Compass Senior Care Hospital

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure grievances were resolved in a timely fashion and following established timelines. This deficient practice was evidenced by failure of the hospital representative to provide written communication to the complainant within 7 days as per hospital policy for 2 of 2 (#2, #3) patient grievances reviewed from a total sample of 3. Findings: Review of the hospital’s policy titled “PC-803: Patient Rights and Responsibilities”, revised 03/2025, revealed in part, “The Lead Investigator will provide the following written communication to the complainant within 7 days. -Description of complaint; -Steps taken to resolve complaint; -Date of completion/resolution” Patient #2 Review of the Grievance Form revealed Patient #2 filed a grievance with the hospital regarding sexually inappropriate behavior from another patient on 04/29/2025. Further review of the document revealed the level at which the resolution occurred was administrator resolved on 04/30/2025. Review of the written letter to Patient #2’s guardian revealed the letter was dated 05/12/2025. Patient #3 Review of the Grievance Form revealed Patient #3 filed a grievance with the hospital regarding sexually inappropriate behavior involving another patient on 04/29/2025. Further review of the document revealed the level at which the resolution occurred was administrator resolved on 04/30/2025. Review of the written letter to Patient #3’s guardian revealed the letter was dated 05/12/2025. In an interview on 05/29/2025 at 10:11 AM S3CCC verified the letters to Patient #2 and Patient #3’s guardians were not sent within 7 days as per hospital policy.”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed, and kept current, an individualized 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. This deficient practice was evidenced by failing to update the care plan of 1 of 1 (#3) patient records reviewed for treatment plans from a total sample of 3. Findings: Review of the hospital’s policy titled “PC-501: Treatment Plans”, effective date 07/10/2012, revealed in part, “Policy: Each patient will have an individualized inter-disciplinary treatment plan developed under the direction of the psychiatrist. This comprehensive plan is initiated upon admission following assessments by the various disciplines and will reflect the individual’s clinical needs, condition, functional strengths, and limitations. The treatment plan will coordinate treatment interventions and outline individualized specific short-term and long-term goals to evaluate therapeutic progress. The plan will be revised throughout the patient’s hospitalization to reflect progress towards the treatment goals. The treatment team is led by the attending psychiatrist and is a collaborative effort to ensure effective treatment planning.” Review of Patient #3’s medical record revealed an admission date of 04/09/2025 with a diagnosis of unspecified mood disorder. Further review of the record revealed Patient #3 was in restraints on 04/29/2025 and 05/12/2025. Review of the Behavioral Restraint/Seclusion Flowsheet dated 04/29/2025 revealed restraints were initiated at 5:45 PM and discontinued at 5:55 PM. Review of the Behavioral Restraint/Seclusion Flowsheet dated 05/12/2025 revealed restraints were initiated at 10:16 AM and discontinued at 10:50 AM. Review of the treatment plan failed to reveal the plan was updated after Patient #3 was placed in restraints. In an interview on 05/29/2025 at 11:47 AM S3CCC verified Patient #3’s treatment plan was not updated to include the intervention of restraints.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 44763 Based on observation, record review, and interview the hospital failed to ensure supplies were maintained to ensure an acceptable level of safety and quality. This deficient practice was evidenced by failure to ensure expired supplies were not available for patient use. Findings: Review of the hospital’s policy titled “EC-201: Unsafe Equipment / Repair / Product Recall / Warnings / Alerts”, effective date 07/02/2012, revealed in part, “Outdated Supplies: 2. When supplies are found to be expired or compromised, they shall be immediately removed from use and immediately replaced with new/sterile items. 3. No item will be processed for reuse once expiration date or compromising even occurs.” Observation of the hospital on 05/28/2025 at 10:09 AM - 10:38 AM accompanied by S1CEO and S2PD revealed the following supplies were expired and were located in the central supply room: 30 of 30 InteliSwab COVID-19 Rapid Test with an expiration date of 03/31/2024 In an interview during the observation S1CEO verified the above stated supplies were expired.