Beacon Behavioral Hospital - Northshore, LLC

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by: 1) Failure to recognize and report unsafe patient conditions in a timely manner; 2) Failure to notify Louisiana Department of Health, Health Standards Section (LDH HSS) of an incident of potential abuse and/or neglect; 3) Failure to maintain documentation of driver credentials and training per hospital policy and job description in 1 (#S3D) of 1 driver personnel file reviewed. Findings: 1) Failure to recognize and report unsafe patient conditions in a timely manner A review of hospital policy, “INCIDENT MANAGEMENT & INTERNAL REPORTING Inpatient Psychiatric Hospitals-Louisiana and Residential (PRTF),” no policy number available, and effective 03/26/2026, revealed in part: “4. DEFINITIONS Incident: Any unplanned, unexpected, or undesired event or unsafe condition that results in or has the potential to result in injury, harm, interruption of care, violation of patient rights, or risk to safety.” A review of the hospital’s internal incident reporting revealed Case 2832 - Internal Incident/Unusual Occurrence Form dated 05/07/2026 and last modified on 05/13/2026 at 7:45 a.m. The form revealed the alleged incident occurring on 05/06/2026 and details as follows: “Pt [patient] was discharged to group home. Group home was notified when the patient was leaving out facility. Upon arrival at the group home the patient refused to go into the group home and started walking down the street. When the driver tried talking the patient into going into the group home to call his son the patient stated, “I am going to a friend’s house and will wait for my son to come get me.” Administrator called pts [patient’s] son and left a message to return call as soon as possible.” A review of hospital document titled, “BEACON BEHAVIORAL HOSPITAL CONFIDENTIAL COMPLAINT FORM,” revealed S2DON initiated the form on 05/06/2026 with a complaint of: “[name] called me at 1830 and stated “I called your facility to find out where the patient is and I was informed by the nurse that the patient was dropped off around 11:30 and refused to come in the group home. and started walking down the street. Nobody from your facility notified us about this.”” In an interview on 05/13/2026 at 12:30 p.m., S3D confirmed she transported Patient #1 to the group home. She confirmed the address of the group home - [address] Holiday Drive, New Orleans, LA. She indicated after the patient exited the van, he began to walk in the opposite direction of the group home and she attempted to redirect the patient. However, the patient indicated to her that he told them he was not returning to that group home. S3D indicated she began to follow Patient #1 in the van and attempted to redirect him by talking to him via the van window as she was driving but was unsuccessful in redirection. She confirmed she did not attempt to notify the group home, the hospital or local authorities at that moment. She confirmed she did not make the hospital aware of this previously mentioned event until she returned to the hospital, and this would have been approximately 1 to 1.5 hours after Patient #1 walked away from the transportation van. The hospital driver failed to recognize the imminent need to report the status of Patient #1 to her supervisor and/or hospital personnel. The delayed reporting of this event further jeopardized the health and safety of the patient. In an interview on 05/13/2026 at 2:00 p.m., S6LMSW confirmed she was made aware of the previously mentioned events by S3D upon her return to the hospital on 05/06/2026 at approximately 1:00 p.m. S6LMSW confirmed she did not notify the group home of these events. In an interview on 05/14/2026 at 1:12 p.m., S4RN confirmed she was made aware of the previously mentioned events by S3D upon her return to the hospital on 05/06/2026. S4RN confirmed she did not notify the group home of these events. In an interview on 05/14/2026 at 1:30 p.m., S5LPN confirmed she was made aware that Patient #1 did not return to the group home when she answered a telephone call from the group home inquiring when the patient would be returning. S5LPN did not remember the time of the call, however she indicated it was later in the afternoon/evening. 2) Failure to notify Louisiana Department of Health, Health Standards Section (LDH HSS) of an incident of potential abuse and/or neglect Pursuant to LA R.S. 40:2009.20, “Duty to make complaints: A. As used in this Section, the following terms shall mean: (1) “Abuse” is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. (2) “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. B.(1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse’s aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician’s assistant, physical therapist, or any other direct caregiver having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.” Louisiana Department of Health has issued the following: “Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.” A review of hospital policy, “INCIDENT MANAGEMENT & INTERNAL REPORTING Inpatient Psychiatric Hospitals-Louisiana and Residential (PRTF),” no policy number available, and effective 03/26/2026, revealed in part: “4. DEFINITIONS Incident: Any unplanned, unexpected, or undesired event or unsafe condition that results in or has the potential to result in injury, harm, interruption of care, violation of patient rights, or risk to safety.” -This policy failed to identify the requirements pursuant to LA R.S. 40:2009.20 and only indicated the hospital requirement of mandatory internal reporting. A