Beacon Behavioral Hospital- New Orleans, LLC

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50453 Based on observation, record review, and interview, the psychiatric hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The psychiatric hospital failed to protect and promote each patient’s rights as evidenced by: 1) Failure to increase Patient #1’s observation level immediately following a violent incident involving Patient #1 per hospital policy (see Findings Tag A0144); 2) Failure to ensure patients did not have access to items that could cause harm to themselves (see Findings Tag A0144); 3) Failure to ensure each patient received an armband for accurate identification per hospital policy (see Findings Tag A0144); 4) Failure to obtain an order for physical hold on 1 (#2) of 3 (#1-#3) medical records reviewed (see Findings Tag A0154); 5) Having standing PRN orders for the administration of Benadryl, Haldol, and Ativan intramuscularly PRN (as needed) for severe physical aggression or threats of physical harm. Indication: aggressive behavior in 13 (#1-#3, #R1-#R10) of 17 (#1-#3, #R1-#R14) medication records reviewed (see Findings Tag A0160); and 6) Failure to maintain documentation of restraint use for 2 (#1, #3) of 3 (#1-#3) patients reviewed for use of chemical restraint (see Findings Tag A0175).”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 50453 Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice is evidenced by: 1) Failure of the hospital to implement a performance improvement plan after a patient to staff physical assault (see Findings Tag A0283); and 2) Failing to accurately self-report an incident involving assault (see Findings Tag A0286).”

“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: 50453 Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting as evidenced by: 1) failure to increase Patient #1’s observation level immediately following a violent incident involving Patient #1 per hospital policy; 2) failure to ensure patients did not have access to items that could cause harm to themselves; and 3) failure to ensure each patient received an armband for accurate identification per hospital policy. Findings: A review of hospital policy titled, “Patient Rights,” last revision 03/21/2018, revealed in part: “In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: 17. Be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. 18. Be free from all forms of abuse and harassment. 19. Receive care in a safe setting.” 1) Failure to increase Patient #1’s observation level immediately following a violent incident involving Patient #1 per hospital policy. A review of hospital policy titled, “Levels of Observation,” last revised 06/13/2024, revealed in part: “Assessment and Determination of Needs: 1. The Charge RN may increase a patient’s level of observation at any time if his/her assessment indicates such a need, but it is the nurse’s responsibility to contact the authorized licensed prescriber on duty to issue a corresponding order. 2. If the patient is found to be “at risk” for self-harm, assaultive, or sexually acting-out behaviors, the registered nurse will initiate/maintain Line of Sight observation until the physician has been consulted. “At Risk” behaviors are evidenced by: a. Suicidal/homicidal ideation without immediate plan, ability to verbalize reasonable safety, and agreement to give staff a warning if their personal risk situation changes. b. Recent history of suicide and/or aggressive or sexually acting out behavior but can process issues and does not demonstrate severe agitation or require constant de-escalation or redirection. 3. If the patient is at “high risk” for self-harm, assaultive, elopement, or sexually acting out behaviors, the registered nurse will initiate 1:1 observation of the patient and will consult the physician as soon as possible who will determine the need for further observation. “High risk” behaviors are evidenced by: a. Constant suicidal/homicidal ideation with plan and the inability to ensure staff of immediate safety. b. Actively involved in property destruction and/or sexually acting out behaviors which require continuous redirection. c. Isolating/secretive behaviors, severe agitation, pacing, threatening others, and not able to process behaviors with staff. d. Any other unsafe behaviors which place self or others in immediate jeopardy.” Review of Patient #1’s medical record revealed the patient was admitted 03/08/2025 on a PEC (Physician’s Emergency Certificate) with Suicidal Ideation and had a diagnosis of MDD. Patient #1 was on Q15 minute observations and Suicide/Self-harm Precautions were initiated on 03/09/2025 at 4:06 AM. Further review of Patient #1’s medical record revealed he was involved in an incident where Patient #1 was aggressive and threatening toward staff, which resulted in a physical altercation with an MHT. Review of nursing assessment for Patient #1 on 03/09/2024 following the altercation revealed in part: Patient #1 was placed in a therapeutic hold and escorted to room. 7:26 AM- Benadryl, Haldol, Ativan given. 7:40 AM- Patient in room crying an yelling out, when staff checked, Patient #1 had broken toilet seat and made several scratches and superficial lacerations to left anterior forearm, picture uploaded to chart. Forearm cleaned, bandage applied. Providers notified. Orders received with observation status 1:1. On 04/07/2025 at 1:03 PM, review of video footage navigated by S1DON of the incident involving Patient #1 on 03/09/2025 from 6:21:16 AM - 6:21:46 AM revealed in part: S4MHT facing camera with back to nurse station. S4MHT exchanging words with Patient #1. Patient #1 standing with back to camera outside medication room. S6MHT walks up with vital sign machine and stands behind S4MHT. Patient #1 runs at S4MHT, knocking the observation tablet out of S4MHT. S4MHT swings right arm with closed fist and hits Patient #1 and both fall back into nurse station. During this time, S6MHT backs up with vital sign machine. S8RN comes out nurse station, S5MHT comes into camera view, both attempting to separate Patient #1 and S4MHT. Patient #1 ends up on the ground when S5MHT attempts to separate S4MHT from Patient #1. Video clip ends 6:21:46 AM. On 04/07/2025 at 2:30 PM, review of video footage navigated by S3MHTC of the incident involving Patient #1 on 03/09/2025 starting at 6:22 AM revealed in part: 6:22 AM- Patient #1 carried by S4MHT using Patient #1’s shirt, while S5MHT is carrying Patient #1’s lower extremities. 6:22:41 AM- Patient #1 carried inside room a by S4MHT and S5MHT. S6MHT and S7MHT in room, door to room closed. 6:23 AM- S9RN enters room a and then exits with S6MHT. S4MHT, S5MHT and S7MHT remain in room a with Patient #1, door cracked open. 6:23:58 AM- S7MHT exits room a and closes door. 6:24:15 AM- S5MHT enters room a and closes door. 6:24:55 AM- S5MHT exits room a. S4MHT and S6MHT remain in room a with Patient #1. 6:27 AM- S9RN and S10LPN enter room and close door. (Per S3MHTC this is when the Patient #1 was given Haldol, Benadryl, and Ativan.) 6:28:10 AM- S9RN and S10LPN exit room a. 6:28:40 AM- S6MHT exits room. 6:28:44 AM- S4MHT exits room a and closes door. Patient #1 alone in room. 6:34:56 AM- An unidentified patient walks to room a and cracks open door and runs toward nurse station. (Patient #1 was left alone in room with door closed for 6 minutes.) 6:35:38 AM- S5MHT, S7MHT, S8RN, and S9RN go to room a. 6:36:23 AM- S5MHT walks out room a carrying a toilet seat followed by S8RN. 6:37:36 AM- Patient #1 placed in chair in hallway outside his room a. 6:38 AM- S8RN talking to Patient #1 in hallway. 6:42 AM- S8RN applies dressing to Patient #1 left forearm. 