Freedom Behavioral Hospital of Bastrop

“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: 40957 Based on record review and interview, the hospital failed to ensure all allegations of abuse were handled as grievances. The deficient practice is evidenced by failure to document the complaint as a grievance and failing to provide a written notice of the grievance resolution and results decision after a complaint of sexual abuse was made for 1 (Patient#1) of 1 (Patients #1) reviewed for grievances. Findings: Review of the medical record for Patient #1 revealed the patient disclosed to S5CSW on 02/11/2025 that he had been sexually assaulted the previous day. Review of the Hospital’s incident report revealed the following, in part: Note by S3RN- “On 02/10/2025 at 6:05 PM, myself and S4LPN was watching cameras and saw Patient #1 in Patient #2’s room and we saw Patient #2 pull Patient #1’s penis out and perform oral sex on Patient #1, after a minute or so Patient #2 appeared to get Patient #1 to go to his bathroom and that is when Patient #1 left the room and went to dayroom and sat down.” During an interview on 02/20/2025 at 12:20 PM, S1ADM and S2DON reported they did not file a grievance for Patient #1 after the incident occurred and the patient did not receive a letter after the incident was investigated.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40957 Based on record review and interview, the hospital failed to ensure a patient remained free from abuse for 1 (Patient #1) of 1 (Patients #1) patients reviewed, as evidenced by failure to implement immediate interventions to prevent further occurrence after a witnessed episode of sexual interaction. Findings: Review of the hospital’s incident report dated 02/10/2025 revealed the following, in part: Patient to patient sexual assault. Date of incident 02/10/2025. Time of incident 6:03 PM, 7A-7P shift. Date of discovery 02/11/2025 at 11:50 AM. Location main campus, Unit A. Specific location patient room. Victim Patient #1 Aggressor Patient #2 Video surveillance- yes. Video was reviewed by S1AIT and S2DON. Video showed the following: 6:02 PM Patient #2 and Patient #1 both seen in the day room. 6:03:18 PM Patient #2 is seen at his door talking to someone off camera. 6:03:27 PM Patient #1 seen entering Patient #2’s room. 6:03:31 PM Patient #2 seen fondling Patient #1’s penis. 6:03:48 PM Patient #2 seen inserting Patient #1’s penis in his mouth. 6:03:59 PM Oral activity noted to be finished. 6:04:02 PM Patient #2 seen taking Patient #1’s hand and leads him into the door of the bathroom. 6:04:08 PM Patient #1 is noted to turn around and walk away. 6:04:12 PM Patient #1 noted to exit patient’s room. 6:04:20 PM Patient #1 returns to day room. 6:04:35 PM Patient #2 returns back to the day room . On 02/19/2025 at 2:15 PM, S1AIT played the video of Patient #1 and Patient #2. Timeline above was accurate. No sound was noted during the video. Patient #1 did not appear to resist the advances, until Patient #2 held his hand and was trying to get Patient #1 to the bathroom and then Patient #1 let go of Patient #2’s hand and walked out. Then Patient #2 left out of his room shortly after Patient #1 left the room. Video of the hallway where Patient #2’s room was viewed. Patient #2 went inside his doorway and was summoning Patient #1 to Patient #2’s room. Then you could see Patient #1 exiting room 18:04:15-20. Patient #2 exited the room 1-2 seconds after Patient #1 left the room. Review of the Hospital’s incident report revealed the following, in part: Note by S3RN- 02/10/2025, At 6:05 PM, myself and S4LPN was watching cameras and saw Patient #1 in Patient #2’s room and we saw Patient #2 pull Patient #1’s penis out and perform oral sex on Patient#1, after a minute or so Patient #2 appeared to get Patient #1 go to his bathroom and that is when Patient #1 left the room and went to dayroom and sat down. During an interview on 02/20/2025 at 9:30 AM, S4LPN reported he saw the video monitoring in the nurse station and saw Patient #1 and Patient #2 in Patient #2’s room and then he saw Patient #2 delivering oral sex and S4LPN went out to go to the room and they had already walked out of the room. S4LPN further reported that Patient #1 and Patient #2 didn’t say anything about what happened, they both just carried on with their daily routine. During an interview on 02/20/2025 at 9:38 PM, S5MHT indicated she had gotten up out of her chair to talk to another MHT and she saw S4LPN coming out of nurse room and by the time he came out and she got up Patient #1 and Patient #2 had already came out Patient #2’s room. Review of Therapist notes revealed the following, in part: (Meeting with Patient #2) At 11:39 AM, therapist met with assigned patient regarding the incident that took place on 02/10/2025 at approximately 6:05 PM. There was a sexual contact incident between Patient #1 and Patient #2. Therapist met with Patient #2 regarding sexual inappropriate contact with another patient. Patient #2 was reluctant to discuss the incident and made light of the situation. As Patient #2 discussed the incident he was laughing and slightly grinning. According to Patient #2, Patient #1 comes by the room to say “Hi” to everyone throughout the day. The difference in 02/10/2025 is that Patient #1 entered Patient #2’s room instead of continuing down the hall. Patient #2 is unsure why the patient entered his room on this day. Patient #2 admitted to touching Patient #1’s private area initially and states, “He touched mine and that was that he ran out.” Patient #2 further admits to performing oral on the patient and states, “It was fast.” Patient #2 states there was no communication between the two prior to the incident. Patient #2 further explains there was no consent to touch by either himself or Patient #1. The patient admitted it was wrong, and it was “spur of the moment.” (Meeting with Patient #1) At approximately 11:50 AM, S6CSW, initiated a conversation with Patient #1 to discuss the incident that took place yesterday, 02/10/2025, at approximately 1800 with Patient #2. The therapist informed the patient that a report was made of the incident and the therapist wanted to hear from him about what took place in Patient #2’s room. The patient was informed that there are cameras on the facility. Initially Patient #1 stated nothing happened. The Therapist asked the patient what he went into the bedroom for, he stated because Patient #2 wanted him to look at his toilet. The therapist asked Patient #1 did he go into Patient #2’s room willing and he stated yes. He was asked what happened in the bedroom and he said nothing. The Therapist informed Patient #1 that therapist was there for him if he needs to talk or discuss anything and if nothing else he could return to the dayroom. As the therapist and MHT walked back into dayroom, Patient #1 tapped the therapist on shoulder and stated he needed to talk. Patient #1 and the therapist walked back down the hall and Patient #1 stated, “I was raped.” The therapist asked him what happened, and he stated Patient #2 asked him to come with hime to his bedroom to look at his toilet. He stated once he entered the bedroom Patient #2 pulled his pants down and began to suck his d**k. The therapist asked did he tell him to stop. He stated “no, but I did not want him to do that.” The therapist asked why he did not stop him and he stated he was scared but Patient #2 asked him to go into the bathroom and he ran out of the room. In an interview on 02/19/2025 at 1:40 PM, SAIT verified the facility became aware of the incident shortly after it occurred on 02/10/2025 and at the time the sexual conduct was considered as consensual. SAIT verified there were no orders for increased observation on 02/10/2025. SAIT verified on 02/11/2025 Patient #1 reported that the sexual act was not consensual. S1AIT then reported to the police department. Police came to the hospital and questioned both Patient #1 and Patient #2. Patient #2 was place on 1:1 after physician was notified (02/11/2025). Law enforcement charged Patient #2. During an interview on 02/20/2025 at 12:00 PM, S4LPN reported he had told the MHTs to keep Patient #1 and Patient #2 separated. When asked if had charted anything related to what he told the MHTs, S4LPN and S2DON reviewed the record and reported there was not any charting completed related to the MHTs being told to keep the two patients separated.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that patients had the right to participate in the implementation of his or her plan of care. This was evidenced by the hospital failing to involve the patient in discharge planning for 3 of 3 sampled patients (Patient #1, 2, 3). Findings: Patient #1 Review of the medical record revealed an 17 year old female with admission date of 09/30/2024 with a diagnosis of major depression. Review of the patient’s treatment plan, signed off by S6MD on 11/25/2024, revealed that the patient improved with treatment and appointments were made with the patient’s primary physician and for the local behavioral health center. The treatment plan revealed that the patient was discharged and accompanied by her guardian. There was no indication where the patient was discharged to. Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital). There was no documentation in the record that the patient was involved in the discharge planning. Patient #2 Review of the medical record revealed an 11 year old female who was admitted to the hospital on 10/02/2024 with admitting diagnosis of persistent mood (affective) disorders. Review of S6MD’s progress note dated 11/26/2024 revealed the patient was deemed stable for discharge and was discharging to Hospital A and all follow-up appointments to be managed by guardian. Review of the nursing discharge summary dated 11/26/2024 revealed the patient was discharged to DCFS worker. Under “facility type”, group home was indicated. There was no documentation in the record that the patient was involved in the discharge planning. Patient #3 Review of the medical record revealed an admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations. Review of the patient’s discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient’s short term goals were met and the patient was discharging to Hospital A. Review of the form titled, Discharge Continuing Care Plan, revealed that this plan was signed off by the nurse and physician on 11/26/2024 at 11:59AM, and stated that the patient was discharged home accompanied by guarantor. There was no documentation in the record that the patient was involved in the discharge planning. On 12/30/2024 at 3:00PM, interview with S2Transportation revealed that he drove the van that transported Patients #1, 2 and 3 to Hospital A on 11/26/2024. S2Transportation stated that he was told by the staff at the hospital not to tell the patients where they were being transferred to and stated that the patients thought they were going home. Further interview with S2Transportation revealed that after pulling up to Hospital A’s campus, the patients saw the sign and became upset and eventually jumped out of the van and attempted to elope. On 01/02/2025 at 9:30AM, interview with S4Discharge Planner revealed that Patients #1, 2 and 3 did jump from the transportation van when they arrived at Hospital A because they stated they did not want to go there. She also stated there was contradictory information in the above records regarding discharge plans. S4Discharge Planner confirmed that there was no evidence that Patients #1, 2, and 3 were involved in their discharge planning. 40957”

“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 ensure the QAPI program took actions aimed at performance improvement as evidenced by failing to implement a performance improvement plan for discharges after three patients eloped from the transport van while being transferred to another hospital (Patients #1, 2, 3). Findings: Review of the hospital policy titled, Case Management-Discharge Planning (Dec. 2023) revealed in part that this organization monitors the effectiveness and compliance of the proactive comprehensive discharge planning process by conducting record of care audits daily and/or per admission. The organization also conducts quality monitoring of completeness of the Discharge Continuing Care Plan daily and/or per discharge occurrence. Patient #1 Review of the medical record revealed an 17 year old female with admission date of 09/30/2024 with a diagnosis of major depression. Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital). Patient #2 Review of the medical record revealed an 11 year old female who was admitted to the hospital on 10/02/2024 with admitting diagnosis of persistent mood (affective) disorders. Review of S6MD’s progress note dated 11/26/2024 revealed the patient was deemed stable for discharge and was discharging to Hospital A. Patient #3 Review of the medical record revealed an admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations. Review of the patient’s discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient’s short term goals were met and the patient was discharging to Hospital A. On 12/30/2024 at 3:00PM, interview with S2Transportation revealed that he drove the van that transported Patients #1, 2 and 3 to Hospital A on 11/26/2024. S2Transportation stated that he was told by the staff at the hospital not to tell the patients where they were being transferred to and stated that the patients thought they were going home. Further interview with S2Transportation revealed that after pulling up to Hospital A’s campus, the patients saw the sign and became upset and eventually jumped out of the van and attempted to elope. On 01/02/2025 at 9:30AM, interview with S4Discharge Planner revealed that Patients #1, 2, and 3 did jump from the transportation van when they arrived at Hospital A because they stated they did not want to go there. When asked if a quality improvement plan was implemented after the incident with the above patients to prevent future occurrences, she stated no. When asked if there was a current quality improvement plan that addressed discharges/discharge planning, she stated no.”

“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: 17450 Based on record review and interview, the hospital failed to ensure medical records for each patient are complete and accurately written for 3 of 3 records reviewed (Patient #1, 2, 3). Findings: Patient #1 Review of the medical record revealed a 17 year old female with admission date of 09/30/2024 and a discharge date of 11/26/2024. Review of the patient’s treatment plan, signed off by S6MD on 11/25/2024, revealed that the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented. There was no indication where the patient was discharged to. Review of a form titled, Discharge Continuing Care Plan, dated 11/26/2024 at 2:13PM and completed by the RN revealed the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented. Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital). On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital’s van) on 11/26/2024. She further confirmed that the patient was not accompanied by her guardian, as noted on the above Discharge Continuing Care Plan. S4Discharge Planner further confirmed that the above records were incomplete and/or inaccurate. Patient #2 Review of the medical record revealed a 11 year old female with admission date of 10/02/2024 with a diagnosis of persistent mood (affective) disorders. Review of the patient’s discharge nursing summary dated 11/26/2024 revealed the patient was discharged to Group Home B with DCFS worker. On 12/30/2024 at 2:15PM, interview with S4Discharge Planner revealed that the patient was not accepted to the group home but was transferred to Hospital A (per this hospital’s van) on 11/26/2024. She further confirmed that the patient’s discharge nursing summary was inaccurate. Patient #3 Review of the medical record revealed a 10 year old female with admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations. Review of the patient’s discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient’s short term goals were met and the patient was discharging to Hospital A. Review of the form titled, Discharge Continuing Care Plan, revealed that this plan was signed off by the nurse and physician on 11/26/2024 at 11:59AM, and stated that the patient was discharged home accompanied by guarantor. Review of the Close Observation form dated 11/26/2024 revealed the patient monitoring stopped at 3:00PM, with “discharged” written at that time. Review of the medical record revealed a group therapy note dated 11/26/2024 from 8:00PM - 8:11PM, stating the patient had fair participation. However, the patient had already been discharged from the hospital prior to that time. On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital’s van) on 11/26/2024 and was not accompanied by her guarantor. She further stated that the group therapy note on 11/26/2024 at 8:00PM was inaccurate because the patient was not a patient at the hospital at that time. S4Discharge Planner further confirmed that the above records were contradictory and inaccurate.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure the discharge plan was updated and reflected any changes for 3 of 3 discharged patients reviewed (Patient #1, 2, 3). Findings: Review of the hospital policy titled, Case Management-Discharge Planning (Dec. 2023) revealed in part that reassessment of the discharge planning process is performed on an ongoing basis to determine the needs of each patient at the hospital. Patient #1 Review of the medical record revealed a 17 year old female with admission date of 09/30/2024 with a diagnosis of major depression. Review of the patient’s treatment plan, signed off by S6MD on 11/25/2024, revealed that the patient improved with treatment and appointments were made with the patient’s primary physician and for the local behavioral health center. The treatment plan revealed that the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented. There was no indication where the patient was discharged to. Review of a form titled, Discharge Continuing Care Plan, dated 11/26/2024 at 2:13PM and completed by the RN revealed the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented. Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital). There was no documentation in the record that Hospital A accepted Patient #1. There was no documentation in the record of when the patient left the hospital or who the patient was accompanied by. There was also no documentation regarding who the patient was released to at Hospital A. On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital’s van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. S4Discharge Planner confirmed that there was no documented evidence in the record of whom from Hospital A accepted Patient #1. She further stated that the patient had multiple notes regarding discharge plans but they were not updated and did not reflect changes that were made. Patient #2 Review of the medical record revealed a 11 year old female with admission date of 10/02/2024 with a diagnosis of persistent mood (affective) disorders. Review of the patient’s discharge nursing summary dated 11/26/2024 revealed the patient was discharged to Group Home B with DCFS worker. On 12/30/2024 at 2:15PM, interview with S4Discharge Planner revealed that the patient was not accepted to the group home but was transferred to Hospital A (per this hospital’s van) on 11/26/2024. She stated that this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. S4Discharge Planner confirmed that there was no documented evidence in the record of whom from Hospital A accepted Patient #2. She further confirmed the patient’s discharge plan was not updated or accurate. Patient #3 Review of the medical record revealed a 10 year old female with admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations. Review of the patient’s discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient’s short term goals were met and the patient was discharging to Hospital A. Review of the form titled, Discharge Continuing Care Plan, revealed that this plan was signed off by the nurse and physician on 11/26/2024 at 11:59AM, and stated that the patient was discharged home accompanied by guarantor. There was no documentation in the record that Hospital A accepted Patient #3. There was no documentation in the record of when the patient left the hospital or who the patient was accompanied by. There was also no documentation regarding who the patient was released to at Hospital A. Review of nurses notes dated 11/26/2024 at 1:57PM revealed “see discharge summary”. The nurse did not document the time the patient left the hospital. On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital’s van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. S4Discharge Planner confirmed that there was no documented evidence in the record of whom from Hospital A accepted Patient #3. She further stated that the patient had discharge planning notes regarding discharge plans for home and for Hospital A. S4Discharge Planner confirmed that the patient’s discharge plans were not updated with changes. 40957”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure an appropriate discharge plan was developed and implemented for 3 of 3 discharged patients reviewed (Patient #1, 2, 3). Findings: Patient #1 Review of the medical record revealed a 17 year old female with admission date of 09/30/2024 with a diagnosis of major depression. Review of the contact log revealed the last contact note was dated 11/19/2024 when a voicemail message was left with the patient’s DCFS worker. Contact note dated 11/15/2024 at 3:02PM revealed voicmail left with DCFS worker to get update on placement with updated discharge date of 11/16/2024. Review of the patient’s treatment plan, signed off by S6MD on 11/25/2024, revealed that the patient improved with treatment and appointments were made with the patient’s primary physician and for the local behavioral health center. The treatment plan revealed that the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented. There was no indication where the patient was discharged to. Review of a form titled, Discharge Continuting Care Plan, dated 11/26/2024 at 2:13PM and completed by the RN revealed the patient was discharged and accompanied by her guardian. Under discharge location, nothing was documented. Review of the nursing discharge summary dated 11/26/2024 at 2:20PM revealed the patient was being transferred to Hospital A (another behavioral health hospital). There was no documentation in the record that Hospital A accepted Patient #1 or that Hospital A was notified that the patient was clinically discharged and was only waiting for DCFS placement. There was no documentation in the record of when the patient left the hospital or who the patient was accompanied by. There was also no documention regarding who the patient was released to at Hospital A. On 12/30/2024 at 11:30AM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital’s van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. She further confirmed that Patient #1 had been clinically discharged for a while and was only waiting for another DCFS placement. When asked if there was any documented evidence in the record that Hospital A was informed that the patient was clinically discharged and only waiting for DCFS placement, S4Discharge Planner stated no. She stated that she emailed all of the patient’s records to Hospital A but none mentioned that patient was only awaiting DCFS placement. S4Discharge Planner further confirmed that a “Transportation Sheet” was supposed to be completed on all transfers which included driver assigned to transport, name of facility, person releasing patient, person receiving patient and date/time and signatures of each person. She stated this form was not completed for Patient #1 and she was unsure exactly when the patient was transported or what staff at Hospital A received her. Patient #2 Review of the medical record revealed a 11 year old female with admission date of 10/02/2024 with diagnoses including persistent mood (affective) disorders. Review of the patient’s discharge summary completed by S6MD, dated 11/26/2024 at 6:55AM, revealed that the patient’s short term goals were met and the patient was stable for discharge. The patient was discharging to Hospital A and all follow-up appointments to be managed per guardian. Review of the form titled, Discharge Continuing Care Plan, revaled that this plan was signed off by S4 Discharge Planner. S4 Disharge Planner signed off on 11/26/2024 at 5:48PM. The plan stated that Patient #2 was transferred to another facility. The physician signed off on 11/26/2024 at 12:03PM. Discharge, other, long term. On 12/30/2024 at 2:30PM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital’s van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. She further confirmed that Patient #2 had been clinically discharged and was only waiting for another DCFS placement. When asked if there was any documented evidence in the record that Hospital A was informed that the patient was clinically discharged and only waiting for DCFS placement, S4Discharge Planner stated no. She stated that she emailed all of the patient’s records to Hospital A but none mentioned that patient was only awaiting DCFS placement. S4Discharge Planner further confirmed that a “Transportation Sheet” was supposed to be completed on all transfers which included driver assigned to transport, name of facility, person releasing patient, person receiving patient and date/time and signatures of each person. She stated this form was not completed for Patient #2 and she was unsure exactly when the patient was transported or what staff at Hospital A received her. Patient #3 Review of the medical record revealed a 10 year old female with admission date of 08/31/2024 with diagnoses including major depression and suicidal ideations. Review of the contact log revealed the last contact note (by the therapist) was dated 11/21/2024 when the patient’s DCFS worker was contacted to discuss placement with at discharge date of 11/16/2024. The therapist informed case worker that this hospital would no longer be able to house the patient after next week. Review of the patient’s discharge summary completed by S6MD, dated 11/26/2024 at 7:20AM, revealed that the patient’s short term goals were met and the patient was discharging to Hospital A. Review of the form titled, Discharge Continuing Care Plan, revaled that this plan was signed off by the nurse and physician on 11/26/2024 at 11:59AM, and stated that the patient was discharged home accompanied by guarantor. Review of nurses notes dated 11/26/2024 at 1:57PM revealed “see discharge summary”. The nurse did not document the time the patient left the hospital or who accompanied the patient. On 12/30/2024 at 2:30PM, interview with S4Discharge Planner revealed that the patient was transferred to Hospital A (per this hospital’s van) on 11/26/2024 because this hospital was not going to be admitting children anymore and they were either discharging or transferring all of their patients to other hospitals. She further confirmed that Patient #3 had been clinically discharged and was only waiting for another DCFS placement. When asked if there was any documented evidence in the record that Hospital A was informed that the patient was clinically discharged and only waiting for DCFS placement, S4Discharge Planner stated no. She stated that she emailed all of the patient’s records to Hospital A but none mentioned that patient was only awaiting DCFS placement. S4Discharge Planner further confirmed that a “Transportation Sheet” was supposed to be completed on all transfers which included driver assigned to transport, name of facility, person releasing patient, person receiving patient and date/time and signatures of each person. She stated this form was not completed for Patient #3 and she was unsure exactly when the patient was transported or what staff at Hospital A received her. 40957”