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 44763 Based on observations and interviews the hospital failed to maintain a clean and sanitary environment to avoid transmission of infection in all areas of the hospital. This deficient practice was evidenced by 1) clean linen stored on top of the linen cart uncovered; 2) the upholstery of chairs were worn down exposing tiny holes to the seat and/or chair back; and 3) the top load washing machine had multiple rust areas noted to the door, around the top of the drum, and inside the drum and there was white powder caked between the door and drum. Findings: A tour of the hospital was conducted on 05/28/2025 at 10:09 AM - 10:38 AM accompanied by S1CEO and S2PD. Observation revealed clean linen stored on top of the clean linen cart uncovered located in the clean workroom. Observation revealed the upholstery of 9 chairs were worn down exposing tiny holes to the seat and/or chair back located in the group therapy room. Observation revealed the top load washing machine had multiple rust areas noted to the door, around the top of the drum, and inside the drum and there was white powder caked between the door and drum located in the laundry room. In an interview during the observation S1CEO and S2PD verified the above stated findings.”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure all allegations of abuse were handled as grievances. This deficient practice was evidenced by failure to document the complaint as a grievance and failing to provide a written notice of the grievance resolution after a complaint of sexual abuse was made for 2 of 2 (#1, #2) patients reviewed for grievances from a total sample of 3. Findings: Review of the hospital’s policy titled “PC-803: Patient Rights and Responsibilities” effective 08/06/2012, revealed in part, “Grievance Procedure: The patient has a right to be free from abuse, harassment, and neglect and from misappropriation of property, and to exercise all rights of a Patient under Louisiana and Federal law. Patients are entitled to information about the hospital’s mechanism for the initiation, review, and resolution of patient complaints. If a Patient believes that these or other rights (or the rights of another Patient) are being violated in any way that the staff cannot resolve or has not resolved, the Patient should bring the matter to the attention of the Charge Nurse or Administration. The Hospital hopes that Patients will make known any complaints about the services they receive, or grievance they may have with respect to another Patient and that all complaints can be immediately resolved. The Patient should submit the complaint to the Charge Nurse or Administration in writing or verbally, stating specifically the facts upon which the complaint is based and the decision or action the Patient seeks. Upon receiving a verbal complaint, a complaint report form will be completed by the employee receiving the complaint. Administration or administrative on-call personnel will be notified immediately upon receipt of a complaint. The patient has a right to complain regarding the quality of care and will receive response from the organization that substantially addresses the complaint.” Further review of the policy revealed in part, “The Lead Investigator will provide the following written communication to the complainant within 7 days. -Description of complaint -Steps taken to resolve complaint -Date of completion/resolution” Review of the grievance log revealed there were no documented grievances from this year (2025). Review of the initial Self- Report revealed in part, on 02/12/2025 Patient #1 told Patient #2 that S3MHT was inappropriate with her but then later recanted and told staff she was lying. Patient #2 wrote a letter to staff detailing inappropriate behavior between her and S3MHT as well as inappropriate behavior between S3MHT and Patient #1. In an interview on 03/17/2025 at 10:30 AM S2CCC stated Patient #1 wrote a letter stating that an employee, S3MHT touched her inappropriately and said inappropriate things to her. S2CCC stated Patient #1 told Patient #2 about S3MHT going into her room and being inappropriate. S2CCC stated Patient #2 then told Patient #1 that it happened to her too. S2CCC stated Patient #1 and Patient #2 wrote letters reporting the incidents. S2CCC stated Patient #1 wrote a letter reporting the incident and then right after, Patient #1 wrote another letter saying she was lying. In an interview on 03/17/2025 at 4:13 PM S2CCC verified the hospital did not document the complaints of alleged sexual abuse from Patient #1 and Patient #2 as grievances. S2CCC verified the hospital did not provide a written letter of the grievance resolution to Patient #1, Patient #2, or their guardians.