review of the ACTS database prior to entry into this hospital failed to reveal a hospital self-report being submitted to LDH HSS related to Patient #1 or the events taking place upon Patient #1’s arrival to the group home on 05/06/2026. A review of the hospital’s internal incident reporting revealed Case 2832 - Internal Incident/Unusual Occurrence Form dated 05/07/2026 and last modified on 05/13/2026 at 7:45 a.m. The form revealed the alleged incident occurring on 05/06/2026 and details as follows: “Pt [patient] was discharged to group home. Group home was notified when the patient was leaving out facility. Upon arrival at the group home the patient refused to go into the group home and started walking down the street. When the driver tried talking the patient into going into the group home to call his son the patient stated, “I am going to a friend’s house and will wait for my son to come get me.” Administrator called pts [patient’s] son and left a message to return call as soon as possible.” A Google internet query using Patient #1’s name revealed a Silver Alert being issued by the Louisiana State Police on 05/08/2026 for a missing elderly person matching Patient #1’s demographics and medical record picture. The alert indicated the patient was last seen on 05/06/2026 at approximately 11:00 a.m. in the vicinity of the group home’s address - [number] block of Holiday Drive. In an interview on 05/13/2026 at 12:30 p.m., S3D confirmed she transported Patient #1 to the group home. She confirmed the address of the group home - [address] Holiday Drive, New Orleans, LA. She indicated after the patient exited the van, he began to walk in the opposite direction of the group home and she attempted to redirect the patient. However, the patient indicated to her that he told them he was not returning to that group home. S3D indicated she began to follow Patient #1 in the van and attempted to redirect him by talking to him via the van window as she was driving but was unsuccessful in redirection. She confirmed she did not attempt to notify the group home, the hospital or local authorities at that moment. She confirmed she did not make the hospital aware of this previously mentioned event until she returned to the hospital, and this would have been approximately 1 to 1.5 hours after Patient #1 walked away from the transportation van. In an interview on 05/13/2026 at 9:30 a.m., S1ADM confirmed the hospital had a recent event in which a patient was transported to a group home by hospital transportation/staff and upon arrival to the group home, the patient exited the van and walked away from the driver and in the opposite direction of the group home. S1ADM confirmed the hospital had not reported the above-mentioned event to LDH HSS via self-report because the hospital did not feel this was an issue of abuse and/or neglect. 3) Failure to maintain documentation of driver credentials and training per hospital policy and job description in 1 (#S3D) of 1 driver personnel file reviewed A review of hospital policy, “AS (ANCILLARY SERVICES) SUBJECT: HOSPITAL TRANSPORTATION SERVICES,” no policy number available, last revised: 03/21/2018 and last approved: 01/25/2024, revealed in part: “Beacon Behavioral Hospital vehicles are inspected frequently and maintained in very good operational and cosmetic condition. Drivers utilized are Beacon Behavioral Hospital employees with chauffeur’s licenses, safe driving training, certification in BLS and training and certification in managing the escalating patient (e.g. CPI or MOAB). Depending on the number of patients being transported and the conditions of patients in the vehicle, a second staff member may assign to accompany patients as a monitor.” A review of S3D’s personnel file revealed an Internal Change Letter dated 04/03/2025 and listed S3D’s General Position Information as: Title: Driver/Unit Secretary and Effective Date: 04/06/2026. S3D’s personnel file revealed a Job Description for “Driver,” and signed by S3D on 01/21/2019. A review of the Driver Job Description revealed in part: “QUALIFICATIONS 5. Chauffeur’s license. SPECIFIC RESPONSIBILITIES AND DUTIES 3. Transports clients to and from the facility and their place of residence. 4. Maintains a current chauffeur’s license.” Further review of S3D’s personnel file failed to reveal a chauffeur’s license or safe driver training. The hospital failed to ensure and maintain documentation of S3D’s capability of transporting patients in a safe and therapeutic manner. In an interview on 05/13/2026 at 12:26 p.m., S3D confirmed she was a driver for the hospital. In an interview on 05/14/2026 at 4:15 p.m., S1ADM confirmed the above-mentioned findings, and the hospital did not have documentation of a chauffeur’s license or safe driver training on file for S3D.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by: 1) Failure to ensure the current glucometer control solutions were not out of the vial’s first opened date range (See Findings Tag A0144); 2) Failure to ensure observation checks were being performed by the assigned personnel (See Findings Tag A0144); 3) Failure to ensure the emergency cart was in accessible condition (See Findings Tag A0144); 4) Failure to ensure the patient care area was free of ligature risks (See Findings Tag A0144); 5) Failure to review and resolve reported grievances for 1 (#4) of 4 (#1 - #4) patients reviewed for grievances (See Findings Tag A0119); and 6) Failure to provide written notice of the grievance decision for a grievance filed for 1 (#4) of 4 (#1 - #4) patients reviewed for grievances (See Findings Tag A0123).”