6:45 AM- S8RN walks away from Patient #1. In an interview on 04/07/2025 at 3:10 PM, S1DON confirmed that the video review revealed Patient #1 had aggressive and assaultive behavior in the above mentioned incident. S1DON confirmed that the RN can increase the level of observation on a patient. S1DON confirmed that Patient #1’s displayed behavior made him “high risk” per policy due to his aggression and assaultive behavior towards staff. S1DON further confirmed that the observation level was not increased immediately after the violent altercation with S4MHT until after Patient #1 was found by another patient harming himself. 2) Failure to ensure patients did not have access to items that could cause harm to themselves. Observations during a walk-through of the hospital on 04/07/2025 from 9:51 AM to 10:30 AM revealed a toothbrush and a tube of toothpaste on the windowsill of the bathroom in room b. In an interview on 04/07/2025 at 10:27 AM, S3MHTC confirmed that patient hygiene products are locked in a closet after use. S3MHTC further confirmed that patients should not have access to the above mentioned items. 3) Failure to ensure each patient received an armband for accurate identification per hospital policy. Review of hospital policy titled, “Medication and Treatment Administration,” approved 01/25/2024, revealed in part: “Procedure-Inpatient: 4. As each patient approaches the medication nurse, the nurse will identify the patient by the following methods: c. Check the patient’s wristband.” Observations during a walk-through of the hospital on 04/07/2025 from 9:51 AM to 10:30 AM revealed an armband for Patient #R1 on the windowsill of the bathroom in room b. In an interview on 04/07/2025 at 10:27 AM, S3MHTC confirmed Patient #R1 was missing her armband and that Patient #R1 should have one on per policy.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 50453 Based on policy review, record review, and interview, the hospital failed to ensure the use of restraints was in compliance with accepted standards of care. This deficient practice was evidenced by failure to obtain an order for physical hold on 1 (#2) of 3 (#1-#3) medical records reviewed. Findings: A review of hospital policy titled, “Patient Rights,” last revision 03/21/2018, revealed in part: “In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: 17. Be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. 18. Be free from all forms of abuse and harassment. 19. Receive care in a safe setting. Additionally, in accordance with La R.S. 28:171 patients at behavioral health hospitals have the right to: 4. Not be placed in restraints or in seclusion except in an emergency to protect you or others from physical injury. 12. Receive medication with a physician’s order and it cannot be used as a punishment or for the convenience of staff. 14. Receive medically appropriate treatment for your condition.” A review of hospital policy titled, “Restraint or Seclusion,” last revision 10/17/2024, revealed in part: “Policy: The use of manual restraints (i.e. physical holds), mechanical restraints, and seclusion are permitted for use only: To ensure the safety and security of individuals due to imminent danger. When less restrictive measures have been considered and are deemed ineffective. NEVER as a punitive measure, for behavior modification, or for the convenience of staff. In accordance with all state and federal regulations and laws and Beacon policy. The use of Restraint or Seclusion requires the following documentation in the patient’s record: A detailed description of the behaviors considered a threat to the patient and/or others and the clinical justification for use. A description of the less restrictive intervention techniques attempted and inadequacy of those techniques. Contact with a licensed prescriber to describe behaviors, interventions, and obtain an order for the use of Restraint or Seclusion. In an emergency, a registered nurse, trained in aggressive behavior management, may direct staff members to implement manual restraints, mechanical restraints, and/or seclusion order by a prescriber. In a case such as this, the registered nurse must contact an authorized licensed prescriber for an order immediately after implementation. Restraint or Seclusion may never be ordered on a PRN (or “as needed”) basis. Procedure: 2. The registered nurse ensures that an order has been obtained from an authorized licensed prescriber and that all documentation is accurately initiated, including an incident report. Definitions: Manual or Mechanical Restraint - Any manual, physical method, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, that cannot be easily and intentionally removed by the patient (considering the patient’s physical condition and ability to accomplish the objective). Chemical Restraint - A drug or medication used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Physical Holding for Medication Administration - If the patient is being held so that the medication can be administered against the patient’s will (that is, during “a forced psychotropic medication procedure”) and/or the patient is held in such a manner that movement is restricted and the patient cannot easily remove or escape the grasp, the hold IS considered a Restraint.” Review of Patient #2’s medical record revealed the Patient #2 was a FVA (formal voluntary admit) on 03/20/2025 with SI (suicidal ideation) and a diagnosis of Schizoaffective Disorder and Bipolar. Seclusion documentation by the nurse for 03/22/2025 revealed in part: 9:35 PM Administered Haldol, Benadryl, and Ativan IM (intramuscular). During administration patient is kicking staff, fighting against the staff for IM injection. Unable to be redirected verbally. Further review of Patient #2’s medical record failed to reveal an order for a physical hold. In an interview on 04/08/2025 at 1:06 PM, S11CE confirmed there was no order for a physical hold to administer PRN medications for aggressive behavior to Patient #2. S11CE confirmed that per policy there should be an order for a physical hold.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 50453 Based on policy review, record review, and interview, the hospital failed to ensure the use of PRN (as needed)medication was standard treatment for the patient’s medical or psychiatric condition and in compliance with accepted standards of care. This deficient practice is evidenced by having standing PRN orders for the administration of Benadryl, Haldol, and Ativan intramuscularly PRN (as needed) for severe physical aggression or threats of physical harm. Indication: aggressive behavior in 13 (#1-#3, #R1-#R10) of 17 (#1-#3, #R1-#R14) medication records reviewed. Findings: A review of hospital policy titled, “Patient Rights,” last revision 03/21/2018, revealed in part: “In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: 17. Be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. 18. Be free from all forms of abuse and harassment. 19. Receive care in a safe setting. Additionally, in accordance with La R.S. 28:171 patients at behavioral health hospitals have the right to: 4. Not be placed in restraints or in seclusion except in an emergency to protect you or others from physical injury. 12. Receive medication with a physician’s order and it cannot be used as a punishment or for the convenience of staff. 