Serenity Springs Specialty Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that all patients receive care in a safe setting. This was evidenced by 1) leaving an unresponsive patient unattended in the transport van and as a result, the patient fell out of the wheelchair (Patient #1) and 2) failing to have policies and procedures that addressed transportation and safety requirements for patients attending the IOP program and transported by the IOP van. Findings: Review of an incident report dated 11/06/2025 at 9:20 AM, completed by S2Transport, revealed in part that as S2Transport was pulling into the hospital parking lot, he noticed in the rear view mirror that Patient #1 was blinking fast and did not look right. S2Transport stopped the van and asked the patient if she was alright and the patient did not respond. S2Transport went to the back of the van to check on the patient and she was slumped down in her wheelchair. The report further stated that S2Transport tried to pull the patient up but could not and he then ran inside to get help. Review of an incident report dated 11/06/2025 at 9:20 AM, completed by S1DON, revealed in part that S1DON was called to the IOP transportation van by S2Transport. Upon entering van, Patient #1 was found in front of the wheelchair on butt slumped over on the van floor. The patient was unable to verbally respond. The patient was lifted up from the floor back into the wheelchair and 911 was called. The patient was later transported to the hospital per EMS. Review of the hospital and IOP policies and procedures revealed none that addressed the transportation requirements for patients attending the IOP program. There were no policies that addressed staffing requirements in the van or safety procedures in the transport van. On 02/05/2026 at 2:15 PM, interview with S2Transport revealed that he picked Patient #1 up from the nursing home on 11/06/2025. S2Transport stated that Patient #1 was in a wheelchair with a seatbelt buckled on her wheelchair. S2Transport stated that he was the only staff on the transport van and when he noticed that the patient was not responding, he pulled over at the hospital (next to the IOP) and went to the back of the van to check on the patient. He stated the patient was slumped over to the side of her wheelchair and he unbuckled her seatbelt to attempt to straighten her up in the wheelchair, but was unable to lift the patient. S2Transport stated he then left the patient unattended, and unbuckled, and ran inside the hospital to get help. On 02/05/2026 at 1:10 PM, interview with S1DON confirmed that she found Patient #1 sitting on her buttocks in front of her wheelchair on 11/06/2025, when requested by S2Transport to come to the van to check on the patient. S1DON stated that the patient was unresponsive and the seatbelt on the patient’s wheelchair was not buckled. When asked if an unresponsive patient should be left alone on the transportation van, S1DON stated no. S1DON further stated that the van drivers have cell phones that they can use for emergencies. When asked if there were any policies and procedures that addressed staffing on the transport van or safety procedures in the transport van, S1DON stated no.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes when a patient was left unattended and unresponsive in the transport van and fell out of the wheelchair (Patient #1). Findings: Review of an incident report dated 11/06/2025 at 9:20 AM, completed by S2Transport, revealed in part that as S2Transport was pulling into the hospital parking lot, he noticed in the rear view mirror that Patient #1 was blinking fast and did not look right. S2Transport stopped the van and asked the patient if she was alright and the patient did not respond. S2Transport went to the back of the van to check on the patient and she was slumped down in her wheelchair. The report further stated that S2Transport tried to pull the patient up but could not and he then ran inside to get help. Review of an incident report dated 11/06/2025 at 9:20 AM, completed by S1DON, revealed in part that S1DON was called to the IOP transportation van by S2Transport. Upon entering van, Patient #1 was found in front of the wheelchair on butt slumped over on the van floor. The patient was unable to verbally respond. The patient was lifted up from the floor back into the wheelchair and 911 was called. The patient was later transported to the hospital per EMS. On 02/05/2026 at 9:15 AM, interview with S2Transport revealed that he picked Patient #1 up from the nursing home on 11/06/2025. S2Transport stated that Patient #1 was in a wheelchair with a seatbelt buckled on her wheelchair. S2Transport stated that he was the only staff on the transport van and when he noticed that the patient was not responding, he pulled over at the hospital (next to the IOP) and went to the back of the van to check on the patient. He stated the patient was slumped over to the side of her wheelchair and he unbuckled her seatbelt to attempt to straighten her up in the wheelchair, but was unable to lift the patient. S2Transport stated he then left the patient unattended, and unbuckled, and ran inside the hospital to get