“PATIENT RIGHTS: REVIEW OF 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.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 48537 Based on record review and an interview, the hospital failed to review and resolve reported grievances for 1 (#4) of 4 (#1 - #4) patients reviewed for grievances. Findings: Review of the hospital policy titled “Patient Complaint and Grievance Processes” last revised on 03/21/2018, revealed in part: “Policy: All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be reported immediately to the supervisor of the staff member receiving the allegation/knowledge. The concern will be immediately reported up the chain of command to the Administrator on duty and/or nursing leadership, so that patient safety is ensured and an investigation may commence immediately. Procedure: 5. The Charge Nurse or Program Director shall ensure that an Incident Report is completed and submitted. 7. The Grievance Committee: a. Reviews the incident report and any other documentation about the concern within 72 hours of receipt of the grievance or more promptly if indicated. b. Initiates an investigation (if the Grievance concerns abuse or neglect, the investigation will have been initiated at the time that the Grievance was received) c. The investigation may include, but not limited to: -Interviews with the complainant and interviews with any patients involved -Interviews with staff members on duty at the time of occurrence of the alleged event -Review of patients’ Medical Records -Review of Policies & Procedures -Review of video surveillance d. After the investigation, meets to discuss: -The findings of the investigation -Further investigation, if necessary -Whether allegations are considered substantiated, unsubstantiated, or unable to substantiate (if the complaint was regarding abuse or neglect) -Actions to be taken to resolve the issue -Actions to reduce the risk of future similar events e. Every attempt shall be made to resolve the issue within 7 days of receipt of the grievance.” Review of Patient #4’s medical record revealed she was admitted to the hospital on 12/01/2024 at from a local hospital for major depressive disorder, suicidal ideations and alcohol abuse with withdrawal. Review of the hospital’s grievance log from September 2024 to current revealed a filed grievance on 12/10/2024 by a family member of Patient #4 regarding a fall with injury Patient #4 had sustained on 12/06/2024 which required her to be transferred out of the facility to an area emergency room for further treatment. Review of Patient #4’s medical record for her completed stay at the facility revealed no investigation documentation regarding the fall with injury Patient #4 sustained on 12/06/2024. On 01/15/2025 at 12:00 PM, an interview was conducted with S1Adm. She confirmed she did not conduct an investigation as required by hospital policy after the grievance filed by Patient #4’s family member.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to provide written notice of the grievance decision for a grievance filed for 1 (#4) of 4 (#1 - #4) patients reviewed for grievances. Findings: Review of the hospital policy titled “Patient Complaint and Grievance Processes” last revised on 03/21/2018, revealed in part: “Policy: All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be reported immediately to the supervisor of the staff member receiving the allegation/knowledge. The concern will be immediately reported up the chain of command to the Administrator on duty and/or nursing leadership, so that patient safety is ensured and an investigation may commence immediately. Procedure: 8. The Administrator will make every attempt to provide a response within seven (7) days of receiving a grievance. 9. If a grievance is not resolved within the seven (7) day timeframe, the hospital shall send written notice to the complainant saying that the hospital continues to work to resolve the complaint and the hospital will follow-up with a final response by a specific date or within a specific time frame. 10. When the grievance has been resolved, the Administrator will send a written response to the complainant (in a language and madder the patient/patient representative can understand) that includes (but may not be limited to): a. The determination of the Grievance Committee and any (general) actions taken to resolve the issue b. The date of completion of the process c. Steps taken on behalf of the patient/complainant to investigate the grievance d. The name and contact information of the Administrator (who should be identified as the individual that the complainant should contact in the event that further concerns and/or questions are to be expressed).” Review of Patient #4’s medical record revealed she was admitted to the hospital on 12/01/2024 at from a local hospital for major depressive disorder, suicidal ideations and alcohol abuse with withdrawal. Review of the hospital’s grievance log from September 2024 to current revealed a filed grievance on 12/10/2024 by a family member of Patient #4 regarding a fall with injury Patient #4 had sustained on 12/06/2024 which required her to be transferred out of the facility to an area emergency room for further treatment. Review of Patient #4’s medical record for her complete stay at the facility revealed no grievance decision notification regarding the investigation into fall with injury Patient #4 sustained on 12/06/2024 was sent to the family member. On 01/15/2025 at 12:00 PM, an interview was conducted with S1Adm. She confirmed she did not send a final grievance decision notification to family member within the 7-10 day timeframe as required by the hospital policy.