14. Receive medically appropriate treatment for your condition.” A review of hospital policy titled, “Restraint or Seclusion,” last revision 10/17/2024, revealed in part: “Policy: The use of manual restraints (i.e. physical holds), mechanical restraints, and seclusion are permitted for use only: To ensure the safety and security of individuals due to imminent danger. When less restrictive measures have been considered and are deemed ineffective. NEVER as a punitive measure, for behavior modification, or for the convenience of staff. In accordance with all state and federal regulations and laws and Beacon policy. Restraint or Seclusion may never be ordered on a PRN (or “as needed”) basis. Definitions: Chemical Restraint - A drug or medication used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Physical Holding for Medication Administration - If the patient is being held so that the medication can be administered against the patient’s will (that is, during “a forced psychotropic medication procedure”) and/or the patient is held in such a manner that movement is restricted and the patient cannot easily remove or escape the grasp, the hold IS considered a Restraint.” A review of the medication records for Patient’s #1-#3 and Patient’s #R1-#R10 revealed standing PRN orders for the following medications: Benadryl 50mg/ml, 50mg (1ml) IM Q6H PRN to be given with Haldol and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior. Haldol 5mg/ml, 5mg (1ml) IM Q6H PRN to be given with Benadryl and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior. Ativan 2mg/ml, 2mg (1ml) IM Q6H PRN to be given with Benadryl and Haldol. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior. In an interview on 04/07/2025 at 3:12 PM while reviewing the medical record of Patient #1, S1DON confirmed the medication listed above was administered to Patient #1 was a chemical restraint. When asked where the order was for the chemical restraint, S1DON confirmed that the above mentioned PRN orders for Haldol, Benadryl, and Ativan as the orders for the restraint . S1DON further confirmed that having the above mentioned standing PRN orders does not follow their Restraint or Seclusion hospital policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure patients were monitored according to accepted standards of care. This deficient practice was evidenced by failure to maintain documentation of restraint use for 2 (#1, #3) of 3 (#1-#3) patients reviewed for use of chemical restraint. Findings: A review of hospital policy titled, “Restraint or Seclusion,” last revision 10/17/2024, revealed in part: “Policy: The use of manual restraints (i.e. physical holds), mechanical restraints, and seclusion are permitted for use only: To ensure the safety and security of individuals due to imminent danger. When less restrictive measures have been considered and are deemed ineffective. NEVER as a punitive measure, for behavior modification, or for the convenience of staff. In accordance with all state and federal regulations and laws and Beacon policy. The use of Restraint or Seclusion requires the following documentation in the patient’s record: A detailed description of the behaviors considered a threat to the patient and/or others and the clinical justification for use. A description of the less restrictive intervention techniques attempted and inadequacy of those techniques. Contact with a licensed prescriber to describe behaviors, interventions, and obtain an order for the use of Restraint or Seclusion. In an emergency, a registered nurse, trained in aggressive behavior management, may direct staff members to implement manual restraints, mechanical restraints, and/or seclusion order by a prescriber. In a case such as this, the registered nurse must contact an authorized licensed prescriber for an order immediately after implementation. Restraint or Seclusion may never be ordered on a PRN (or “as needed”) basis. Procedure: 2. The registered nurse ensures that an order has been obtained from an authorized licensed prescriber and that all documentation is accurately initiated, including an incident report. 3. The nursing documentation in the EMR serves as the Restraint of Seclusion log. 4. A qualified staff member is assigned to provide continuous monitoring at a 1:1 level of observation. Restraint and Seclusion Log: Data elements from the log are analyzed for patterns/trends related to excessive use of all types of restraints, use of physical restraints or drugs to substitute for adequate staffing, monitoring, assessment, unmet patient care needs, prolonged restraint use, effectiveness of actions taken to reduce prolonged restraint use and opportunities for improving compliance with standards. The log contains the following elements: A. Date and time of order B. Shift C. Staff who initiated the process D. The length of each episode E. Day of the week each episode was initiated F. Type of restraint or seclusion used (including physical restraint or drug used as restraint) G. Compliance with requirements defined in the standards H. Injuries sustained by the patient or staff I. Age of the patient. Definitions: Manual or Mechanical Restraint - Any manual, physical method, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, that cannot be easily and intentionally removed by the patient (considering the patient’s physical condition and ability to accomplish the objective). Chemical Restraint - A drug or medication used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Physical Holding for Medication Administration - If the patient is being held so that the medication can be administered against the patient’s will (that is, during “a forced psychotropic medication procedure”) and/or the patient is held in such a manner that movement is restricted and the patient cannot easily remove or escape the grasp, the hold IS considered a Restraint.” Patient #1 Review of Patient #1’s medical record revealed the patient was admitted 03/08/2025 on a PEC (Physician’s Emergency certificate) with Suicidal Ideation and had a diagnosis of MDD (major depressive disorder). Review of Patient #1’s Medication Administration Record revealed the following medications were administered on 03/09/2025 at 8:21 AM: Benadryl 50mg/ml, 50mg (1ml) IM Q6H PRN (intramuscular every 6 hours as needed) to be given with Haldol and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior. Haldol 5mg/ml, 5mg (1ml) IM Q6H PRN to be given with Benadryl and Ativan. PRN (as needed) for severe physical aggression or threats of physical harm. Indication: aggressive behavior. Ativan 2mg/ml, 2mg (1ml) IM Q6H PRN to be given with Benadryl and Haldol. PRN (as needed) for severe physical aggression or threats of physical harm. Indication: aggressive behavior. Further review of Patient #1’s medical record failed to reveal restraint documentation by the nurse. In an interview on 04/07/2025 at 3:12 PM, S1DON confirmed that the Haldol, Benadryl, and Ativan PRN orders were the order for the chemical restraint. S1DON confirmed there was no documentation of restraint use in Patient #1’s medical record. Patient #3 Review of Patient #3’s medical record revealed the patient was admitted on 02/26/2025 with Suicidal Ideation and had a diagnosis of Schizoaffective Disorder, Methamphetamine/Cocaine/Cannabis Use Disorder. Review of Patient #3’s Medication Administration Record revealed the following medications were administered on 02/28/2025 at 10:08 AM and at 9:36 PM: Benadryl 50mg/ml, 50mg (1ml) IM Q6H PRN to be given with Haldol and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior. Haldol 5mg/ml, 5mg (1ml) IM Q6H PRN to be given with Benadryl and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior. Ativan 2mg/ml, 2mg (1ml) IM Q6H PRN to be given with Benadryl and Haldol. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior. Further review of Patient #3’s medical record failed to reveal restraint documentation by the nurse. In an interview on 04/08/2025 at 1:45 PM, S11CE confirmed that the Haldol, Benadryl, and Ativan PRN orders is a chemical restraint. S11CE confirmed there was no documentation of restraint use in Patient #3’s medical record.”