help. On 02/05/2025 at 12:55 PM, further interview was conducted with S2Transport. When asked if he had received any trainings or education after the incident with Patient #1, he stated no. When asked if it was routine procedure to have only the transport driver on the van when transporting IOP patients, he stated yes. S2Transport stated it was hard to drive and watch patients at the same time. On 02/05/2026 at 1:10 PM, interview with S1DON confirmed that she found Patient #1 sitting on her buttocks in front of her wheelchair on 11/06/2025, when requested by S2Transport to come to the van to check on the patient. S1DON stated that the patient was unresponsive and the seatbelt on the patient’s wheelchair was not buckled. When asked if an unresponsive patient should be left alone on the transportation van, S1DON stated no. S1DON further stated that the van drivers have cell phones that they can use for emergencies. When asked if there were any policies and procedures that addressed staffing on the transport van or safety procedures in the transport van, S1DON stated no. When asked if the hospital had identified any concerns involving the incident with Patient #1 in which new policies were developed or further education/training was provided to the staff, S1DON stated no. Review of the personnel file for S2Transport revealed no documented evidence that he had a signed job description for driver, and no evidence of training or competency evaluations related to transportation and patient safety procedures while in the transport van. Further review of personnel files revealed three other drivers, S3Transport, S4Transport and S5Transport had no documented evidence of signed job descriptions for driver and no evidence of training or competency evaluations related to transportation and patient safety procedures while in the transport van. On 02/06/2026 at 3:30 PM, interview with S6Program Director confirmed that S2Transport, S3Transport, S4Transport and S5Transport had no evidence of job descriptions or competency evaluations. S6Program Director further stated that no opportunities for improvement had been initiated since the incident with Patient #1, including ensuring that the transport drivers were adequately trained and competent. 20310”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 17450 Based on observation, record review, and interview, the hospital failed to meet the 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 for 10 of 10 current patients on line of sight observation levels with diagnoses including suicidal ideations (Patient #2, 3, R1-R8) and 5 of 8 current patients on routine observation levels (Patients #R11-R15); 2) Failure of the hospital to provide documentation of line of sight observations and every 15 minute observations for 15 of 18 total psychiatric patients who had these observation levels ordered by the physician 3) Failure to ensure that all staff were trained on observation levels 4) Failure to ensure that 1 discharged patient was observed per line of sight observation level and as a result, this patient eloped from the hospital (Patient #1). Findings: This resulted in an Immediate Jeopardy Situation. S1Administrator was notified on 08/20/2025 at 3:45 PM. The hospital provided the following plan of removal for the Immediate Jeopardy situation: All nurses and mental health technicians present on the day shift and night shift of 08/20/2025 were retrained on observation levels, staff responsibilities, documentation requirements and review of the observation policy. The observation levels will now be added to the white board in the nurses station in addition to the mental health technician’s sheet to ensure that all staff are aware of teach patient’s observation level. Updating the white board will be the responsibility of the nurse taking the order. Retraining will be conducted for all remaining nurses and mental health technicians on observation levels, staff responsibilities, documentation requirements and review of the observation policy. This training will be mandatory before being allowed to work on the floor. This training will be completed by 08/31/2025. It will be documented and filed in each employee’s file. To ensure continued compliance, observation levels will be reviewed by the DON or Program Director each morning for accuracy. During their rounds, nurse practitioners will meet with all Level 1 and Level 2 patients first to determine any changes needed in observation levels. RN staff will supervise the mental health technicians to ensure that observation is completed per the policy and review observation sheets to ensure accurate and timely completion. On 08/21/2025 at 3:00 PM, 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 deficiency remains at a Condition level (See findings in A0144);”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 17450 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 for 10 of 10 current patients on line of sight observation levels with diagnoses including suicidal ideations (Patient #2, 3, R1-R8) and 5 of 8 current patients on routine observation levels (Patients #R11-R15); 2) Failure of the hospital to provide documentation of