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by: 1) Failure to ensure the current glucometer control solutions were within the vial’s first opened date range; 2) Failure to ensure observation checks were being performed by the assigned personnel; 3) Failure to ensure the emergency cart was in accessible condition; and 4) Failure to ensure the patient care area was free of ligature risks. Findings: 1) Failure to ensure the current glucometer control solutions were within the vial’s first opened date range A review of hospital policy, “NS (Nursing Service), Subject: Capillary Blood Glucose Monitoring,” no policy number available, effective 09/01/2011 and last revised 03/21/2018, revealed in part, “Procedure: 1. Quality control assessment with control solutions shall be completed at least daily on Capillary Blood Glucose Meters. Control assessment shall be conducted by a nurse. 2. Calibration of Capillary Blood Glucose Meters should be performed by a nurse in accordance with manufacturers’ recommendations.” A review of the package insert of the EVENCARE ProView Glucose Control Solutions revealed in part, “Discard any unused control solution 90 days after first opening or after the expiration date, whichever comes first.” A review of a staff reminder placed in the front of the, “Blood Glucose Daily Quality Control Log,” binder revealed in part, “Glucose control solutions and test strips are only good for 90 days after first opening or after the expiration date, whichever comes first. This is per the manufacturer. Please date the box for the glucose controls and the bottle of test strips when opened!” Observations during a walk-through of the hospital on 01/14/2025 from 11:05 AM to 12:20 PM revealed the EVENCARE ProView Glucose Control Solutions currently being used, had an open date of 07/24/2024 written on the box containing a Control Solution Level 2 vial (Lot #3AR2A11) and a Control Solution Level 3 vial (Lot #3ARA09). In an interview on 01/14/2025 at 12:01 PM, S3LPN confirmed the EVENCARE ProView Glucose Control Solutions currently being used and further confirmed they were beyond their first opened date range. In an interview on 01/14/2025 and present during this hospital walk-through, S2DON confirmed the above mentioned findings. 2) Failure to ensure observation checks were being performed by the assigned personnel A review of hospital policy, “Nursing Service (NS), Subject: Levels of Observation,” no policy number available, effective 09/01/2011 and last revised 06/13/2024, revealed in part, “Routine Observation is the routine Level of Observation applied to patients that are not considered at risk and/or need of increased supervision. At least every 15 minutes, a staff member directly visually observes the patient to determine: 1. Signs of Life (breathing while asleep-rise and chest fall, no obvious distress) 2. Location 3. Behavior. While observing the patient, the staff member documents (as described above), the patient’s location and behavior. Line of Sight Observation is defined as always maintaining visual observation of a patient. A staff member may be assigned to maintain Line of Sight on up to three patients (thought this number may be increased if the Line of Sight patients are involved in a Group Activity). It is always the staff member’s responsibility to maintain visual contact with the patient (not the patient’s responsibility). If assigned more than on Line of Sight patient and at least one patient needs to use the bathroom, shower, or leave the group for another reason, the staff member maintaining Line of Sight must enlist the assistance of another staff member, to ensure that all patients on Line of Sight are maintained within visual range of staff. When the assistance of another staff member is necessary there should be verbal acknowledgement of change in activity. The staff member assigned to Line of Sight is continuously observing for: 1. Signs of Life (breathing while asleep-rise and chest fall, no obvious distress) 2. Location 3. Behavior.” A record review of the 12/04/2024 hospital census revealed 14 (#1, #2, #4, #R1 - #R11) patients. with 6 (#2, #4, #R3, #R6, #R9, #R11) of 14 (#1, #2, #4, #R1 - #R11) patients having orders for Line of Sight (LOS). A review of provider orders revealed Patient #2 LOS order began on 11/30/2024 and ended on 12/04/2024 at 4:41 PM; Patient #4 LOS order began on 12/01/2024; Patient #R3 LOS order began on 11/25/2024; Patient #R6 LOS order began on 12/02/2024; Patient #R9 LOS order