“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: 50453 Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. This deficient practice was evidenced by failure of the hospital to implement a performance improvement plan after a patient to staff physical assault. Findings: A review of hospital policy titled, “Patient Rights,” last revision 03/21/2018, revealed in part: “In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: 17. Be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. 18. Be free from all forms of abuse and harassment. 19. Receive care in a safe setting. Additionally, in accordance with La R.S. 28:171 patients at behavioral health hospitals have the right to: 4. Not be placed in restraints or in seclusion except in an emergency to protect you or others from physical injury. 12. Receive medication with a physician’s order and it cannot be used as a punishment or for the convenience of staff. 14. Receive medically appropriate treatment for your condition.” A review of hospital policy titled, “Restraint or Seclusion,” last revision 10/17/2024, revealed in part: “Policy: The use of manual restraints (i.e. physical holds), mechanical restraints, and seclusion are permitted for use only: To ensure the safety and security of individuals due to imminent danger. When less restrictive measures have been considered and are deemed ineffective. NEVER as a punitive measure, for behavior modification, or for the convenience of staff. In accordance with all state and federal regulations and laws and Beacon policy. Definitions: Manual or Mechanical Restraint - Any manual, physical method, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, that cannot be easily and intentionally removed by the patient (considering the patient’s physical condition and ability to accomplish the objective). Chemical Restraint - A drug or medication used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Seclusion - The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Escort - Escorting a patient to a location IS considered a Restraint if the patient cannot easily remove or escape the grasp of a staff member. Physical Holding for Medication Administration - If the patient is being held so that the medication can be administered against the patient’s will (that is, during “a forced psychotropic medication procedure”) and/or the patient is held in such a manner that movement is restricted and the patient cannot easily remove or escape the grasp, the hold IS considered a Restraint.” On 04/07/2025 at 1:03 PM, review of video footage navigated by S1DON of the incident involving Patient #1 on 03/09/2025 from 6:21:16 AM - 6:21:46 AM revealed in part: S4MHT facing camera with back to nurse station. S4MHT exchanging words with Patient #1. Patient #1 standing with back to camera outside medication room. S6MHT walks up with vital Sign machine and stands behind S4MHT. Patient #1 runs at S4MHT, knocking the observation tablet out of S4MHT. S4MHT swings right arm with closed fist and hits Patient #1 and both fall back into nurse station. During this time, S6MHT backs up with vital sign machine. S8RN comes out nurse station, S5MHT comes into camera view, both attempting to separate Patient #1 and S4MHT. Patient #1 ends up on the ground when S5MHT attempts to separate S4MHT from Patient #1. Video clip ends 6:21:46 AM. On 04/07/2025 at 2:30 PM, review of video footage navigated by S3MHTC of the incident involving Patient #1 on 03/09/2025 starting at 6:22 AM revealed in part: 6:22 AM- Patient #1 carried by S4MHT using Patient #1’s shirt, while S5MHT is carrying Patient #1’s lower extremities. 6:22:41 AM- Patient #1 carried inside room a by S4MHT and S5MHT. S6MHT and S7MHT in room, door to room closed. In an interview on 04/07/2025 at 1:10 PM, S1DON confirmed that staff did not respond using proper CPI technique. In an interview on 04/07/2025 at 2:43 PM, S3MHTC confirmed that the video footage revealed Patient #1 was inappropriately brought to his room. In an interview on 04/07/2025 at 2:55 PM, S1DON confirmed that staff on duty did not intervene when Patient #1 was being carried by his shirt and feet to his room by S4MHT and S5MHT. S1DON confirmed that S4MHT was terminated following this incident. S1DON commented that the staff know proper de-escalation, but they were just caught up in the moment because Patient #1 was fighting them. S1DON confirmed that all the staff she interviewed did not receive education on what is considered a restraint or proper de-escalation following the above mentioned incident. S1DON further confirmed that staff have not been educated on intervening to ensure the safety of each patient.”

“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: 50453 Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failing to accurately self-report an incident involving assault. Findings: Review of Patient #1’s medical record revealed the patient was admitted 03/08/2025 on a PEC with Suicidal Ideation and had a diagnosis of MDD. Patient #1 was on Q15 minute observations and Suicide/Self-harm Precautions were initiated on 03/09/2025 at 4:06 AM. Review of Patient #1’s History and Physical Examination on 03/09/2025 revealed Patient #1 was evaluated at 9:05 AM by S12APRN. S12APRN documented the ROS, Patient #1 complained of jaw pain. Review of the Hospital/Licensed Provider Abuse/Neglect Initial Report finalized on 03/10/2025 revealed the following documentation: Incident Type documented as: Alleged Physical Abuse and Self-Injurious Behaviors Date/Time Incident: 03/10/2025 at 7:30 AM Patient Information documented on report included: Patient #1 documented as Victim Video Surveillance information documented on report included: Video surveillance at incident site: yes What was revealed on video? Answer: 03/09/2025 at 6:21 AM Patient #1 and S4MHT is observed in the hall in conversation with inappropriate nonverbal gestures (no audio). Patient #1 leans against the wall and seems to be removing his socks. S4MHT steps back as Patient #1 ambushes S4MHT by assaulting him. S4MHT responds in a defensive manner also swings with a closed fist hitting Patient #1 to left side of his face. Altercation continues as multiple staff members immediately respond attempting to