. Patient #4 was placed on 1:1 observation and the provider and parents were notified. Further review of psychiatric hospital documents failed to reveal the incident was further investigated, analyzed and reported to the appropriate protective services agency. In an interview on 03/11/2025 at 2:15 PM, S2DOR confirmed the incident had not been investigated or reported as per hospital policy. Patient #4 Review of Patient #4’s medical record revealed Patient #4 was accused of touching another patient inappropriately then a male patient physically assaulted Patient #4 by hitting her in the face. An interview on 03/12/2025 at 2:15 PM, S17CD confirmed the incident of physical assault had not been investigated or reported as per hospital policy. 48050”

“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 48050 Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by failure to notify MD and document an assessment following patient-to-patient abuse causing an injury. Findings: Review of Patient #4’s medical record revealed a nursing note documented on 11/11/2024 at 11:36 PM revealing the following: 7:50 PM- staff notified by the roommate of Patient #4, that while she was taking a nap during shift change, Patient #4 touched her on her side and then “tried to touch me in my pelvic area.” 7:55 PM- Patient #4 was asked about the incident and became anxious responded only “it was an accident, it was an accident.” Patient #4 didn’t clarify further, but remained anxious and agitated- difficult to calm. 8:09 PM- NP notified 8:13 PM- Patient #4 placed on 1:1 precautions While the RN was obtaining orders and assigning 1:1 the roommate that alleged she was touched by Patient #4 told other patients on the unit about the incident. A male patient became angry and ran into the Patient #4’s room hitting Patient #4 in the face before he could be stopped by staff. Staff separated patients, and a staff member remained 1:1 with Patient #4 at bedside. The male patient who was the aggressor was placed on assault precautions and received Zyprexa 5mg IM and Benadryl 50mg IM. 10:38 PM- Patient #4’s mother notified. Review of Patient #4’s medical record failed to reveal nursing documentation that the provider was notified of assault by another patient which resulted in being hit in the face. An interview on 03/12/2025 at 2:15 PM, S17CD verified there is no documentation that staff reported the assault agianst Patient #4 by a male patient resulting in Patient #4 being hit in the face. S17CD also verified there was no incident report completed for Patient #4 being hit by male patient.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This deficient practice is evidenced by failure to ensure an Registered Nurse made all patient care assignments. Findings: Review of psychiatric hospital policy# NU 432 titled, “Levels of Observation”, revised on 11/2024, revealed in part: “Charge RN/RN Designee, in part: Assignment for Observations will be done by the charge RN/RN Designee. The assignment sheet will reflect the time period and team members assigned to that time-period. Any changes made during the shift should be indicated on the assignment sheet accordingly. Review of psychiatric hospital policy# NU 401 titled, “Assignment of Patient Care”, reviewed on 02/2024, revealed in part: “I. Policy, in part: The DON/designee will assign patient care to appropriate staff members. II. Purpose: To define the policy for providing nursing staff assignment to meet he nursing care needs of patients. E., in part: Adjustments in the level of staffing are made based on the daily needs as determined by the ongoing assessment of the patient population treatment needs acuity and safety requirements. This assessment will occur every 4 hours and prn by the DON/designee. The daily adjustment process is the reasonability of the Director of Nursing or designee to ensure accurate staffing in relation to acuity of the unit. Review of psychiatric hospital policy# NU 401 titled, “Assignment of Nursing Staff”, reviewed on 02/2024, revealed in part: “Procedures: 1. Staffing assignments reflective of this policy will be completed at the beginning of each shift by the Charge Nurse. 2. Staffing assignments will be documented on the Staffing Assignment Sheet. 3. The name and title of the staff member to be assigned will be entered in the space provided. 