“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 provide care in a safe setting for 5 of 5 sampled patients. This is evidenced by 1) failing to ensure that Patients #1 and #2 did not engage in sexual activity without the staff awareness and 2) failing to ensure Patients #1, #2, #3, #4 and #5 were observed per ordered observation levels. Findings: 1) Failing to ensure that Patients #1 and #2 did not engage in sexual activity without the staff awareness Review of an LDH self-report (dated 10/05/24) revealed in part that during the morning report on 10/05/2024, it was reported that Patient #1 had stuffed her bed the night before and was not in her bed when the night shift tech was performing rounds. The tech was unaware that the patient was not in her bed. Upon the 10/05/2024 day shift tech arriving, she noticed a “hickey” on Patient #2’s neck and the other patients reported that Patient #1 and Patient #2 had engaged in sexual behaviors the night before. This allegedly took place in the bathroom of Patient #2. Review of psychiatric evaluation, dated 10/01/2024, for Patient #1 revealed the patient had a history of sexual abuse. Further review revealed physician orders for routine every 15 minute observation level. Review of the medical record for Patient #2 revealed an admission date of 10/02/2024. The patient was placed on routine every 15 minute observation level. Review of the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 10/04/2024 at 9:15 p.m. until 10/05/2024 at 6:15 a.m. revealed the tech documented the patients were in their rooms asleep in bed with eyes closed (during the alleged incident). On 10/23/2024 at 9:45 a.m., interview with S1Compliance revealed that Patient #1 admitted to stuffing her bed and going to Patient #2’s room during the night to perform sexual activities. S1Compliance confirmed that Patient #1 and #2 were not observed and monitored every 15 minutes as required, when the above alleged incident occurred. When asked if there was any documented education for the staff after this incident occurred regarding the observation of patients to ensure they are alive and breathing on rounds, he stated no. 2) Failing to ensure Patients #1, #2, #3, #4 and #5 were observed per ordered observation levels Review of the hospital policy titled, Admission Assessment Management-Safety Precautions (December 2023), revealed in part that patients on routine every 15 minute observation level should be observed every 15 minutes and the observation is logged by the observer on the Close Observation form. Review of the medical record for Patient #1 revealed routine every 15 minute observation level was ordered. Review of the observation log dated 10/03/2024 revealed the log stopped at 5:45 a.m. and did not pick up until 7:00 a.m. (no observations for one hour, 15 minutes). The RN signed off on the observation log during this time frame as being completed, but it was blank. Review of the medical record for Patient #2 revealed routine every 15 minute observation level was ordered. Review of the observation sheet dated 10/16/2024 revealed the log stopped at 4:00 p.m. and did not pick up until three hours later, at 7:00 p.m. Review of the medical record for Patient #3 revealed an admission date of 10/11/2024 with orders for every 15 minute routine observations. Review of the patient’s observation logs from admit until discharge on 10/16/2024 revealed there was no observation log for the night shift (7PM-7AM) on 10/12/2024. Review of the medical record for Patient #4 revealed an admission date of 10/02/2024 with orders for routine every 15 minute observation level. Review of the patient’s observation logs from admit to present revealed the following missing observation logs for the night shift (7PM-7AM): 10/19/2024, 10/12/2024, 10/08/2024, 10/06/2024, 10/05/2024. Review of the medical record for Patient #5 revealed and admission date of 10/02/2024 with orders for routine every 15 minute observation level. Review of the patient’s observation logs from admit to present revealed the following missing observation logs: 10/21/2024 - day shift (7AM-7PM) 10/19/2024 - night shift (7PM-7AM) 10/16/2024 - day shift 10/13/2024 - day shift 10/07/2024 - no observation sheets for this day 10/03/2024 - day shift On 10/23/2024 at 1:45 p.m., S2RN reviewed Patient #5’s record and confirmed she was unable to locate the missing observation logs. She further stated that the hospital has been using a lot of agency staff and they may have misplaced the logs. On 10/23/2024 at 3:00 p.m., interview with S1Compliance confirmed that the above missing observation logs for Patients #3, #4 and #5 were unable to be located. S1Compliance further confirmed that the patients were not being monitored/observed as ordered.”

“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 ensure the QAPI program took actions aimed at performance improvement as evidenced by failing to implement a performance improvement plan after two patients (Patient #1 and #2) were not observed per ordered observation level and engaged in sexual behaviors. Findings: Review of an LDH self-report (dated 10/05/24) revealed in part that during the morning report on 10/05/2024, it was reported that Patient #1 had stuffed her bed the night before and was not in her bed when the night shift tech was performing rounds. The tech was unaware that the patient was not in her bed. Upon the 10/05/2024 day shift tech arriving, she noticed a “hickey” on Patient #2’s neck and the other patients reported that Patient #1 and Patient #2 had engaged in sexual behaviors the night before. This allegedly took place in the bathroom of Patient #2. Review of the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 10/04/2024 at 9:15 a.m. until 10/05/2024 at 6:15 a.m. revealed the tech documented the patients were in their rooms asleep in bed with eyes closed. On 10/23/2024 at 9:45 a.m., interview with S1Compliance confirmed that Patient #1 and #2 were not observed and monitored every 15 minutes as required, when the above alleged incident occurred. S1Compliance confirmed Patient #1 had stuffed her bed with sheets, making it look like she was in bed. When asked if there was any performance improvement plan implemented after this incident to ensure that observations were being accurately performed, he stated no. When asked if there was any education provided to the staff after this incident regarding the observation of patients on rounds to make sure they are alive and breathing, he stated no. Further review of the medical records for Patients #1, #2, #3, #4 and #5 revealed their observation logs had gaps in documentation of observations and/or multiple missing observation logs. On 10/23/2024 at 2:30 p.m., interview with S1Complaince revealed that the hospital currently had a performance improvement plan in place for monitoring for completeness of the observation logs and had been doing this for several months. S1Compliance stated that S3BHT Lead had been completing the monitoring of the logs and turns the information into him weekly. The surveyor requested the most current data, and at that time S1Compliance reviewed his computer and stated the last time data had been turned in was on 09/16/2024. At that time, S1Compliance called S3BHT Lead on the phone and she stated she had not been performing any monitoring of the observation logs. S1Compliance stated he did not realize that monitoring was not being performed, although he had not received any data in over a month. S1Compliance then confirmed that there was no current monitoring of observation logs.”

“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 hospital failed to ensure that the registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to have a policy in place to follow for safety precautions (suicide, elopement, homicidal/assault, hypersexual) as ordered by the physician for 3 of 3 patients reviewed for precautions (Patient #1, #2, #3). Findings: 1. Review of the medical record for Patient #1 revealed an admission date of 09/30/2024 with diagnoses including major depressive disorder and suicidal ideations. Review of the physician orders revealed the physician ordered the patient to be placed on suicidal precautions on 10/01/2024 and hypersexual precautions on 10/05/2024. 2. Review of the medical record for Patient #2 revealed an admission date of 10/02/2024 with a diagnosis of suicidal ideations. Review of the nurses notes dated 10/03/2024 revealed the patient was on suicidal precautions. Review of the physician orders dated 10/05/2024 revealed the physician ordered the patient to be placed on hypersexual precautions. 3. Review of the medical record for Patient #3 revealed an admission date of 10/11/2024 with a diagnosis of disruptive mood dysregulation disorder. The patient was under OJJ custody. Review of the physician orders dated 10/11/2024 revealed the physician ordered the patient to be placed on elopement precautions and assault/violence precautions. Review of the hospital policy titled, Admission Assessment Management-Safety Precautions (December 2023), revealed in part that prior to admission and upon admission, patients are assessed for high risk indicators which require safety precaution interventions. Recognized precaution interventions are as follows: suicide precautions, homicide/violence/aggression precautions, elopement precautions. The policy did not indicate interventions that would be utilized for patients on these precautions. On 10/23/2024 at 11:20 a.m., interview with S1Compliance confirmed there was no policy developed that instructed the nursing staff and techs on what interventions to implement for patients on specific precautions. S1Compliance further also confirmed that “hypersexual” precautions was not even addressed in the policy, although Patients #1 and #2 are currently on hypersexual precautions. When asked what the specific interventions would be for these specific precautions, S1Compliance stated he was unsure. On 10/23/2024 at 1:00 p.m., interview with S4BHT revealed that patients on specific precautions (such as suicidal, homicidal, hypersexual) would be placed on 1:1 monitoring and that they would be watched a little closer. On 10/23/2024 at 1:22 p.m., interview with S5BHT revealed that patients on specific precautions (such as suicidal, homicidal, hypersexual) would be watched a little more and stated she would keep a “close eye on them”. When asked if anything extra is done with these patients on special precautions than patients who don’t have them, she stated no.”