began on 12/01/2024 and Patient #R11 LOS order began on 12/04/2024 at 12:39 PM. A review of the MHT Shift Assignments log for the AM shift did not reveal which patients were currently on LOS, however, Patients #2 and #4 were assigned to S7MHT, Patients #R3 and #R7 were assigned to S8MHT, Patient #R9 was assigned to S6MHT and Patient #R11 was assigned to S15MHT. A review of Patient Observation Sheets, for Patients #1, #2, #4, #R1 - #R4 and #R6 - #R11, revealed S8MHT as the observer on the logs from approximately 7:00 AM to 11:45 AM, S6MHT as the observer on the logs from approximately 11:55 AM to 1:00 PM and again from 1:00 PM to 4:00 PM and S7MHT as the observer on the logs from approximately 4:00 PM to 6:00 PM. A review of Patient #1’s provider orders revealed the observation level of LOS being added on 12/04 at 7:00 PM. A review of the 12/04/2024 MHT Shift Assignments log for the PM shift did not reveal which patients were currently on LOS and Patient #2 was not listed on the assignment sheet, however, Patients #4 and #R9 were assigned to S12MHT, Patient #R3 was assigned to S9MHT, Patients #1¸#R7 and #R11 were assigned to S11MHT. A review of “Patient Observation Sheets,” for Patients #1, #2, #4, #R1 - #R4 and #R6 - #R11, revealed S10MHT as the observer from approximately 7:00 PM to 10:15 PM, S11MHT as the observer from approximately 10:15 PM to 12/05/2024 at 1:30 AM, S12MHT as the observer from approximately 1:45 AM to 5:00 AM, and S9MHT from 5:00 AM to 6:30 AM. The before mentioned documented observer did not match the MHT Shift Assignment logs. These 14 patient’s, including the Line of Sight patients (#1, #2, #4, #R3, #R7, #R9, #R11), medical record documentation revealed the before mentioned MHT as their observer. This would indicate the AM shift documented observer had 6 (#2, #4, #R3, #R7, #R9, #R11) LOS patients and 8 (#1, #3, #R1, #R2, #R4, #R6, #R8, #R10) Routine Observation patients and the PM shift documented observer had 7 (#1, #2, #4, #R3, #R7, #R9, #R11) LOS patients and 7 (#3, #R1, #R2, #R4, #R6, #R8, #R10) Routine Observation patients. Further, Patient Observation Sheets from 12/04/2024 revealed no documentation of observation checks being performed on these 14 patients from approximately 10:30 AM to 11:52 AM (approximately 80 minutes). In an interview on 01/16/2025 at 9:00 AM, S2DON and S5CCO confirmed the above mentioned findings. In an interview on 01/16/2025 at 9:00 AM, S2DON and S5CCO confirmed the above mentioned findings. 3) Failure to ensure the emergency cart was in accessible condition Observations during a walk-through of the hospital on 01/14/2025 from 11:05 AM to 12:20 PM revealed the emergency cart with a combination lock being used to secure the drawers. Further observations revealed a delay of approximately 30 to 45 seconds when staff was asked to open the emergency cart as the code to the lock had to be located. The Automatic External Defibrillator was located in drawer 3 of this cart. In an interview on 01/14/2025 and present during this hospital walk-through, S3DON confirmed the above mentioned findings. In an interview on 01/15/2025 at 3:50 PM, S5CCO confirmed the emergency cart should not be secured with a combination lock and be easily accessible. 4) Failure to ensure the patient care area was free of ligature risks A) Observations during a walk-through of the hospital on 01/14/2025 from 11:05 AM to 12:20 PM revealed square top doors which posed a ligature risk in patient bedrooms “a” - “k.” Rooms “a” - “c” and “f” - “k” revealed a square top door on the restroom door, closet door A and closet door B; and Rooms “d” and “e” revealed a square top door on closet door A and closet door B. In an interview on 01/14/2025 and present during the walk-through of the hospital, S2DON confirmed the above mentioned findings. B) Observations during a walk-through of the hospital on 01/15/2025 from 9:30 AM to 10:00 AM revealed built-in shelving, approximately 5 feet in height, located with-in the closets of each patient bedroom. This shelving could be used a means of access to the ceiling tiles located within these closets, which could lead to the potential for self-injurious behavior by a patient. The following patient bedroom closets had unsecured ceiling tiles: Room “a” closet B; Room “b” closet A; Room “d” closets A and B; Room “g” closet B; Room “i” closet A; Room “j” closet A; and Room “k” closets A and B. In an interview on 01/15/2025 and present on during this walk-through, S4Maint confirmed the above mentioned findings. C) Observations during a walk-through of the hospital on 01/15/2025 from 9:30 AM to 10:00 AM revealed a privacy wall in Room “j” that abuts the exterior wall and window. However, where the privacy wall, the exterior wall and the window seal (approximately 4 feet in height) intersect, a space of approximately 4 inches continues between the privacy wall and the window. This space was ligature risk and had the potential for self-injurious behavior by a patient. In an interview on 01/15/2025 and present on during this walk-through, S4Maint confirmed the above mentioned findings.”