4. The names of the patients assigned to the staff member will be entered in the space provided. Review of psychiatric hospital policy# LD-015 titled, “Staffing Plan”, reviewed on 08/2024, revealed in part: “Core Coverage, in part: C. When assigning the patient/staff ratio, the charge nurse or designee will consider the abilities and competencies of all nursing staff personnel. The charge nurse or designee will modify the patient/staff ratio as deemed necessary according to the current patient acuity and / or patient volume. Staffing Procedure For Inpatient Units: 1., in part: A Registered Nurse plans, assigns, supervises and evaluates the nursing care of each patient daily. On 03/10/2025 between 8:40 AM-9:28 AM, a tour of the psychiatric hospital, guided by S23DON and S24PCNO, revealed the following: Observation of Unit c at 8:50 AM revealed an adult unit. S25RN was the charge nurse. A review of the Shift Assignment Sheet revealed it was not completed. S25RN began to complete the Shift Assignment Sheet while surveyor on unit. S25RN completed the Shift Assignment Sheet at 8:52 AM. Of note, the completed Shift Assignment Sheet did not reveal names of patients on the sheet. Only the names of the charge nurse, the med nurse and the two behavioral health associates. Observation of Unit d at 8:46 AM revealed an adult unit. S26RN was the charge nurse. A review of the Shift Assignment Sheet revealed it was incomplete. The assignments section listed the names of two Behavioral Health Associates but patient names were not listed. S26RN stated the assignments were completed by S27BHA. S26RN reported the Behavioral Health Associate would complete the assignments then S26RN approved the assignments and completed the rest. S26RN stated she had been busy on that morning and was unable to complete the Shift Assignment Sheet until 8:46 AM. Observation of Unit a at 9:04 AM revealed a co-ed adolescent unit. S27RN was the charge nurse. A review of the Shift Assignment Sheet revealed it was blank. S27RN carried the Shift Assignment Sheet from the nursing station to S29BHA for her to complete the assignments at 9:05 AM. Observation of Unit b at 9:20 AM revealed a co-ed adolescent, higher acuity and overflow unit recently opened in February 2025. S30RN was the charge nurse. A review of the Shift Assignment Sheet revealed the observation assignment section was blank. S30RN was in the process of preparing medications for patients and was unable to complete the assignment sheet while surveyor was on the unit. On 03/10/2025 between 8:40 AM-9:28 AM, S23DON and S24CPNO were present during these observations and confirmed the above findings. During an interview on 03/12/2025 at 3:07 PM, S18RNS confirmed the registered nurses should always complete the patient observation assignments and the Behavioral Health Associates should not complete the observation assignments.”

“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 48050 Based on record review and interview, the hospital nursing staff failed to administer medications in accordance with the accepted standards of practice. This deficient practice is evidenced by failure of the nursing staff to administer medications within the appropriate timeframe per physician order in 1 (#4) of 6 (#1-#3, #5, #6) patient medical records reviewed. Findings: Review of Patient #4’s medication administration record revealed the following order: Hydroxyzine Pamoate (Vistaril) 50mg by mouth every 6 hours, PRN Anxiety. Further review of Patient #4’s medication administration record revealed the following dates/times of administration: 11/07/2024 at 1:27 PM 11/07/2024 at 1:32 PM Review of Patient #4’s medical record failed to reveal nursing documentation that the provider was notified or that the provider approved the administration of the medication to be given early. In an interview on 03/12/2025 at 3:00 PM, S17CD confirmed the PRN medication was given early and not as prescribed by the provider. S17CD also verified that there was no documentation by the nurse that the provider approved them to administer the medication early. At this time S1ADM also confirmed that the medication above was administered within 5 minutes of each other and not within 6 hours as prescribed by the provider.”