“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: 17450 Based on observation, record review and interview, the hospital failed to maintain an accurate medical record for 2 (Patient #1, #2) of 5 sampled patients (Patients #1-5) who had orders for observation levels every 15 minutes. Findings: Review of an LDH self-report (dated 10/05/24) revealed in part that during the morning report on 10/05/2024, it was reported that Patient #1 had stuffed her bed the night before and was not in her bed when the night shift tech was performing rounds. The tech was unaware that the patient was not in her bed. Upon the 10/05/2024 day shift tech arriving, she noticed a “hickey” on Patient #2’s neck and the other patients reported that Patient #1 and Patient #2 had engaged in sexual behaviors the night before. This allegedly took place in the bathroom of Patient #2. Review of the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 10/04/2024 at 9:15 p.m. until 10/05/2024 at 6:15 a.m. revealed the tech documented the patients were in their rooms asleep in bed with eyes closed (during the alleged incident). On 10/23/2024 at 9:45 a.m., interview with S1Compliance revealed that Patient #1 admitted to stuffing her bed and going to Patient #2’s room during the night to perform sexual activities. S1Compliance confirmed that Patient #1 and #2 were not observed and monitored every 15 minutes as required, when the above alleged incident occurred. S1Compliance confirmed the tech inaccurately documented the monitoring of Patients #1 and #2 in their medical records.”

“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: 20310 Based on observation, record review and interview, the hospital failed to provide care in a safe setting as evidenced by failing to provide appropriate patient observation and monitoring for 2 (#1, #2) of 3 (#1, #2, #3) sampled patients reviewed who were at risk for sexual abuse. Findings: Review of LDH self-reports revealed: On 05/24/2024 at 1:00pm, Patient #2 was overheard by S3Educator saying to Patient #1, “Don’t make me tell them what you made me do last night.” Patients #1 and #2 allegedly engaged in sexual behaviors in the bathroom of room a on the night of 05/23/2024 at 9:59p.m. Patient #2 reported that “we were doing nasty stuff” and Patient #2 denied that anything happened at all. Video of the alleged event was reviewed by the administrative staff and the following timeline was established: 21:59 - Patient #2 and Patient #1 are in their room getting ready for bed when Patient #1 gets up and closes the door to room a completely. 22:05 - Patient #2 gets up and opens the door and looks down the hallway. Patient #1 closes the door and both patients enter the bathroom together. 22:16 - Bathroom light is turned off and then back on. 22:25:38 - Patient #2 comes out of the bathroom. 22:25:51 - Patient #1 comes out of the bathroom. 22:26 - Patients open the door and both patients exit towards the dayroom. 22:27:45 - Both patients return to room a and sit on the floor with the light on to play cards. 22:30:28 - S2MHT enters the room and instructs the patients to get in their respective beds and to go to sleep. No further incident is witnessed on video. On 06/10/2024 at 10:30am, the above video was reviewed with S1Director of Compliance, which confirmed the above observations. During observation of the video, it was noted that the door to room a that opens into the hallway was closed from 21:59-22:30 (31 minutes), and no staff member entered the room during that period of time. S1Director of Compliance confirmed that the boys were not able to be observed with the door closed. S1Director of Compliance confirmed that the bedroom doors should always be left open when patients are in their rooms. Review of the medical record for Patient #1 revealed an order on 05/18/2024 for observation levels every 15 minutes. Review of the medical record for Patient#2 revealed an order on 05/23/2024 for observation levels every 15 minutes. Review of the documentation on the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 05/23/2024 21:59-22:30, completed by S2MHT, showed that Patient #1 was in the room asleep in his bed during this time and Patient #2 was in the room and calm. On 06/10/2024 at 10:30 a.m, interview with S1Director of Compliance confirmed that Patients #1 and #2 were not observed and monitored every 15 minutes as ordered, when the above alleged incident occurred.”

“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 observation, record review and interview, the hospital failed to maintain an accurate medical record for 2 (#1, #2) of 3 (#1, #2, #3) sampled patients who had orders for observation levels every 15 minutes. Findings: Review of LDH self-reports revealed: On 05/24/2024 at 1:00pm, Patient #2 was overheard by S3Educator saying to Patient #1, “Don’t make me tell them what you made me do last night.” Patients #1 and #2 allegedly engaged in sexual behaviors in the bathroom of room a on the night of 05/23/2024 at 9:59p,m. Patient #2 reported that “we were doing nasty stuff” and Patient #2 denied that anything happened at all. Video of the alleged event was reviewed by the administrative staff and the following timeline was established: 21:59 - Patient #2 and Patient #1 are in their room getting ready for bed when Patient #1 gets up and closes the door to room a completely. 22:05 - Patient #2 gets up and opens the door and looks down the hallway. Patient #1 closes the door and both patients enter the bathroom together. 22:16 - Bathroom light is turned off and then back on. 22:25:38 - Patient #2 comes out of the bathroom. 22:25:51 - Patient #1 comes out of the bathroom. 22:26 - Patients open the door and both patients exit towards the dayroom. 22:27:45 - Both patients return to room a and sit on the floor with the light on to play cards. 22:30:28 - S2MHT enters the room and instructs the patients to get in their respective beds and to go to sleep. No further incident is witnessed on video. On 06/10/2024 at 10:30am, the above video was reviewed with S1Director of Compliance, which confirmed the above observations. During observation, it was noted that the door to room a that opens into the hallway was closed from 21:59-22:30 (31 minutes), and no staff member entered the room during that period of time. S1Director of Compliance confirmed that the boys were not able to be observed with the door closed. S1Director of Compliance confirmed that the bedroom doors should always be left open when patients are in their rooms. Review of the medical record for Patient #1 revealed an order on 05/18/2024 for observation levels every 15 minutes. Review of the medical record for Patient#2 revealed an order on 05/23/2024 for observation levels every 15 minutes. Review of the documentation on the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 05/23/2024 21:59-22:30, completed by S2MHT, showed that Patient #1 was in the room asleep in his bed during this time and Patient #2 was in the room and calm. On 06/10/2024 at 10:30 a.m., interview with S1Director of Compliance confirmed that the documentation did not accurately show the activity of Patient #1 and Patient #2.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital 1) failed to ensure that employees immediately reported witnessed abuse (Patient #1) and 2) failed to thoroughly investigate all incidents of possible abuse and/or neglect and implement corrective action. This deficient practice is evidenced by failure to immediately report observed physical abuse and thoroughly investigate and implement corrective actions for all reported cases of possible abuse or neglect in 4 of 4 reviewed incidents reports involving physical abuse (Patient #1), elopements (Patient #2, 3, 4) and vape use (Patient #2). Findings: 1) Failure to ensure that employees immediately report witnessed abuse as required by R.S. 40:2009.20 for 1 incident involving patient abuse (Patient #1) Review of LA R.S. 40:2009.20 revealed in part, “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.” Review of the policy titled, “Reporting Abuse/Neglect,”(no date), revealed in part, “All staff members are required to immediately report alleged, suspected or witnessed abuse and/or neglect to their supervisors. The administrator on duty is notified of all alleged, suspected, or witnessed abuse and/or neglect immediately.” Review of the abuse/neglect self-report submitted to LDH dated 03/05/2024 revealed that on 03/03/2024 at 8:15 a.m., S2RN (Charge Nurse) slapped Patient #1 across her face. Further review of the report revealed that S1Compliance reviewed the video footage and observed the physical abuse involving S2RN and Patient #1. The report revealed that S4BHT Supervisor was notified of the incident on 03/03/2024 at 9:00 p.m. and S3DON was notified on 03/03/2024 at 10:00 p.m. The report did not indicate what staff member reported the abuse to S4BHT Supervisor and S3DON. The report did not indicate if S2RN was immediately sent home after this incident of physical