“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: 48537 Based on record review and interviews, the hospital failed to identify an opportunity for change that could have led to improvements in patient safety between the hospital and the contracted lab services. This failed opportunity had the potential to affect all residents in the facility receiving lab services, including any newly admitting patients requiring admission lab services upon admit. Findings: Review of the hospital’s Quality Assurance and Performance Improvement Plan, last revised on 01/23/2024 revealed in part: “Quality Assurance and Performance Improvement Team Scope of Activities: The scope of the organizational Quality Assurance and Performance Improvement program includes an overall assessment of the efficacy of QAPI activities with a focus on continually improving care and safety practices throughout the hospital. The program focuses on the components of Quality Assurance and Performance Improvement Plan, patient safety, quality assessment/improvement, and quality control activities. Collaborative and specific indicators of both processes and outcomes are designed, measured, and assessed by all appropriated departments/services and disciplines of the facility to improve patient safety and organizational performance. These indicators are objective, measurable, and structured to produce data-driven, performance measures of the care provided. This mechanism also provides for evaluation of improvements and the stability of the improvement over time. The scope of the organizational Quality Assurance and Performance Improvement program includes QAPI priorities identified by leaders, as well as performance of the following medical staff functions: - Patient care and quality control activities in the following services are monitored, assessed, and evaluated: - Clinical Laboratory Services” On 01/14/2025 at 11:35 AM, during the facility tour, an interview was conducted with S2DON. S2DON stated the hospital contracted with an outside lab company for lab services who come to the facility on a daily scheduled basis. S2DON stated the contracted outside lab company was responsible for checking for expiration dates on all patient lab supplies kept in the facility’s “Lab/Supply Room” behind the nurses’ station. An array of expired patient lab testing supplies were found ready and available for patient use (See Tag A0724 for reference). S2DON stated neither him nor any of his staff had checked any of the supplies for expiration dates because they were lab supplies and not for their use. S2DON confirmed the dates on the supplies as expired. On 01/14/2025 at 12:00 PM, an interview was conducted with S5CCO. She stated the hospital contracted out for its lab services. S5CCO stated there was no current QAPI activities or projects related to lab services, however the hospital was about to be reviewing the contract agreement with the contracted company. S5CCO confirmed a project related to accountability for lab supply inventory management would be a patient safety concern and should be addressed by the QAPI committee.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the change to an increased observation level without a subsequent notification of the provider. Findings: A review of hospital policy, “Nursing Service (NS), Subject: Levels of Observation,” no policy number available, effective 09/01/2011 and last revised 06/13/2024, revealed in part, “Policy: Although an authorized licensed prescriber will issue orders for the Level of Observation, a registered nurse may increase a Level of Observation without an order from a licensed prescriber to ensure the safety and security of patients. If a Level of Observation is increased by a registered nurse, it is that nurse’s responsibility to contact the authorized licensed prescriber on duty to issue a corresponding order.” A medical record review of Patient #1 revealed an order on 12/04/2024 at 7:00 PM for Line of Sight every 15 minutes placed by S13RN. Medical record documentation did not reveal a reason for the change in the level of observation or documentation related to the provider being contacted to notify of this change. The order was signed by S14MD on 12/20/2024 at 10:22 AM. In an interview on 01/16/2025 at 9:00 AM, S13RN confirmed the provider was not contacted for the increased level of observation.