line of sight observations and every 15 minute observations for 15 of 18 total psychiatric patients who had these observation levels ordered by the physician; 3) Failure to ensure that all staff were trained on observation levels and 4) Failure to ensure that 1 discharged patient was observed per line of sight observation level and as a result, this patient eloped from the hospital (Patient #1). Findings: 1. On 08/20/2025 at 12:50 PM, observations in the day room revealed no staff were in the room or to be seen. Further observations at this time revealed that Patients #2, R1 and R2 were in the day room unsupervised. These patients had orders for line of sight observation levels. On 08/20/2025 at 1:00 PM, the surveyor asked S5BHT to review her (electronic) observation sheets. At that time, S5BHT stated that she had not documented on any of her 6 assigned patients for the day, including 3 line of sight patients (Patient #2, R6, R8). The surveyor then requested to reviewed the observation sheets of S6BHT. Review of S6BHT’s observation sheets revealed the last documented observation for her 6 assigned patients was at 7:15 AM that morning, which included 4 line of sight patients (R1, R3, R4, R5). The techs stated they would document later in the shift. When asked how they remember what the patients were doing for the past several hours, they stated that they remembered it all in their heads. On 08/20/2025 at 1:30 PM, observation revealed Patient #3 was asleep in bed unsupervised. There was no staff on the hall. The patient was ordered line of sight observations at all times. On 08/20/2025 at 1:35 PM, all three techs assigned for that shift (S5BHT, S6BHT, S7BHT) were sitting at a table in the day room. The surveyor reviewed their assignment sheets with them and noted that they had several Level 2 (line of sight) patients that were not in the day room. They stated the patients were in their bedrooms. When asked how often they check on the line of sight patients who were in their bedrooms, they stated about every 15 minutes. When asked the difference in observations of the Level 2 and Level 3 patients, they all shrugged their shoulders. On 08/20/2025 at 1:45 PM, S1Program Director went with the surveyor to make observations on the halls. At this time, observations revealed Patients R1, R2, R3, R4, R5 and R7 were in their bedrooms unsupervised. There was no staff on the halls. S1Program Director confirmed that all three techs were currently sitting at the table in the day room. S1Program Director further confirmed that these above patients were on line of sight observation levels and were not being properly observed per physician orders. She stated that line of sight observations meant the staff should be within 20 feet of the patient and in eyesight at all times. S1Program Director further stated that the techs should be documenting the location and behavior of each patient every 15 minutes on the close observation forms and these should be current and up to date. At that time, S1Program Director acknowledged the hospital had issues with the staff properly observing the patients per ordered observation level. 2. On 08/20/2025 at 1:00 PM, the surveyor asked S5BHT to review her (electronic) observation sheets. At that time, S5BHT stated that she had not documented on any of her 6 assigned patients for the day, including 3 line of sight patients (Patient #2, R6, R8). The surveyor then requested to reviewed the observation sheets of S6BHT. Review of S6BHT’s observation sheets revealed the last documented observation for her 6 assigned patients was at 7:15 AM that morning, which included 4 line of sight patients (R1, R3, R4, R5). The techs stated they would document later in the shift. When asked how they remember what the patients were doing for the past several hours, they stated that they remembered it all in their heads. 3. On 08/20/2025 at 12:10 PM, the current census and observation levels were reviewed with S3RN. When asked what the difference in Level 2 and Level 3 observation levels were as noted on the census sheet, S3RN revealed that she was unsure and she proceeded to ask S4LPN. S4LPN stated that Level 2 observations indicated line of sight and Level 3 observations were routine every 15 minute observations. On 08/20/2025 at 1:25 PM, S5BHT was asked what Level 2 and Level 3 observation levels meant, as noted next to each patients name on the tech’s assignment sheets. S5BHT stated that she did not know and told the surveyor to ask S7BHT. At that time, S7BHT was asked what Level 2 and Level 3 observation levels meant. S7BHT stated that Level 2 was routine every 15 minute observations and Level 3 was line of sight observations (which was the opposite of what the levels actually meant). On 08/20/2025 at 1:35 PM, all three techs assigned for that shift (S5BHT, S6BHT, S7BHT) were sitting at a table in the day room. The surveyor reviewed their assignment sheets with them and noted that they had several Level 2 (line of sight) patients that were not in the day room. They stated the patients were in their bedrooms. When asked how often they check on the line of sight patients who were in their bedrooms, they stated about every 15 minutes. When asked the difference in observations of the Level 2 and Level 3 patients, they all shrugged their shoulders. 