separate both S4MHT and Patient #1. Immediately after separation, S7MHT enters patient room where he is brought into his room by S4MHT and S5MHT. S9RN and S10LPN enter the room and shortly exits. S6MHT returns and enters Patient #1’s room. 6:27 AM S9RN and S10LPN return to the room. 6:28 AM all employees exit the room. 6:36 AM S5MHT enters Patient #1’s room and S8RN follows. Patient #1 was removed from his room to sit into a chair outside with his left sleeve pulled up. S8RN returns to his chairside, completes an assessment, and provided wound care. Incident Details revealed in part: 2. How was incident discovered? Answer: Patient reported. Patient #1 became verbally aggressive and threatening S9RN. S4MHT approached and attempted to verbally de-escalate Patient #1. Patient #1 was redirected to his room. Patient #1 returned to hall area where Patient #1 took his socks off and charged at S4MHT assaulting him in his face area. Patient #1 required to be brought to his room where he received an IM Benadryl, Haldol, and Ativan. Patient #1 alleged S4MHT left his room and entered again with a nurse who kicked him in the face saying, “Welcome to Beacon.” Patient #1 continued to scream and yell. Upon reassessment, Patient #1 had broken the toilet seat and used the broken piece cutting his left forearm. He was removed from his room for assessment, placed on increased observation, and room reassigned. 10. Did the Patient(s) sustain injury(ies) or adverse effects in relation to the incident? Answer: No 11. Describe injury(ies) and/or adverse effects and Treatment Provided: Answer: Multiple self-inflicted lacerations to left forearm. Area was cleaned with saline and wrapped with gauze. 03/10/2025 Patient #1 woke up with a blood vessel in his left eye, tenderness and swelling to his left jaw. Patient 1 was transferred to the hospital for evaluation and diagnosed with Subconjunctival Hemorrhage. Patient #1 returned to facility at 9:15 PM. Initial Actions Taken: Patient #1 was placed on 1:1 observation. Patient #1 received Benadryl, Haldol, Ativan IM following self-injurious behaviors. Patient #1 received wound care. Comments documented on report revealed in part: S1DON conducted individual interviews with both Patient #1 and the staff members that were on duty during the event. In interview S4MHT denied kicking Patient #1 in face at all. After reviewing video footage, S4MHT stated, he didn’t realize that he responded defensively as he remembered taking Patient #1 down. In interviews with S5MHT, S6MHT, and S7MHT, they stated they responded to the impact and did not witness the entire incident. In review of the camera, S4MHT did not respond with proper CPI disengagements. S4MHT proceeded with an unauthorized defensive response to Patient #1. Camera footage did not show S4MHT entering his room following event at any time while Patient #1 was in the room. S4MHT was removed from the schedule and terminated. On 04/07/2025 at 1:03 PM, review of video footage navigated by S1DON of the incident involving Patient #1 on 03/09/2025 from 6:21:16 AM - 6:21:46 AM revealed in part: S4MHT facing camera with back to nurse station. S4MHT exchanging words with Patient #1. Patient #1 standing with back to camera outside medication room. S6MHT walks up with vital Sign machine and stands behind S4MHT. Patient #1 runs at S4MHT, knocking the observation tablet out of S4MHT. S4MHT swings right arm with closed fist and hits Patient #1 and both fall back into nurse station. During this time, S6MHT backs up with vital sign machine. S8RN comes out nurse station, S5MHT comes into camera view, both attempting to separate Patient #1 and S4MHT. Patient #1 ends up on the ground when S5MHT attempts to separate S4MHT from Patient #1. Video clip ends 6:21:46 AM. On 04/07/2025 at 2:30 PM, review of video footage navigated by S3MHTC of the incident involving Patient #1 on 03/09/2025 starting at 6:22 AM revealed in part: 6:22 AM- Patient #1 carried by S4MHT using Patient #1’s shirt, while S5MHT is carrying Patient #1’s lower extremities. 6:22:41 AM- Patient #1 carried inside room a by S4MHT and S5MHT. S6MHT and S7MHT in room, door to room closed. 6:23 AM- S9RN enters room a and then exits with S6MHT. S4MHT, S5MHT and S7MHT remain in room a with Patient #1, door cracked open. 6:23:58 AM- S7MHT exits room a and closes door. 6:24:15 AM- S5MHT enters room a and closes door. 6:24:55 AM- S5MHT exits room a. S4MHT and S6MHT remain in room a with Patient #1. 6:27 AM- S9RN and S10LPN enter room and close door. (Per S3MHTC this is when the Patient #1 was given Haldol, Benadryl, and Ativan.) 6:28:10 AM- S9RN and S10LPN exit room a. 6:28:40 AM- S6MHT exits room. 6:28:44 AM- S4MHT exits room a and closes door. Patient #1 alone in room. 6:34:56 AM- An unidentified patient walks to room a and cracks open door and runs toward nurse station. (Patient #1 was left alone in room with door closed for 6 minutes.) 6:35:38 AM- S5MHT, S7MHT, S8RN, and S9RN go to room a. 6:36:23 AM- S5MHT walks out room a carrying a toilet seat followed by S8RN. 6:37:36 AM- Patient #1 placed in chair in hallway outside his room a. 6:38 AM- S8RN talking to Patient #1 in hallway. 6:42 AM- S8RN applies dressing to Patient #1 left forearm. 6:45 AM- S8RN walks away from Patient #1. The incident report failed to reveal that Patient #1 was left in his room alone, with the door closed, after receiving a chemical restraint and was not on 1:1 observation. The incident report failed to reveal that Patient #1 was found harming himself by another patient and not by the staff. The incident report also failed to reveal that S4MHT did enter Patient #1’s room during the event. In an interview on 04/07/2025 at 2:43 PM, S3MHTC confirmed that the video footage revealed Patient #1 was alone in his room after receiving medication. S3MHTC confirmed that video footage revealed that Patient #1 was found harming himself by another footage. S3MHTC further confirmed during video footage review that S4MHT inappropriately carried Patient #1 to his room at 6:22:41 AM and did not exit Patient #1’s room until 6:28:44 AM. In an interview on 04/07/2025 at 2:55 PM, S1DON confirmed that Patient #1 was not placed on 1:1 observation until after he was found harming himself.”