“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 psychiatric hospital failed to ensure each patient had an individualized and comprehensive treatment plan for 4 (#1, #2, #3, #4) of 6 (#1-#6) treatment plans reviewed. This deficiency is evidenced by failure to include all medical and psychiatric diagnoses and updates, as part of an individualized and comprehensive treatment plan. Findings: Review of psychiatric hospital’s policy# PM 032, titled “Provision of Care, Treatment and Services”, revised on 05/17/2017, revealed in part: “Procedure, in part: 3. The treatment plan shall involve all clinical staff/disciplines who have contact with the patient and shall include (as a minimum): a. Problems and needs relevant to admission and discharge as identified in the various assessments, expressed in behavioral and descriptive terms; d. Problems, both physical and mental, that require therapeutic management f. Treatment modalities individualized in relation to patient’s needs; h. Evidence of patient’s involvement in formulation of the plan; 4. Guidelines for the Interdisciplinary Treatment plans: b. The treatment plan will also identify deferred problems with rational for not addressing the deferred proble. Patient #1 Review of Patient #1’s medical record revealed and admission date of 01/30/2025, with a history of depression and anxiety. Patient ran away from school and got into trouble for hypersexual behaviors, attempting to give oral sex to multiple peers at school. Has a history of cutting herself around twice a month. Patient #1 with a history of being bullied at school and PTSD due to suffering a gunshot wound less than 30 days ago during a drive by shooting. Review of document titled “Hospital / Licensed Provider Abuse/Neglect Initial Report” dated 01/31/2025, revealed Patient #1 was in a physical altercation on 01/31/2025 at approximately 3:10 PM that caused abrasions to both of her feet and she was placed on unit restrictions. Review of document titled “Hospital / Licensed Provider Abuse/Neglect Initial Report” dated 02/11/2025, revealed an incident that occurred on 02/04/2025 at 9:40 PM. S11BHA entered Patient #1’s room while performing Q 5 minute rounds. S11BHA’s electronic observation tablet detected a signal from 2 beacons coming from the bathroom. S11BHA heard noises in the bathroom. She opened the bathroom door to find Patient #2 (12 y/o) lying on the ground with his pants down and Patient #1 (14 y/o) on top of him with her pants down and her bra open. The two appeared to be attempting to have intercourse. S11BHA immediately separated the patients. Review of Patient #1’s psychiatric progress note dated 02/05/2025 revealed the following medication: Continue Prazosin 5 mg by mouth at bedtime to help with PTSD symptoms. Review of Patient #1’s treatment plan failed to reveal Active Psychiatric Problems related to PTSD (Post-Traumatic Stress Disorder). Further review failed to reveal the treatment plan was updated to include active problems related to the altercation with another patient that occurred on 01/31/2025. Additional review failed to reveal the treatment plan was updated to include active problems related to the sexual incident that occurred on 02/04/2025. During an interview on 03/11/2025 at 12:05 PM, S2DOR confirmed Patient #1’s treatment plan failed to reveal Active Psychiatric Problems related to PTSD, the altercation with another patient and the sexual incident. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 01/29/2025 for Depression with self-harm behavior. Nursing note dated 02/04/2025 at 11:00 PM documented at 9:40 PM Patient #2 was involved in a sexual incident with a female patient. Patient #2 was on Q15 minute observations at the time of the incident. Further review revealed a Nursing Note on 02/04/2025 at 7:00 PM Patient #4 caused self-harm by punching wall/door bruising his knuckles. Further review of Patient #2’s treatment plan revealed that Patient #2’s treatment plan was not updated with sexual precautions from sexual incident that occurred 02/04/2025 at 9:40 PM or updated when Patient #2 caused self-harm by punching wall/door bruising his knuckles on 02/04/2025 at 7:00 PM. In an interview on 03/11/2025 at 4:18 PM, S17CD verified the above information. Patient #3 Review of medical record revealed Patient #3 was admitted on 11/05/2024 with a long history of anxiety disorder, depression and ADHD (Attention Deficit hyperactivity Disorder) and attempted suicide by bashing her head into the wall 10 times in an attempt to kill herself. Patient reported having suicidal thoughts of drowning and cutting herself. Patient #3 struggled with her sexual identity and was bullied in school. Review of document titled “Incident Report Form”, dated 11/11/2024, revealed on 11/11/2024 at 7:50 PM, Patient #3 notified the nurses that during rest time she was napping in her room when she felt her roommate, Patient #4, touch her side and then reach for her pelvic area. Patient #3 then fully awakened and sat up, stopping the incident. Patient #3 was moved to another room