4. Review of the medical record revealed Patient #1 was admitted to the psychiatric hospital on 07/22/2025 with diagnoses including auditory hallucinations and schizoaffective disorder. The patient was PEC’d and had admission orders for line of sight observation level at all times. Review of an LDH abuse/neglect self-report dated 07/27/2025 at 6:55 AM revealed in part that the patient moved his bed and furniture and barricaded his bedroom door, preventing staff from entering. The patient then broke the window in his room with the nightstand drawer and eloped from the hospital. Review of the close observation form revealed documentation that the patient was in his bedroom asleep from 07/26/2025 at 7:30 PM until 07/27/2025 at 6:45 AM. Review of the close observation form dated 07/27/2025 at 7:00 AM revealed the patient of off the unit. The patient returned at 11:00 AM that day after being located. Review of the close observation form dated 07/28/2025 at 11:15 PM revealed the form was blank until 07/29/2025 at 6:45 AM. Further review of the close observation forms revealed no documented evidence that the patient was on a line of sight observation level. There was no mention of the observation level on the forms. On 08/21/2025 at 1:20 PM, interview with S1Program Director confirmed that the patient had physician orders for line of sight observation level at the time of the above incident. S1Program Director confirmed the patient was not being properly observed per physician order. When asked if there had been any education conducted to any of the hospital staff after this incident, she stated no. When asked if there were any new processes put into place after this incident with Patient #1 eloping while being on line of sight observations, she stated no.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. This deficient practice was evidenced by failure of the hospital to implement a performance improvement plan after one patient who was on line of sight observations eloped from the hospital (Patient #1). Findings: Review of the medical record revealed the patient was admitted to the psychiatric hospital on 07/22/2025 with diagnoses including auditory hallucinations and schizoaffective disorder. The patient was PEC’d and had admission orders for line of sight observation level at all times. Review of an LDH abuse/neglect self-report dated 07/27/2025 at 6:55 AM revealed in part that the patient moved his bed and furniture and barricaded his bedroom door, preventing staff from entering. The patient then broke the window in his room with the nightstand drawer and eloped from the hospital. Review of the close observation form revealed documentation that the patient was in his bedroom asleep from 07/26/2025 at 7:30 PM until 07/27/2025 at 6:45 AM. Review of the close observation form dated 07/27/2025 at 7:00 AM revealed the patient of off the unit. The patient returned at 11:00 AM that day. Further review of the close observation forms revealed no documented evidence that the patient was on line of sight observation level. There was no mention of the observation level on the forms. On 08/21/2025 at 1:20 PM, interview with S1Program Director confirmed that the patient was on line of sight observation level at the time of the above incident. S1Program Director confirmed the patient was not being properly observed per physician order. When asked if there had been any education conducted to any of the hospital staff after this incident, she stated no. When asked if there were any new processes put into place after this incident with Patient #1 eloping while being on line of sight observations, she stated no. Observations at various times during the survey on 08/20/2025 and 08/21/2025 revealed the staff failed to provide constant supervision for 10 of 10 current patients who were on line of sight observation levels. On 08/20/2025 at 1:45 PM, S1Program Director acknowledged that the hospital had current issues with the staff properly observing the patients per ordered observation level.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 17450 Based on record review and interview, the registered nurses failed to supervise and evaluate the nursing care for each client as evidenced by failing to ensure that patients received supervision as ordered by the physician for 10 of 10 current patients on line of sight observation levels with diagnoses including suicidal ideations (Patient #2, 3, R1-R8) and 5 of 8 current patients on routine observation levels (Patients #R11-R15). Findings: On 08/20/2025 at 12:10 PM, the current census and observation levels were reviewed with S3RN. When asked what the difference in Level 2 and Level 3 observation levels were as noted on the census sheet, S3RN revealed that she was unsure and she proceeded to ask S4LPN. S4LPN stated that Level 2 observations indicated line of sight and Level 3 observations were routine every 15 minute observations. On 08/20/2025 at 12:50 PM, observations in the day room revealed no staff were in the room or to be seen. Further