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to investigate an alleged adverse patient event for 1 (#1) of 2 (#1, #2) patients involved in staff member-to-patient sexual abuse involving adolescents from a total sample of 3. Findings: Review of the hospital’s policy titled “PC-1017: Alleged Patient Abuse or Neglect During Hospitalization”, revised 09/2019, revealed in part, “Procedures: I. Whenever a staff member becomes aware that a patient has been abused or patient alleges abuse: c. The incident of alleged abuse does not have to be witnessed by staff member. Every report of alleged abuse is to be thoroughly investigated, while maintaining patient’s safety and privacy. k. An internal investigation of the alleged incident will be conducted to determine and record the facts of the incident.” Review of the initial Self- Report revealed in part, on 02/12/2025 Patient #1 told Patient #2 that S3MHT was inappropriate with her but then later recanted and told staff she was lying. Patient #2 wrote a letter to staff detailing inappropriate behavior between her and S3MHT as well as inappropriate behavior between S3MHT and Patient #1. Review of the final Self-Report included interviews that were conducted during the hospital investigation. The final Self-Report failed to include an interview that was conducted with Patient #1. In an interview on 03/17/2025 at 10:30 AM S2CCC stated Patient #1 wrote a letter stating that an employee, S3MHT touched her inappropriately and said inappropriate things to her. S2CCC stated Patient #1 told Patient #2 about S3MHT going into her room and being inappropriate. S2CCC stated Patient #2 then told Patient #1 that it happened to her too. S2CCC stated Patient #1 and Patient #2 wrote letters reporting the incidents. S2CCC stated Patient #1 wrote a letter reporting the incident and then right after, Patient #1 wrote another letter saying she was lying. In an interview on 03/17/2025 at 4:01 PM S2CCC stated the allegation was reported on 02/12/2025 night shift. She stated Patient #1 was discharged the next morning on 02/13/2025. In an interview on 03/17/2025 at 4:40 PM S2CCC verified there was no documentation of hospital staff interviewing Patient #1 after she reported the allegation and there was no investigation into her allegations.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44763 Based on observations, record reviews, and interviews, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks. Findings: Review of the hospital’s policy titled “PC-803: Patient Rights and Responsibilities” effective date 08/06/2012, revealed in part, “Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned”. Observation on 12/16/2024 at 10:15 a.m. - 10:55 a.m. of the hospital accompanied by S1CEO, S2DON, S3CD, and S4CO revealed in the bathroom of rooms ‘a’, ‘b’, ‘f’, and ‘h’ there was a gap between the toilet and the wooden built-in creating an anchor point and ligature risk. During the observation at 10:43 a.m. in room ‘f’ S3CD was observed to get a sheet around the toilet through the gap between the toilet and the wooden built-in. In the bathrooms of rooms ‘b’ and ‘g’ there were 2 handrails in each shower that had a gap between the wall and handrail creating an anchor point and ligature risk. In the bathrooms of rooms ‘a’, ‘b’, ‘f’, ‘h’, ‘g’, and ‘e’ the shower outlet had to be connected to a hose that the shower head was attached to creating a ligature risk. In an interview during the observation S1CEO and S3CD verified the above stated findings. Observation on 12/17/2024 at 2:24 p.m. - 2:40 p.m. of the hospital accompanied by S3CD revealed in the bathroom of rooms ‘d’ and ‘c’ there was a gap between the toilet and the wooden built-in creating an anchor point and ligature risk. In the bathrooms of rooms ‘d’ and ‘c’ the shower outlet had to be connected to a hose that the shower head was attached to creating a ligature risk. In an interview during the observation S3CD verified the above stated findings. S3CD verified all showers are the same in all patient bathrooms and requires the hose with the shower head to be connected to the outlet to be able to use the shower. Observation on 12/17/2024 at 2:24 p.m. - 2:40 p.m. of the 2 shower heads with the hose attached revealed each hose was approximately 4 foot in length making the hose a safety risk for patients. In an interview during the observation S1CEO and S3CD verified the 2 shower heads with the hose attached revealed each hose was approximately 4 foot in length.