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48537 Based on record review and interview, the hospital failed to ensure nursing staff documented current patient assessment immediately post-fall for 2 (#3 & #4) of 4 (#1 - #4) patients reviewed for falls. Findings: Review of the hospital’s policy titled “Ongoing Nursing Assessments,” last revised on 03/21/2018 revealed in part: “Policy: In addition to the comprehensive assessment conducted on each shift, the registered nurse will conduct focused assessments in response to the patient: -Having been witnessed falling or reporting a fall Procedure: 1. The registered nurse conducts an assessment of the patient in accordance with the reason for the assessment, the patient’s signs and symptoms, hospital policy, prudent nursing practice 2. The registered nurse conducts re-assessments at time frames based on reason for the assessment, the patient’s signs and symptoms, hospital policy, prudent nursing practice, physician’s orders 4. The assessment and findings are documented in the medical record by the registered nurse” Patient #3: Review of the hospital’s census dated 01/15/2025 revealed Patient #3 had fallen in the facility on 01/13/2025. Review of Patient #3’s “Nursing Shift Assessment” dated 01/13/2025 for 7P to 7A shift revealed in part: “At 11:50 PM, patient fell in bathroom, VSS, AA&O MD, ADMIN notified left message for daughter. At 3:00 AM, Ibuprofen given for generalized discomfort. Signed by S17RN at 01/14/2025 at 5:50 AM.” Review of Patient #4’s medical record revealed no post-fall nursing assessment had been completed for Patient #3 on 01/13/2025. On 01/15/2025 at 1:43 PM, an interview was conducted with S2DON. He reviewed Patient #3’s medical record for the evening of 01/13/2025 when he sustained a fall. He confirmed a post fall assessment should have been completed by S17RN and was not. Patient #4: Review of the hospital’s incident report log dated September 2024 to current revealed fall with injury on the evening of 12/06/2024 and transport to local emergency department for further evaluation in the early hours of 12/07/2024. Review of Patient #4’s “Nursing Shift Assessment” dated 12/06/2024 for 7P to 7A shift revealed in part: “At 11:35 PM, the patient fell down in the bathroom while a tech was helping her use the bathroom. The patient hit her nose and right eyelid causing bruising. The patient was sent off to the hospital per MD order later on. Signed by S16RN on 12/07/2024 at 4:45 AM.” Review of Patient #4’s medical record revealed no post-fall nursing assessment had been completed for Patient #4 on 12/06/2024. On 01/15/2025 at 1:10 PM, an interview was conducted with S2DON. He reviewed Patient #4’s medical record for the evening of 12/06/2024 when she sustained a fall with injury resulting in a transfer to the hospital. He confirmed a post fall assessment should have been completed by S16RN and was not.”

“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: 48051 Based on record review and interview, the hospital failed to ensure the registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualification and competence of the nursing staff. This deficient practice was evidenced by the MHT Shift Assignment logs not matching the documented MHT observer on the Patient Observation Sheets. Findings: A review of hospital policy, “Nursing Service (NS), Subject: Levels of Observation,” no policy number available, effective 09/01/2011 and last revised 06/13/2024, revealed in part, “Assessment and Determination of Needs: 5. The Charge RN is responsible for ensuring all patient observations are completed and documented by a member of the staff. 6. Patient rounds will be assigned to specific staff members on each shift by the Charge RN.” A record review of the 12/04/2024 hospital census revealed 14 (#1, #2, #4, #R1 - #R11) patients. with 6 (#2, #4, #R3, #R6, #R9, #R11) of 14 (#1, #2, #4, #R1 - #R11) patients having orders for Line of Sight (LOS). A review of provider orders revealed Patient #2 LOS order began on 11/30/2024 and ended on 12/04/2024 at 4:41 PM; Patient #4 LOS order began on 12/01/2024; Patient #R3 LOS order began on 11/25/2024; Patient #R6 LOS order began on 12/02/2024; Patient #R9 LOS order began on 12/01/2024 and Patient #R11 LOS order began on 12/04/2024 at 12:39 PM. A review of the MHT Shift Assignments log for the AM shift did not reveal which patients were currently on LOS, however, Patients #2 and #4 were assigned to S7MHT, Patients #R3 and #R7 were assigned to S8MHT, Patient #R9 was assigned to S6MHT and Patient #R11 was assigned to S15MHT. A review of Patient Observation Sheets, for Patients #1, #2, #4, #R1 - #R4 and #R6 - #R11, revealed S8MHT as the observer on the logs from approximately 7:00 AM to 11:45 AM, S6MHT as the observer on the logs from approximately 11:55 AM to 1:00 PM and again from 1:00 PM to 4:00 PM and S7MHT as the observer on the logs from approximately 4:00 PM to 6:00 PM. A review of Patient #1’s provider orders revealed the observation level of LOS being added on 12/04 at 7:00 PM. A review of the 12/04/2024 MHT Shift Assignments log for the PM shift did not reveal which patients were currently on LOS and Patient #2 was not listed on the assignment sheet, however, Patients #4 and #R9 were assigned to S12MHT, Patient #R3 was