observations at this time revealed that Patients #2, R1 and R2 were in the day room unsupervised. These patients had orders for line of sight observation levels. On 08/20/2025 at 1:00 PM, the surveyor asked S5BHT to review her (electronic) observation sheets. At that time, S5BHT stated that she had not documented on any of her 6 assigned patients for the day, including 3 line of sight patients (Patient #2, R6, R8). The surveyor then requested to reviewed the observation sheets of S6BHT. Review of S6BHT’s observation sheets revealed the last documented observation for her 6 assigned patients was at 7:15 AM that morning, which included 4 line of sight patients (R1, R3, R4, R5). The techs stated they would document later in the shift. When asked how they remember what the patients were doing for the past several hours, they stated that they remembered it all in their heads. On 08/20/2025 at 1:30 PM, observation revealed Patient #3 was asleep in bed unsupervised. There was no staff on the hall. The patient was ordered line of sight observations at all times. On 08/20/2025 at 1:35 PM, all three techs assigned for that shift (S5BHT, S6BHT, S7BHT) were sitting at a table in the day room. The surveyor reviewed their assignment sheets with them and noted that they had several Level 2 (line of sight) patients that were not in the day room. They stated the patients were in their bedrooms. When asked how often they check on the line of sight patients who were in their bedrooms, they stated about every 15 minutes. When asked the difference in observations of the Level 2 and Level 3 patients, they all shrugged their shoulders. On 08/20/2025 at 1:45 PM, S1Program Director went with the surveyor to make observations on the halls. At this time, observations revealed Patients R1, R2, R3, R4, R5 and R7 were in their bedrooms unsupervised. There was no staff on the halls. S1Program Director confirmed that all three techs were currently sitting at the table in the day room. S1Program Director further confirmed that these above patients were on line of sight observation levels and were not being properly observed per physician orders. She stated that line of sight observations meant the staff should be within 20 feet of the patient and in eyesight at all times. S1Program Director further stated that the techs should be documenting the location and behavior of each patient every 15 minutes on the close observation forms and these should be current and up to date. At that time, S1Program Director acknowledged the hospital had issues with the staff properly observing the patients per ordered observation level. On 08/21/2025 at 2:20 PM, interview with S2CEO revealed that the nurses are supposed to make sure that the techs are observing the patients at the correct observation level as ordered by the physician and that they are documenting timely on the close observation forms. When asked if this was occurring, S2CEO stated “It does not look like it.” S2CEO further confirmed that no new processess were put in place with the nurses after the incident with Patient #1, who was on line of sight observation level but eloped from the hospital on 07/27/2025.”

“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: 20310 Based on record review and interview, the registered nurse failed to supervise and evaluate the nursing care for each patient by failing to assess the care needs of patients at risk for elopement upon admission and when appropriate on an ongoing basis for 1 (Patient #1) of 3 sampled patients (Patients #1, #2, #3) in a total census of 18 patients. Findings: Review of the facility’s policy #2015 revised 10/2013 for patient observation levels revealed, in part: Indication of...a desire to elope, increasing agitation...will be immediately evaluated by the staff member who becomes aware of such. 2. A. RN will assign a Special Precaution Level based on assessments, observation and history of the patient at time of admission... B. RN may change the level of monitoring based on changes in the patient’s behavior or condition. All changes must be documented to include the level of monitoring and the reasons for the monitoring level. Review of the medical record for Patient #1 revealed he was admitted on 02/14/2024 with diagnoses including Schizoaffective disorder of bipolar type. Physician orders included level 2 observation (Line of sight - must be within 20 feet of a staff member at all times). Review of the nursing admission assessments for Patient #1 revealed no documented evidence that he was assessed for risk factors related to potential for elopement. Review of the nurse notes dated 02/14/2024 - 02/17/24 revealed Patient #1 was frequently restless, fidgety and noted pacing and wandering in the common areas and hallways. He appeared to be responding to internal stimuli and expressed paranoid ideas. He became aggressive and combative, and was attempting to break through locked doors. Review of an incident report dated 02/17/2024 at 10:40p.m. revealed Patient #1 broke through the fire door on the North (women’s) hall. Staff went out to get the patient and redirected him back in. There was no documented evidence that the patient was