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) who performed the face-to-face evaluation after the initiation of restraints or seclusion consulted with the attending physician or other licensed practitioner as soon as possible after the evaluation for 1 (#3) of 3 (#1, #2, #3) patient records reviewed. Findings: Review of the hospital’s policy titled “PC-1502: Restraints and Seclusion Use” revised 03/18/2024, revealed in part, “l. If the face-to-face evaluation is conducted by someone other than the patient’s attending physician, the person completing the face-to-face evaluation must consult the attending physician or other licensed independent practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation.” Review of Patient #3’s medical record revealed an admission date of 11/07/2024. Further review of the record revealed restraints were initiated on 11/24/2024 at 10:29 a.m. and discontinued at 11:50 a.m. Review of the restraint documentation, the 1 hour face-to-face evaluation was conducted by S5RN on 11/24/2024 at 11:20 a.m. Further review of the restraint documentation failed to reveal documentation of the RN consulting with the attending physician as soon as possible after the completion of the 1 hour face-to-face evaluation. Further review of Patient #3’s medical record revealed restraints were initiated on 11/24/2024 at 6:15 p.m. and discontinued at 8:15 p.m. Review of the restraint documentation, the 1 hour face-to-face evaluation was conducted by S5RN on 11/24/2024 at 7:15 p.m. Further review of the restraint documentation failed to reveal documentation of the RN consulting with the attending physician as soon as possible after the completion of the 1 hour face-to-face evaluation. In an interview on 12/17/2024 at 1:01 p.m. S3CD verified there was no documentation of the RN consulting with the physician after the completion of the 1 hour face-to-face evaluation for both restraint occurrences included in Patient #3’s medical record.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iii) [there must be documentation in the patient’s medical record of] Alternatives or other less restrictive interventions attempted (as applicable); This Standard is not met as evidenced by: 44763 Based on record reviews and interview, the hospital failed to ensure there was documentation of alternatives or less restrictive interventions attempted prior to initiating the use of restraints for 1 (#3) of 3 (#1, #2, #3) patient medical records reviewed. Findings: Review of the hospital’s policy titled “PC-1502: Restraints and Seclusion Use” revised 03/18/2024, revealed in part, “(G) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: c. Alternatives or other less restrictive interventions attempted (as applicable)” Review of Patient #3’s medical record revealed an admission date of 11/07/2024. Further review of the record revealed restraints were initiated on 11/24/2024 at 6:15 p.m. and discontinued at 8:15 p.m. Review of the restraint documentation failed to reveal documentation of less restrictive interventions implemented/attempted. In an interview on 12/17/2024 at 1:01 p.m. S3CD verified there was no documentation of less restrictive interventions implemented/attempted prior to placing Patient #3 in restraints on 11/24/2024 at 6:15 p.m.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 44763 Based on record reviews and interview, the hospital failed to ensure all nursing staff received training and demonstrated competency for the use of restraints and seclusion. This deficient practice was evidenced by no documentation of competencies for the use of restraints and seclusion for 3 (S5RN, S6RN, S7RN) of 6 (S5RN, S6RN, S7RN, S8MHT, S9MHT, S10MHT) personnel records reviewed for training and competencies for the use of restraints and seclusion. Findings: Review of the hospital’s policy titled “Restraints and Seclusion Use” revised 03/18/2024, revealed in part, “(D) Documentation will be maintained in staff personnel records that training and demonstration of competency were successfully completed.” Review of S5RN, S6RN, and S7RN’s personnel records failed to reveal documentation of competencies for the use of restraints and seclusion. In an interview on 12/17/2024 at 3:40 p.m. S1CEO verified there was no documentation of restraint and seclusion competencies included in S5RN, S6RN, and S7RN’s personnel records.”