“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: 50453 Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by: 1) failure of the Registered Nurse to document patient observations every 2 hours for 1 (#3) of 3 (#1-#3) medical records reviewed; and 2) failure of the Registered Nurse to supervise staff to ensure timely observation rounds performed by the MHT for 1 (#1) 3 (#1-#3) Patient observation sheets reviewed. Findings: A review of hospital policy titled, “Levels of Observation,” last revised 06/13/2024, revealed in part: “Routine Observation is the routine Level of Observation applied to patients that are not considered at risk and/or in need of increased supervision. At least every 15 minutes, a staff member directly visually observes the patient to determine: 1. Signs of life (breathing while asleep-rise and chest fall, no obvious distress) 2. Location 3. Behavior. While observing the patient, the staff member documents, the patient’s location and behavior. Any change in behavior or demonstration of increased risk should be brought to the attention of the Charge Nurse immediately. Line of Sight observation is define as always maintaining visual observation of a patient. Although visualization is continuous, the staff member documents the patient’s location and behavior at least every 15 minutes. One-to-One (1:1) Observation is maintained when a patient is considered at high risk and requires observation by a staff member dedicated only to that patient. Although visualization is continuous, the staff member documents the patient’s location and behavior at least every 15 minutes.” 1) Failure of the Registered Nurse to document patient observations every 2 hours for 1 (#3) of 3 (#1-#3) medical records reviewed. Review of Patient #3’s medical record revealed the patient was admitted on 02/26/2025 with Suicidal Ideation and had a diagnosis of Schizoaffective Disorder, Methamphetamine/Cocaine/Cannabis Use Disorder. Patient #3’s medical record failed to reveal documentation by the Registered Nurse that observations were completed every 2 hours on 02/28/2025 from 7:00 AM - 7:00 PM. Further review of the Patient Observation Sheet failed to reveal documentation by the Registered Nurse that observations were performed every 2 hours on 02/28/2025 from 7:00 AM - 7:00 PM. In an interview on 04/08/2025 at 1:52 PM, S11CE confirmed that the Registered Nurse should round every 2 hours on patients. S11CE also confirmed that there was no documentation that the RN performed rounds every 2 hours on 02/28/2025 from 7:00 AM - 7:00 PM. 2) Failure of the Registered Nurse to supervise staff to ensure timely observation rounds performed by the MHT for 1 (#1) 3 (#1-#3) Patient observation sheets reviewed. Review of Patient #1’s medical record revealed the patient was admitted on 03/08/2025 with Suicidal Ideation and had a diagnosis of MDD. Review of Patient #1’s Patient Observation Sheet failed to reveal documentation by the MHT that Q15 minute observations were performed on 03/09/2025 between 1:53 AM - 3:17 AM. In an interview on 04/08/2025 at 11:39 AM, S11CE confirmed that the MHT did not document that Q15 minute observations were performed on 03/09/2025 between 1:53 AM - 3:17 AM on Patient #1.”

“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: 50453 Based on observation and interview, the hospital failed to ensure supplies were maintained to an acceptable level of safety and quality. This deficient practice was evidenced by expired patient care supplies available for patient use. Findings: Observations during a walk-through of the hospital on 04/07/2025 from 9:51 AM to 10:30 AM revealed expired patient care supplies available for patient use and included: 1) BD Vacutainer Purple Top 4ml Vials, quantity 100 vials, with an expiration of 01/31/2025; 2) BD Vacutainer Red Top 10ml Vials, quantity 200 vials, with an expiration of 01/31/2025; and 3) BD Vacutainer Red Top 10ml Vials, quantity 100 vials, with an expiration of 02/28/2025. In an interview on 04/07/2025 at 10:15 AM, S3MHTC confirmed the above mentioned findings.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47397 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: 1) failure to provide patient observations as per hospital policy (See findings in A0145); 2) Failure to maintain a patient care environment free of ligature risk related to square top bathroom doors (See findings in A0144); 3) failure to provide a focused assessment following a claim of sexual assault (See findings in A0145); 4) failure to complete nursing rounds per hospital policy (See findings in A0145); and 5) Failure to maintain a patient care environment free of items that could potentially be self-injurious to patients (See findings in A0144).”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 48051 Based on observation, policy review and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice is evidenced by: 1) Failure to maintain a patient care environment free of ligature risk related to square top bathroom doors in 12 (e - h, m - t) of 16 (a - t) patient rooms; and 2) Failure to maintain a patient care environment free of items that could potentially be self-injurious to patients. Findings: A review of hospital policy, “PR (Patient Rights),” with an effective date of 09/01/2011 and last revision 03/21/2018, revealed in part: “19. Receive care in a safe setting. The Hospital is committed to providing a safe, secure, therapeutic environment. As part of this endeavor, clinical staff have identified items that are considered a risk to safety and/or are counter-therapeutic. Such items are considered “contraband.” The Hospital utilizes a number of methods for controlling the existence of Contraband, including, but not limited to: Checking patient rooms daily. Maintaining a safe environment is the responsibility of all staff members. Contraband: 2. Prohibited Items: This category includes any items that a patient will not be permitted to access at any time while on the unit. b. Sharp Objects: Nails and screws.” 1) Failure to maintain a patient care environment free of ligature risk related to square top bathroom doors in 12 of 16 patient rooms Observations during a walk-through of the hospital’s offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed wooden, square-top style restroom doors in 12 (e - h, m - t) of 16 (a - t) patient bedrooms. This wooden, square-top style door would create a ligature risk with the potential for self-injurious behavior by a patient. In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mention findings. 2) Failure to maintain a patient care environment free of items that could potentially be self-injurious to patients Observations during a walk-through of the hospital’s offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed a crosshead screw protruding from the restroom wall of Room “t.” It appeared this was the location of a prior paper towel dispenser that was removed and the screw was not removed. The screw was loosely fastened in its wall anchor and could be removed by hand. This crosshead screw had the potential for self-injurious behavior by a patient. In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mention findings.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficiency is evidenced by: 1) failure to provide patient observations as ordered by the physician for 2 (#3 and #R20) of 2 (#3 and #R20) psychiatric patients observed on hospital video; and 2) failure to provide a focused assessment on Patient #2 following a sexual assault; and 3) failure to complete nursing rounds per hospital policy. Findings: Review of psychiatric hospital’s policy titled “Patient Rights”, approved 01/25/2014, revealed in part: “Policy [in part]: In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to [in part]: 18. Be free from all forms of abuse and harassment.” 