reassessed for elopement risk, or that any changes were made to the observation level of the patient. Review of an incident report dated 02/17/2024 at 11:30p.m. revealed Patient #1 ran down the North hall and busted through the door. Staff were unable to hold him, and notified 911. Staff were able to locate him at 11:41p.m. and talked him into returning. There was no documented evidence that the patient was reassessed for elopement risk, or that any changes were made to the observation level of the patient. Review of an incident report dated 02/18/2024 at 1:44p.m. revealed Patient #1 left the building via the South Hall (men’s) door running toward the highway. S2MHT quickly ran after him. Before the patient could be reached, he darted into traffic and was struck by a vehicle. EMS was notified and Patient #1 was sent to the hospital. Further review of the medical record for Patient#1 revealed no evidence that a nursing assessment was conducted regarding the patient’s elopement risk at any time prior to or after elopement attempts and no documented changes were made to his level of observation. On 03/12/2024 at 11:30a.m., an interview with S1DON confirmed that there were no documented risk assessments conducted for Patient #1 and that the hospital did not have a procedure for conducting elopement risk assessments for any patients. When asked why the facility doors were kept locked, she stated it was so patients couldn’t leave the building. She also confirmed that there was a high population of patients in the building that would be considered at risk for elopement. She further confirmed that the nurse should have reassessed Patient #1 and increased the observation status to level 1 (1:1) following the initial elopement attempt.”

“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: 20310 Based on record review and interview, the hospital failed to maintain accurate medical records for each patient by failing to accurately and completely document the patients’ observation levels and activity on the Observation Sheets for 3 of 3 sampled patients in a total census of 18 patients. Findings: Review of the facility’s policy #2015 revised 10/2013 revealed, in part: Procedure- 1. In order to provide protection to patients, three levels of staff monitoring are provided. A. Level I: constant monitoring within arms-length distance B. Level II: constant monitoring within 20 feet distance C. Level III: monitoring on a routine basis every 15 minutes Review of the Observation Sheets for Patient #1 dated 02/14/2024-02/18/2024 revealed there was no documentation on the forms of the observation level of the patient. Further review revealed inaccuracies and incomplete documentation of activities on the Observation Sheet as follows: On the Observation Sheet dated 02/17/2024 from 7:00p.m.-6:45a.m., Patient #1’s location and activity is documented as follows: from 7:00p.m.-9:45p.m the location is noted as D-Day Room; activity is noted as 8-Other. There is no explanation on the form describing what the “other” activity includes; from 10:00p.m.-6:45a.m the location is noted as P-Patient Room; activity is noted as 1-Sleeping. Review of an incident report dated 02/17/2024 at 10:40p.m. revealed Patient #1 broke through the fire door on the North (women’s) hall. Staff went out to get the patient and redirected him back in. Review of an incident report dated 02/17/2024 at 11:30p.m. revealed Patient #1 ran down the North hall and busted through the door. Staff were unable to hold him, and notified 911. Staff were able to locate him at 11:41p.m. and talked him into returning. On the Observation Sheet dated 02/18/2024 from 7:00a.m.-6:45p.m., Patient #1’s location and activity is documented as follows: from 8:45a.m.-1:15p.m the location is noted as D-Day Room; activity is noted as 8-Other. There is no explanation on the form describing what the “other” activity includes; from 1:30p.m.-6:45a.m the location is noted as MD-Doctor; activity is noted as 8-Other. There is no explanation on the form describing what the “other” activity includes. Review of an incident report dated 02/18/2024 at 1:44p.m. revealed Patient #1 left the building via the South Hall (men’s) door running toward the highway. S2MHT quickly ran after him. Before the patient could be reached, he darted into traffic and was struck by a vehicle. EMS was notified and Patient #1 was sent to the hospital. Review of the Observation Sheets for sampled Patient#2 and Patient #3 revealed they were current patients in the hospital on the days of the survey 03/11/2024-03/12/2024. The current forms contain no documented evidence of the patients’ observation levels, and entries for activities noted as 8-Other contain no detail of the activity. On 03/12/2024 at 11:45a.m., an interview with S1DON confirmed that the above Observation Sheets were inaccurately and incompletely documented for the observation level, location and activities of Patient #1. She further confirmed that the current Observation Sheets for Patient #2, #3 and all other patients do not contain the observation levels and there is no provision on the form to include an explanation when the activity level is documented as 8-Other.”