abuse. The bottom of the report indicated that S2RN was an agency nurse and would not be scheduled to work at this hospital anymore. At handoff report, all staff members are reminded that they must report alleged, suspected or witnessed abuse immediately. Formalized mandatory trainings are scheduled for all staff members, for the remainder of March 2024 and will conclude no later than 03/29/2024. Review of Patient #1’s night shift nurses note completed by S2RN, dated 03/03/2024 (no time) revealed in part that Patient #1 was on the floor and tried to kick S2RN and “this nurse tap her on the face no bruises/swelling/redness on client”. On 04/08/2024 at 2:30 p.m., Patient #1’s abuse self-report, completion date of 03/05/2024, was reviewed with S1Compliance and S5CEO. They confirmed that the report revealed that S3DON and S4BHT Supervisor was notified of the abuse on the night it occurred. When asked if S2RN was removed of her duties immediately after the incident was reported, they stated no. They stated that S2RN completed her shift at the hospital on the night of 03/03/2024. When asked how they found out about the abuse, they stated that staff was talking about it the next morning and that is when they began to investigate it. When asked if there was any documented evidence that trainings had occurred with all staff regarding abuse reporting, S1Compliance stated no. On 04/09/2024 at 9:45 a.m., interview with S3DON revealed that the ward clerk and S2RN called her on the night of 03/03/2024. When asked what they reported, S3DON stated they reported Patient #1’s behaviors that night. When asked if they reported any physical abuse to her, S3DON stated no. When asked if it was normal for the ward clerk to call her late at night, S3DON stated, “she calls me for everything”. S3DON stated she was not aware of the incident until the next morning when staff were talking about it. On 04/09/2024 at 10:50 a.m., interview with S4BHT Supervisor was conducted. S4BHT Supervisor stated that on the night of 03/03/2024, the ward clerk contacted him and informed him that S2RN slapped Patient #1 across the face. S4BHT Supervisor stated he immediately notified S6RN/Administrative and S3DON on the night of 03/03/2024 of the physical abuse that was reported to him by the ward clerk. He further stated that one of the techs working that night also called him and reported that S2RN “lost it” on Patient #1. When asked if he had performed any recent trainings on abuse and abuse reporting, S4BHT Supervisor stated no. On 04/09/2024 at 11:10 a.m., interview with S5CEO revealed that he was not sure where the breakdown was on the night of 03/03/2024, but confirmed that S2RN should not have continued to work her shift after being witnessed abusing Patient #1. S5CEO further confirmed that there was no documented evidence that an action plan was implemented after this incident to prevent it from happening again in the future. 2) Failure to thoroughly investigate all incidents of abuse and neglect and implement corrective action Patient #1 Review of the LDH abuse/neglect self report revealed the patient was slapped across the face by S2RN. The report indicated that the abuse was witnessed by staff, but no documented investigation as to who the staff reported the abuse to or why S2RN continued to finish her shift after witnessed physical abuse. The self report indicated that all staff members are reminded that they must report alleged, suspected or witnessed abuse immediately. Formalized mandatory trainings are scheduled for all staff members, for the remainder of March 2024 and will conclude no later than 03/29/2024. On 04/08/2024 at 2:30 p.m., S1Compliance was asked if there was any documented evidence that the staff had received any recent trainings regarding abuse or abuse reporting and he stated no. Patient #2 and #3 Review of the abuse/neglect self-report submitted to LDH on 03/25/2024 revealed that on 03/23/2024, Patients #2 and #3 eloped from the hospital after placing blankets and sheets in their beds to resemble bodies under the covers. The patients eloped from a non-functional door on their hallway. Video surveillance was reviewed which revealed the patients eloped at 9:47 p.m. on 03/23/2024. The staff was not aware of the patients being missing until Patient #4’s mother called the hospital that night to inform them that the patient had just called her from a fast food restaurant in the town. The police were called and they returned the patients to the hospital on 03/24/2024 at 12:56 a.m. The self-report further revealed that all direct care staff will be educated to observe for signs of life when doing rounds. This will commence on 03/25/2024 and will be mandatory to be completed by 03/31/2024, or the staff member will not be assigned to rounds until completed. A tech will be stationed at the faulty door until it can be repaired. Review of the medical records for Patients #2 and #3 revealed their close observation logs (every 15 minute checks) revealed inaccurate documentation that the patients were asleep in the beds during the entire time of the elopement on 03/23/2024 and 03/24/2024. On 04/09/2024 at 1:30 p.m., interview with S1Compliance confirmed there was no documented evidence that education was performed to all direct care staff regarding observing for signs of life during rounds. S1Compliance further stated that he and the hospital’s consultant developed the action plan but it was not passed on S4BHT Supervisor, who could implement the plan and perform the training. Patient #2 Review of an incident report dated 03/15/2024 revealed it was reported that Patient #2 had stolen a vape from the nurses station on 03/14/2024. The report further stated that a pink vape was recovered where patient was said to have had it all night and used it. Peer states that patient told her she stole it from the nurses station and was using it all night. There was no documented evidence that the incident was thoroughly investigated to determine how the patient got into the nurses station in order to steal the vape. On 04/09/2024 at 12:40 p.m., interview with S1Compliance revealed that the nurses station should be locked at all times and patients should not be in the nurses station. When asked if there was any documented evidence that an investigation was completed to determine how the patient got into the nurses station to prevent an incident like this one from occurring again, S1Compliance stated no. Patient #4 Review of an abuse/neglect self-report submitted to LDH on 04/02/2024 revealed that Patient #4 ran toward an open gate on the north lawn adjacent to the dumpsters after housekeeping left the door open after taking out the trash. A tech saw the patient outside the fence and escorted him back to the dorm. The self-report further stated that housekeeper that left the gate open was re-educated by S4BHT Supervisor on the importance of ensuring that all exits/entrances remain locked. On 04/09/2024 at 2:45 p.m., interview with S4BHT Supervisor revealed that he is over the techs, housekeepers and maintenance. He stated that he re-educated the housekeeper that left the gate open on 04/02/2024. When asked how many staff have the key to unlock the gate that was left open on 04/02/2024, S4BHT Supervisor stated 4 staff members. When asked if he had re-educated the other staff members that have the potential to leave the gate unlocked on the importance of locking all exits/entrances, he stated no. On 04/09/2024 at 3:45 p.m., interview with S1Compliance confirmed that all staff that have access to keys that lock exit/entrance gates should have been re-educated. When asked if there was a documented investigation to determine why the door was left open, such as a faulty lock or faulty gate, S1Compliance stated no.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that the director of nursing service provided adequate supervision and evaluation of all nursing personnel who provide services in the hospital as evidenced by failing to have evidence of orientation or competency skills on 2 of 2 contracted agency nurses who provide care at the hospital (S2RN, S7RN) Findings: On 04/08/2024 at 1:30 p.m., S3DON and S5CEO was asked for the personnel file for S27RN, an agency nurse who currently works nights at the hospital. At that time, they confirmed that there was no personnel file for the nurse, only a contract with the staffing agency stating they had checked the nurses qualifications. When asked if the nurse had CPI or CPR certification, they stated they were unsure. When asked if the nurse had been assessed for competency, S3DON stated no, but stated the nurse had worked in a psychiatric hospital in the past. Further interview with S3DON and S5CEO revealed that there was no personnel file for S2RN, an agency nurse who was witnessed by staff of slapping a patient on the face on 03/03/2024. They further stated that the hospital has no policy and procedure that addresses training/competency/personnel files for agency nurses.”