1) Failure to provide patient observations per hospital policy for 2 (#3 and #R20) of 2 (#3 and #R20) psychiatric patients observed on hospital video. Review of psychiatric hospital’s policy titled “Levels of Observation”, approved 01/25/2024, revealed in part: “Policy [in part]: In the inpatient setting, the levels of observation for any patient, must be directly observed, in-person, according to prescriber orders. Procedure [in part]: Close Observation is the routine level of observation applied to patients that are not considered at risk and in need of increased supervision. At least every 15 minutes, a staff member directly visually observes the patient”. A review of psychiatric hospital document titled “Louisiana Department of Health Hospital/Licensed Provider Abuse/Neglect Initial Report” dated 12/16/2024-12/17/2024 at 7:00 AM and submitted on 12/18/2024, revealed in part: “Alleged incident: Patient #3 woke up yelling around the halls asking to see the cameras. “I need to see the cameras because I feel like someone came into my room and put their fingers in my ass!” Further review of the report revealed video surveillance was reviewed: “Camera footage shows observations q 15 minute rounds being completed by mental health techs and q 2 hour rounds by nursing staff.” Review of hospital assignment sheet dated 12/16/2024 PM revealed S5MHT was assigned Patient #3 and Patient #R20. Patient #3 was on aggression precautions and every 15-minute observations and was assigned to room ‘u’. Patient #R20 was on suicide, aggression and detoxification precautions, and every 15-minute observations and was assigned to room ‘v’. A review of Patient #3’s Patient Observation Sheet dated 12/17/2024 between 12:01 AM-7:06 AM revealed documentation that Patient #3 was observed by the following: S14MHT from 12:01 AM until 1:00 AM approximately every 15 minutes. S13MHT from 1:14 AM until 2:29 AM approximately every 15 minutes. S6MHT from 2:41 AM until 4:01 AM approximately every 15 minutes. S5MHT from 4:16 AM until 5:29 AM approximately every 15 minutes. S14MHT from 5:40 AM until 6:53 AM approximately every 15 minutes. On 12/26/2024 from 1:57 PM until 2:25 PM, a review of video from 12/17/2024 at 12:01 AM through 6:58 AM was navigated by S2DON with S3ADON present. The video, with camera focus on rooms ‘u’ and ‘v’, revealed the following: 12:01 AM until 1:10 AM: S5MHT with tablet in hand walked down the middle of the hall, aimed the tablet towards the closed doors of rooms ‘u’ and ‘v’. The video failed to reveal S5MHT opened the doors to rooms ‘u’ and ‘v’ to observe Patients #3 and #R20. 1:10 AM until 1:55 AM: S14MHT observed Patients #3 and #R20 approximately every 15 minutes. 1:55 AM until 3:51 AM: S13MHT with tablet in hand walked down the middle of the hall, aimed the tablet towards the closed doors of rooms ‘u’ and ‘v’. The video failed to reveal S13MHT opened the doors to rooms ‘u’ and ‘v’ to observe Patients #3 and #R20. 3:51 AM: S6MHT went into room ‘u’ but not room ‘v’. 4:12 AM: S6MHT went into room ‘u’ but not room ‘v’. 4:38 AM: S6MHT went into room ‘u’ but not room ‘v’. 5:00 AM: difficult to ascertain if S6MHT opened the door to room ‘u’, S2DON reports she did peek in the room through a crack but did not go into room ‘v’. 5:09 AM until 6:58 AM: S5MHT with tablet in hand walked down the middle of the hall, aimed the tablet towards the closed doors of rooms ‘u’ and ‘v’. The video failed to reveal S5MHT opened the doors to rooms ‘u’ and ‘v’ to observe Patients #3 and #R20. During an interview on 12/26/2024 at 2:30 PM, S2DON and S3ADON confirmed the above video findings. S2DON confirmed the observation sheets did not correlate with the video findings. S2DON did not comment on the self report and video finds not correlating. S2DON reported she had already addressed the failure of the MHTs to observe patients per hospital policy. S2DON stated she would provide documentation the issue had been addressed. At 5:30 PM, when exit conference was held, the documentation still had not been provided to the surveyor. 2) Failure to provide a focused assessment on Patient #2 following a sexual assault. Review of psychiatric hospital’s policy titled “Ongoing Nursing Assessments”, approved on 01/25/2024, revealed in part: “Policy [in part]: In addition to the comprehensive assessment conducted on each shift, the registered nurse will conduct focused assessments in response to the patient, in part: Demonstrating or verbalizing indications that the patient has been assaulted or has engaged in high-risk behavior during hospitalization.” Review of Patient #2’s medical record revealed an admission date of 12/16/2024 with admitting diagnoses of bipolar disorder, stimulant use disorder, sedative, hypnotic or anxiolytic use. Patient with recent history aggressive behaviors and abuse by her husband. A review of psychiatric hospital document titled “Louisiana Department of Health Hospital/Licensed Provider Abuse/Neglect Initial Report” dated 12/18/2024 at 1:48 AM and submitted on (date written as “9/17/2024”), revealed in part: On 12/18/2024 at 1:48 AM, Patient #1 was found attempting to hide on the side of Patient #2’s bed with no pants on naked from the waist down. On further observation, Patient #2 was discovered to be not wearing any bottoms, also naked from the waist down. Review of statement taken from Patient #2 on 12/19/2024 revealed the following: “Mood stabilizer-I did not want to take it but she made me take it to sleep. ‘Just take it, so you can go to sleep.’ Wrong answer. I was knocked out. I came to and he was on top of me. He was already having intercourse with me. He said, ‘the door is locked.’ I then could hear the nurse’s voice yelling. I don’t know what staff was in there, it was a lot, but I heard the night nurse’s voice. Next thing I knew, I felt her hand grab the blanket off of me and I was exposed. I could tell because when I woke up the next morning, my pants were stuck around my ankles. Did they come back to check on me? I don’t even think they came back to check on me! Please pull the tapes to check if they came back and check on me. I haven’t even taken a shower since it happened! Please don’t let me see him get arrested, let me be in my room. This should not have happened in any situation. No one should have been in anyone’s room.” A review of social worker note dated 12/19/2024 at 4:26 PM revealed the social worker typed up Patient #2’s statement regarding her disclosure of sexual assault by another patient on 12/18/2024 at 2 AM. The social worker emailed statement to DON, ADON, administrator and provider. Social worker filed incident report of patient’s disclosure. Review of Patient #2’s medical record failed to reveal a focused assessment in response to the patient demonstrating and verbalizing indications that she had been assaulted during her hospitalization. During an interview on 12/26/2024 at 3:15 PM, S2DON confirmed the medical record failed to reveal a focused assessment in response to Patient #2 demonstrating and verbalizing indications that she had been assaulted during her hospitalization. 3) Failure to complete nursing rounds per hospital policy. Review of psychiatric hospital’s policy titled “Ongoing Nursing Assessments”, approved on 01/25/2024, revealed in part: “Policy [in part]: The registered nurse is required to make rounds on and observe each patient at least every two hours.” On 12/26/2024 from 3:58 PM until 4:45 PM, a review of video from 12/17/2024 at 7:00 PM through 12/18/2024 at 12:07 AM was navigated by S2DON with S3ADON present. The video, with camera focused on nurses’ station located at offsite location, 4201 Woodland Drive, Suite 400, New Orleans, LA 70131, revealed the following: 7:00 PM: S15RN in nurses’ station on computer. 8:00 PM: S15RN had not left nurses’station. 9:00 PM: S15RN had not left nurses’station. 9:54 PM: S15RN walked out of nurses’ station into admission room. 10:11 PM: S15RN back in nurses’station. 11:11 PM: S15RN left for hydration and back in nurses’ station at 11:12 PM 11:15 PM: S15RN went to lunch. 12:00 AM: S15RN back in nurses’ station in restroom. 12:07 AM: S15RN in hallway rounding on patients. During an interview on 12/26/2024 at 4:45 PM, S2DON and S3ADON confirmed the above video findings. S2DON verified S15RN failed to make nursing rounds every 2 hours as required per hospital policy.”