with a peer she identified as supportive. Review of Patient #3’s physician orders revealed an order for Adderall 10 mg every day for treatment of ADHD. Further review revealed the Adderall was changed to extended release and increased to 15 mg every day to treat ADHD. Review of Patient #3’s treatment plan failed to reveal Active Psychiatric Problems related to ADHD and anxiety. Further review failed to reveal Active Psychiatric Problems related to the sexual abuse Patient #3 endured on 11/11/2024. During an interview on 03/12/2025 at 1:41 PM, S2DOR confirmed Patient #3’s treatment plan failed to reveal Active Psychiatric Problems related to ADHD, anxiety disorder and the sexual abuse that occurred on 11/11/2024. Patient #4 Review of Patient #4’s medical record revealed Patient #4 was admitted on 11/06/2024 12:59 PM with the following diagnosis Bipolar Disorder, ADHD, Depression, and Autism Disorder. Review of Patient #4’s treatment plan identifies the following psychiatric diagnoses: Bipolar disorder, Attention-Deficit Hyperactivity Disorder, Depression, and Autistic Disorder, but fails to address ADHD, Depression, and Autism on the treatment plan. In an interview on 03/12/2025 at 3:29 PM, S17CD verifies the information documented above. 48050”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 44495 Based on record review and interview the hospital failed to comply with mandated reporting of abuse and neglect. The deficient practice is evidenced by failure of the facility to notify the Louisiana Department of Health (LDH) within 24 hours in 6 of 10 reviewed incidents with possible abuse when local police were involved and/or in cases of patient to patient abuse when the involved parties were not injured. Findings: The surveyor reviewed 10 incidents documented between 11/10/2024 and 12/04/2024 described as “Patient Attacked Other Patient.” Of the 10 incidents, six involved one patient hitting another patient, one incident involved a patient kicking another patient, one involved a patient grabbing the face of another patient, one involved a thrown sock, and the last was threatening behavior. Of the six that involved closed fist hitting, only one was reported to Louisiana Department of Health as possible abuse or neglect. Review of the incident that occurred on 01/30/2024 and reported to LDH on 12/04/2024, revealed Patient #3 hit a nurse in the face twice. A second patient tried to defend the nurse, and began fighting with Patient #3 and “slammed him [Patient#3] to the ground.” Two Behavioral Health Assistants (BHA) immediately responded and code was initiated. After the fight, local police were called and after statements were taken, Patient #3 was taken to acute care for evaluation and then returned to the facility. There were two staff members who were also taken to acute care for evaluation with serious injuries, but they refused to press charges against the two patients. Review of the incident from 11/10/2024 at 6:45 PM revealed Patient #4 and Patient #5 were sharing a room and got into an argument. Patient #4 spit on Patient #5 and then Patient #5 hit Patient #4 on his ear and left middle back leaving redness. Patient #4 was given an ice pack and the patients were assigned separate rooms. The physician and both guardians were notified. Review of the incident from 11/11/2024 at 8:00 PM revealed Patient #6 ran into the room of Patient #7 and hit Patient #7 on the left side of the face. The patients were separated and first aid was provided to Patient #7. The practitioner was notified and Patient #6 received Zyprexa and Benadryl. The mother of Patient #7 was notified and attempts were made to contact the guardian of Patient #6. Review of the incidents from 11/13/2024 at 11:30 AM and 11/14/2024 at 6:03 PM revealed Patient #8 and Patient #9 exchanged punches to the face on two consecutive days. On 11/13/2024 Patient #9 hit Patient #8 in the face. On 11/14/2024 Patient #8 hit Patient #9 in the face and Patient #9 responded by hitting Patient #8 in the face. After both incidents the practitioner and both guardians were notified. Review of the incident from 12/04/2024 at 5:48 PM revealed Patient #10 hit Patient #11 in the nose with a closed fist. The 2 were separated and Patient #11 was evaluated and given pain medication. Patient #11 wanted to press charges and police were called. During the review on 12/11/2024 at 12:33 PM, S3DR verified she did not initially report the incident involving Patient #3 to LDH because the police were called and she understood if the police were involved, a report to the licensing authority was not necessary. S3DR verified the incident was only reported to Louisiana Department of Health after a grievance for abuse by staff was submitted on 12/03/2024 to the hospital about the event. The incident had been thoroughly investigated prior to receiving the grievance and the allegation of abuse by staff was not substantiated. S3DR also verified LDH was not notified of the incidents involving Patients #4-#11 because the patients involved were not seriously injured.”