“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 received care in a safe setting for 1 (Patient #3) of 3 patients whose records were reviewed as evidenced by having large industrial staples in the walls of both seclusion rooms. As a result, Patient #3 obtained a staple from the seclusion room and self-injured herself with the staple. Findings: On 03/04/2024 at 10:20 a.m., observation of the seclusion room on the boys dorm revealed blue padded cushions on the walls and the floors. Further observations revealed the wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible. On 03/04/2024 at 10:55 a.m., observation of the seclusion room on the girls dorm revealed blue padded cushions on the walls and the floors. Further observations revealed the wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible. Review of the current medical record for Patient #3 revealed the 10 year old had an admission date of 10/27/23 with diagnoses including bipolar disorder. Review of the physician orders revealed the patient was frequently on room restrictions and in the seclusion room due to behaviors. Review of the patient’s nurses notes dated 02/28/2024 at 4:15 p.m. revealed that the patient had stuck an industrial sized staple that she found in the “blue room” (seclusion room) into the top of her left foot. The note further stated that the nurse pulled the staple out of the patient’s foot. Review of the NP progress note dated 02/29/2024 (no time) revealed “s/p incident with staple”. The note further revealed a raised pustule to the left foot with a diagnosis of “wound to the left foot”. Antibiotic ointment was ordered. Review of the 2024 incident reports and LDH self reports provided by S1Compliance revealed none that addressed the staple incident with Patient #3. On 03/05/2024 at 11:00 a.m., interview with S1Compliance confirmed there was no incident report or LDH self-report completed when Patient #3 obtained an industrial sized staple fromt the seclusion room and self-injured herself. When asked if S1Compliance was aware of the staple incident with Patient #3, he stated yes. When asked if there was any investigation or corrective action put into place after this incident to prevent further injuries, he stated no.”

“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: 17450 Based on observation, record review and interview, the hospital failed to track and analyze medical errors and adverse patient events. This deficient practice is evidenced by failure to complete incident reports and implement corrective actions 1) for a documented medication error (Patient #1) and 2) a patient injury involving safety (Patient #3) for 2 of 3 patients whose records were reviewed. Findings: Patient #1 Review of the medical record revealed an admission date of 01/08/2024 with diagnoses including ODD, anxiety and autism. The patient was discharged home on 01/16/2024. Review of the nurses notes dated 01/16/2024 at 8:35 a.m. revealed the patient informed the nurse that he took another patient’s medication last night. Patient #1 states he told the night nurse that he was another patient when asked during medication pass. Review of the patient’s January 2024 MAR with S1Complaince and S2DON revealed all night medications for 01/15/2024 were circled, indicating not given. Further review of documentation on the MAR revealed that Olanzapine and Fluoxetine was held because patient took another patient’s Amitriptyline and Singulair “by mistake”. On 03/05/02024 at 11:30 a.m., S1Compliance and S2DON were asked if they were aware that Patient #1 was involved in a medication error on 01/16/2024 and they stated no. When asked if there was an incident report or medication variance completed and an investigation conducted in order to implement preventive actions, they stated no. Patient #3 On 03/04/2024 at 10:20 a.m., observation of the seclusion room on the boys dorm revealed blue padded cushions on the walls and the floors. Further observations revealed the wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible. On 03/04/2024 at 10:55 a.m., observation of the seclusion room on the girls dorm revealed blue padded cushions on the walls and the floors. Further observations revealed the wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible. Review of the current medical record for Patient #3 revealed the 10 year old had an admission date of 10/27/23 with diagnoses including bipolar disorder. Review of the physician orders revealed the patient was frequently on room restrictions and in the seclusion room due to behaviors. Review of the patient’s nurses notes dated 02/28/2024 at 4:15 p.m. revealed that the patient had stuck an industrial sized staple that she found in the “blue room” (seclusion room) into the top of her left foot. The note further stated that the nurse pulled the staple out of the patient’s foot. Review of the NP progress note dated 02/29/2024 (no time) revealed “s/p incident with staple”. The note further revealed a raised pustule to the left foot with a diagnosis of “wound to the left foot”. Antibiotic ointment was ordered. Review of the 2024 incident reports and LDH self reports provided by S1Compliance revealed none that addressed the staple incident with Patient #3. On 03/05/2024 at 11:00 a.m., interview with S1Compliance confirmed there was no incident report or LDH self-report completed when Patient #3 obtained an industrial sized staple fromt the seclusion room and self-injured herself. When asked if S1Compliance was aware of the staple incident with Patient #3, he stated yes. When asked if there was any investigation or corrective action put into place after this incident to prevent further injuries, he stated no”

“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 hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to assess for bowel movements for 3 of 3 patient medical records reviewed (Patient #1, 2, 3). Findings: Patient #1 Review of the medical record revealed the patient was admitted to the hospital on 01/08/2024 and discharged on 01/16/2024. Further review of the record revealed the patient was on multiple psychoactive medications. Review of the patient’s nurses notes for the entire admission revealed no evidence that bowel movements were assessed and documented. Patient #2 Review of the medical record revealed the patient was admitted to the hospital on 01/25/2024 and discharged on 02/07/2024. Further review of the record revealed the patient was on multiple psychoactive medications. Review of the patient’s nurses notes for the entire admission revealed no evidence that bowel movements were assessed and documented. Patient #3 Review of the medical record revealed the patient was admitted to the hospital on 10/27/202 and was a current patient in the hospital. Further review of the record revealed the patient was on multiple psychoactive medications. Review of the patient’s nurses notes from admit until present (over 4 months) revealed the patient’s bowel movements were assessed and documented only 5 times. On 03/05/2024 at 9:45 a.m., interview with S4RN revealed that the nurses should be assessing for bowel movements on all patients daily. S4RN stated there is no check off box on the daily shift assessment form, so assessments of bowel movements must be documented in the nurses notes daily. On 03/05/2024 at 11:40 a.m., interview with S2DON confirmed that the nurses should be assessing all patients for bowel movements daily. When asked if psychoactive medications cause constipation, S2DON stated yes.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients. Findings: On 03/04/2024 at 10:00 a.m., tour of the boys dorm building with S1Compliance revealed the following observations: - Room a had loose and missing floor tiles in the bathroom. When the button was pressed on the sink for water, the water sprayed over the sink and onto the floor. - Room b had loose and missing floor tiles in the bathroom. - Room d had the only window in the room boarded up with wood. There was missing floor tile in the bathroom. The bathroom light did not work. - Rooms e and f had missing floor tiles in the bathrooms. - Room g had a screw missing from the light switch cover. The cover was loose and the light in the room flickered when the cover was moved. - The seclusion room had blue padded cushions on the walls and the floors. The wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible to patients. - Room s had water spraying over the sink onto the floor when the water was turned on at the bathroom sink. - Room h had missing floor tiles in the bathroom. When the water was turned on, the water sprayed over the sink onto the back wall in the bathroom. On 03/04/2024 at 10:30 a.m., tour of the boys dorm building with S1Compliance revealed the following observations: - Room i had water spraying over the sink onto the back wall when the water was turned on at the bathroom sink. - Room l had a commode that did not flush. - Rooms m and n had missing floor tiles in the bathrooms. - The seclusion room had blue padded cushions on the walls and the floors. The wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible to patients. At that time, interview with S1Complaince revealed that the dorms were in need of maintenance. On 03/05/2024 at 1:15 p.m., observation of Room e revealed a piece of bread was stuck between the plexiglass and the window. At that time, S1Compliance pushed on the plexiglass and it buckled, causing an open area (approximately 2-3 inches) at the top of the window.