assigned to S9MHT, Patients #1¸#R7 and #R11 were assigned to S11MHT. A review of “Patient Observation Sheets,” for Patients #1, #2, #4, #R1 - #R4 and #R6 - #R11, revealed S10MHT as the observer from approximately 7:00 PM to 10:15 PM, S11MHT as the observer from approximately 10:15 PM to 12/05/2024 at 1:30 AM, S12MHT as the observer from approximately 1:45 AM to 5:00 AM, and S9MHT from 5:00 AM to 6:30 AM. The before mentioned documented observer did not match the MHT Shift Assignment logs. These 14 patient’s, including the Line of Sight patients (#1, #2, #4, #R3, #R7, #R9, #R11), medical record documentation revealed the before mentioned MHT as their observer. This would indicate the AM shift documented observer had 6 (#2, #4, #R3, #R7, #R9, #R11) LOS patients and 8 (#1, #3, #R1, #R2, #R4, #R6, #R8, #R10) Routine Observation patients and the PM shift documented observer had 7 (#1, #2, #4, #R3, #R7, #R9, #R11) LOS patients and 7 (#3, #R1, #R2, #R4, #R6, #R8, #R10) Routine Observation patients. Further, Patient Observation Sheets from 12/04/2024 revealed no documentation of observation checks being performed on these 14 patients from approximately 10:30 AM to 11:52 AM (approximately 80 minutes). In an interview on 01/16/2025 at 9:00 AM, S2DON and S5CCO confirmed the above mentioned findings..”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure verbal orders were authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This deficient practice was evidenced by a verbal order authentication being performed greater than 10 days after issuing. Findings: A review of hospital policy, “NS (Nursing Service), Subject: Receiving and Transcribing Prescribers’ Orders,” no policy number or effective date available and last revised on 03/21/2018, revealed in part, “Procedure: Telephone and Verbal Orders: 7. Telephone and Verbal Orders must be authenticated by the prescriber within 10 day of issuing the orders.” A medical record review of Patient #1 revealed an order on 12/04/2024 at 7:00 PM for Line of Sight every 15 minutes placed by S13RN. The order was signed by S14MD on 12/20/2024 at 10:22 AM (approximately 16 days after issuing the order). In an interview on 01/16/2025 at 10:30 AM, S5CCO confirmed the above mentioned findings.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure a discharge summary was completed for 2 (#1 & #4) of 4 (#1 - #4) patients reviewed for discharge summaries. Findings: Review of the hospital’s policy titled “Timely Documentation in Medical Record,” last revised on 03/21/2018 revealed in part: “Policy: Beacon Behavioral Hospital requires that Medical Records are complete within 30 days, per federal regulation. This policy relates to all personnel making entries into the patient’s Medical Record, including, but not limited to: -Physicians -Advanced Practice Registered Nurses -Physicians Assistants -Psychologists -Social Workers -Counselors -Nursing Staff -Other Personnel (as indicated).” Patient #1: Review of Patient #1’s medical record revealed she was discharged from the hospital on 12/05/2024. No “Discharge Summary” had been completed by the discharging physician. On 01/16/2025 at 10:30 AM, an interview was conducted with S2DON. He stated a “Discharge Summary” for a patient needs to be completed within 7 days of discharge. He confirmed no Discharge Summary had been completed on Patient #1 and should have been. Patient #4: Review of Patient #4’s medical record revealed she was discharged from the hospital on 12/07/2024. No “Discharge Summary” had been completed by the discharging physician. On 01/15/2025 at 1:18 PM, an interview was conducted with S2DON. He stated a “Discharge Summary” for a patient needs to be completed within 7 days of discharge. He confirmed no Discharge Summary had been completed on Patient #1 and should have been.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to ensure supplies were maintained to an acceptable level of safety and quality. This deficient practice was evidence by expired patient care supplies available for patient use. Findings: Observations during a walk-through of the hospital on 01/14/2025 from 11:05 AM to 12:20 PM revealed expired patient care supplies available for patient use and included: 1) BioTak PBS Solution Vials, quantity 111 vials, with an expiration of 12/04/2024; 2) BD Vacutainer Blue Top Vials, quantity 2 vials, with an expiration of 10/31/2024; 3) eSwab Collection & Preservation Swabs and Collection Vial Kit, quantity 23 kits, with an expiration of 10/20/2024; 4) Medline MicroKill+ Cleaning Wipes, quantity 1 container of 160 count wipes, with an expiration of 10/24/2024; and 5) Medline Lemon Glycerin Triple Pak Swab Sticks, quantity 12 packs, with an expiration of 12/2024. In an interview on 01/14/2025 and present on the hospital walk-through, S2DON confirmed the above mentioned findings.”