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by failing to maintain an sanitary environment. Findings: On 03/04/2024 at 10:00 a.m., tour of the boys dorm building with S1Compliance revealed the following observations: - The shower room (short hall) had multiple old dirty towels in the shower stalls and on the floor. Mildew was observed in the shower stalls. Old toilet paper balls were all over the ceiling. The storage cabinet that held small containers of personal hygiene supplies (uncovered toothbrushes, uncapped toothpaste) for the patients had several pairs of dirty underwear, socks and trash and debris in the bottom of the cabinet. - Room a had trash and debris all over the floor. There was a large build up of grime in all corners of the floor. There was a horrible odor in the bathroom. - Room b had a mattress on the bed that had the inside foam exposed. The cabinets had thick build up of dirt and grime and trash. The faucet in the bathroom had no working water. - Room c had build up of grime and debris and trash in the closets. - Room d had no working water at the bathroom faucet. - Rooms e and f had no working water at the bathroom faucet. - The seclusion room had a thick powdery substance on the floor. Two tears in the floor mat vinyl was observed. There was a white dried smeared substance on the floor mat. - The shower room (long hall) had a dead roach in the shower stall. The other stall had multiple old wet towels in the floor. Mold was observed on the ceiling in multiple spots. - Room g had no working water at the faucet. Thick build up of dirt and grime was observed in all corners of the room. Two pillows were on the floor. The pillows had multiple tears in them exposing the inside foam. - Room h had multiple tears in the mattress, exposing the inside foam. On 03/04/2024 at 10:30 a.m., tour of the girls dorm building with S1Compliance revealed the following observations: - Room i had multiple tears in the mattress, which makes it unable to be adequately disinfected. - Room j had a build up of dirt and grime in all corners of the room. At this time, interview with the patient in the room revealed that the water did not work at the bathroom faucet. - Room k had no running water at the bathroom faucet. - Room l had a pillow on the bed with multiple tears in the outside covering. There was no running water at the sink. The air vents were covered in a thick build up of dust. - Room m had a tear in the mattress with the insides exposed. The air vents were covered in a thick build up of dust. - Room n had multiple tears in the mattress. There was no running water at the bathroom faucet. - The seclusion room had old dried substances on the floor. - Room o had a torn mattress. - Rooms p, q and r had no running water at the bathroom faucet. At this time, S1Complaince confirmed all above observations. On 03/05/2024 at 1:15 p.m., S1Compliance stated that there were issues with water pressure on 03/04/2024 and all sinks should have running water now. At this time, the surveyor checked the water in random rooms and rooms e, l, j, k, q and r still had no running water at the bathroom faucets.”

“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: 20310 Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by having a seclusion room door with a missing screw in the door’s deadbolt faceplate, causing the faceplate to move freely. The sharp edges of the faceplate were exposed, posing an injury risk to patients and staff. This deficient practice has the potential to affect 26 of 26 patients who are housed in the girls Dorm B and might be placed in the seclusion room. Findings: On 11/13/2023 at 3:35 p.m., observation of the door to the “Blue” seclusion room in Dorm B revealed the deadbolt’s faceplate located on the door’s edge was missing the lower screw and the faceplate was protruding outward and moving freely. The faceplate had sharp edges which were exposed, causing a potential risk for cutting injuries. An interview at this time with S1Corporate Compliance confirmed that the loose faceplate had sharp edges and had the potential to cause injury to patients or staff who made contact with the plate.”

“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: 20310 36293 Based on observation, record review and interview, the hospital failed to analyze adverse patient events and implement preventive actions by failing to complete a thorough investigation of the cause of a patient’s (Patient #1) laceration injury sustained while in Dorm B’s seclusion room. The deficient practice has the potential to affect 26 of 26 patients residing in girls Dorm B. Findings: Review of an incident report dated 11/06/2023 at 5:45 p.m. revealed Patient #1 suffered a laceration injury to the ring finger of her right hand while in the seclusion room. The investigation conducted by the hospital staff concluded that she smashed her finger in the bottom of the door as it was closing. Due to the partially closed door obstructing the view, the injury was not witnessed by any of the staff and it was not visible on the video reviewed. Patient #1 stated, “I went to get my shirt and my finger got cut in the door.” The investigation report revealed the door was initially inspected by the nurses and maintenance staff and they did not note any damage; they could not discern how the injury occurred. Observation of the seclusion room door on 11/13/2023 at 3:30 p.m. revealed the dead bolt faceplate located on the door’s edge was missing the lower screw and the faceplate was protruding outward beyond the door’s edge. The faceplate had sharp edges which were exposed. In an interview at this time, S1Corporate Compliance confirmed they had not inspected the faceplate of the door during the inspection and were unaware of the missing screw. They had focused on the fact that the door was crooked and assumed she had injured her hand at the bottom of the door near the floor. On 11/15/2023 at 8:45 a.m., an interview with Patient #1 confirmed she had cut her finger in the area of the door where the faceplate was protruding.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that each patient’s treatment plan was individualized, comprehensive and updated with changes related to the patient’s goal progression for 1 (Patient #F1) of 3 sampled patients (Patient #F1-#F3) whose records were reviewed. Findings: Review of the hospital policy titled Individualized Treatment Plan Development Procedures revealed in part that the staff members who participate in patient care revise the treatment plan to reflect changes to the patient’s clinical status, needs and/or goals. Review of Patient #F1’s medical record revealed the 13 year old patient was admitted to the psychiatric hospital on a PEC on 10/13/2023 with diagnoses including depression and oppositional defiant disorder. The patient was admitted with physician orders for routine observations every 15 minutes but the order was changed to line of sight observations at all times on 10/15/2023 at 9:27 a.m. due to the patient having aggressive behaviors. Review of the patient’s medical record revealed a note from the medical nurse practitioner dated 10/16/2023 stating that the patient possibly swallowed staples on 10/15/2023. The note further stated that the patient denied swallowing any of the staples. The provider ordered for the patient to be watched every 30 minutes for four hours and “continue to monitor patient.” On 11/06/2023 at 10:15 a.m., S1CorpRN reviewed the patient’s medical record with the surveyor and confirmed there was no other documented evidence (besides the above provider’s note) in the record related to the incident on 10/15/2023 when the patient was found with staples in her mouth. S1CorpRN confirmed that the patient was on ordered line of sight observations at the time that she obtained the staples. On 11/06/2023 at 10:35 a.m., S2DON provided an incident report dated 10/15/2023 at 6:00 p.m. regarding the incident with Patient #F1. The report stated that at 5:50 p.m., it was reported by a peer that they saw the patient had staples in her mouth. The LPN brought the staples that the patient had spit out to the RN/DON to witness. Patient denies swallowing any staples. The patient states that she pulled out a few staples from a drawer while she was on the phone in the NP room and placed them in her mouth. Review of the patient’s initial treatment dated 10/13/2023 revealed problems of poor impulse control and aggressive/homicidal. Goals included: comply and take prescribed medications and ordered medical treatment, participate in therapeutic activities and assigned therapy, and decrease signs and symptoms of agitation/aggression, homicidal ideation, absence of assault, absence of dangerous impulsive acts. Interventions included: order the appropriate precaution level/reassess. The treatment plan did not indicate the specific observation level that was ordered for the patient and was not updated with the incident on 10/15/2023 regarding the patient putting staples in her mouth. There were no new interventions noted on the treatment plan to address the incident on 10/15/2023. The patient’s treatment plan was not individualized and comprehensive. On 11/07/2023 at 10:00 a.m., S2DON reviewed Patient #F1’s master treatment plan with the surveyor and confirmed it was not individualized or comprehensive and not updated with new approaches or interventions to address the incident involving staples on 10/15/2023.”