“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: 48051 Based on observation, record review and interview, the hospital failed to recognize patient safety issues through the Quality Assurance and Performance Improvement (QAPI) review process. The deficient practice is evidenced by the hospital failing to implement an action plan for locking housekeeping carts. Findings: Observations during a walk-through of the hospital’s offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed an open housekeeping cart being pushed by housekeeping in the patient care area with cleaning products and accessories within arms-reach of the patients. A review of hospital document titled, “Committee of Whole Meeting Minutes and Agenda,” revealed the minutes of the meetings taking place on 10/16/2024, 11/20/2024 and 12/18/2024. Each of these meetings minutes for the Topic: Annual EOC Risk Assessment for West (4201 Woodland Drive, Suite 400, New Orleans, LA 70131) included, “Housekeeping care(t) are not lockable.” The Action Plan included, “Locked Housekeeping carts ordered for replacement.” In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the housekeeping cart was in the patient care area and the housekeeping supplies were not secured. In an interview on 12/23/2024 at 3:10 PM, S3ADON confirmed the above mention findings and further indicated the hospital had not received lockable housekeeping carts.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure to ensure patient precautions were accurately communicated to the Mental Health Technician (MHT) assigned to monitor the entire census. Findings: Review of the psychiatric hospital policy titled “NS (Nursing Services), Precautions”, last approved 01/25/2024, revealed in part: “Precautions [in part]: All direct care staff members (i.e. nurses, mental health technicians, counselors, etc.) are fully trained on the components of all precautions. The following are components of suicide precautions: unit restriction, sharps restriction. The following are components of aggression/violent behavior precautions: unit restriction, shoe restriction, signage, and 10-foot door parameter. The following are components of sexual acting out precautions: 10-foot parameter, line of sight while with peers, and restriction from room.” Further review failed to reveal policy pertaining to alcohol/detoxification precautions. Review of psychiatric hospital document titled “Daily Nursing Assignment Sheet” dated 12/26/2024, presented as correct per S2DON at 9:56 AM revealed a census of 20. 2 patients on 1:1 observation with 1 pending admission. Further review revealed R1 was on 1:1 observation with suicide precautions. R2 was on aggression precautions, R3 was on ETOH precautions and R4 was on 1:1 observation with aggression precautions. The following assignments were documented: S12MHT assigned to R5, R6, R7, R8, R9, and R10. Tablet time from 7 AM - 9 AM and 3 PM-5 PM. S9MHT assigned to R1. Tablet time from 9 AM-11 AM and 5 PM-7 PM. S10MHT assigned to R1 (when S9MHT is on Tablet time), R2, R3, R11, R12, R13, and R14. Tablet time 11 AM- 1 PM. S11MHT assigned to R4. Tablet time 1 PM- 3 PM. S4MHT assigned to (R4 when S11MHT on Tablet time), #2, R15, R16, R17, R18 and R19. No assigned tablet time. On 12/26/2024 at 10:04 AM, observation revealed S10MHT was observing R1 while S9MHT was on Tablet time. During an interview on 12/26/2024 at 10:04 AM, S10MHT reported R1 was on 1:1 observation because she banged her head on the wall. When asked, S10MHT stated R1 was not on suicide precautions. On 12/26/2024 at 10:10 AM observation, revealed S9MHT was walking with an electronic tablet down each hallway. She was attempting to locate a patient stating that sometimes tablet time was difficult because she could not always find the patients since they move around the unit. When asked, S9MHT indicated R2 was not on any precautions. S9MHT was surprised when she learned R2 was on aggression precautions. “it doesn’t say that in the tablet”. She reported the tablet showed R3 was on fall, seizure, suicide and ETOH precautions and was surprised when she learned the assignment sheet showed R3 was on only on ETOH precautions. During an interview on 12/26/2024 at 3:42 PM, S2DON and S3ADON reported the hospital does not have a policy outlining the procedure for the one MHT observing the entire census every 15 minutes. The MHTs were taught that one MHT should observe all the patients on the census every 15 minutes while the other MHTs tended to needs of the patients and performed tasks such as showers, redirection, laundry, taking patients on smoke breaks, etc. S2DON indicated that when S4MHT was on 1:1 observation with R4, the other MHTs and S11MHT observed his assigned patients. When S10MHT was on 1:1 with R1 the other MHTs and S9MHT observed his assigned patients. During an interview on 12/26/2024 at 3:42 PM, S2DON and S3ADON verified that the hospital does not have a policy on this procedure. Also during the interview S2DON verified the tablet is not always updated to reflect the precautions shown on the assignment sheet.”

“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: 47397 Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to include medical diagnoses and condition changes in the plan of care for 2 (#2 and #3) of 2 (#2 and #3) sampled patients with medical diagnoses and condition changes. Findings: Review of the psychiatric hospital policy titled “Multidisciplinary Treatment Plan”, last approved 01/25/2024, revealed in part: “Policy [in part]: The Multidisciplinary Treatment Plan includes: b. Medical problems that require intervention during hospitalization. 9. As changes in the patient’s needs and/or condition changes or as interventions not already listed in the Multidisciplinary Treatment Plan are implemented, the multidisciplinary Treatment Plan is revised and updated.” Patient #2 Review of Patient #2’s medical record revealed an admission date of 12/16/2024 with admitting diagnoses of bipolar disorder, stimulant use disorder, Sedative, hypnotic or anxiolytic use, with withdrawal and hypokalemia requiring potassium chloride administration. A review of psychiatric hospital document titled “Louisiana Department of Health Hospital/Licensed Provider Abuse/Neglect Initial Report” dated 12/18/2024 at 1:48 AM and submitted on (date written as “9/17/2024”), revealed in part: On 12/18/2024 at 1:48 AM, Patient #1 was found attempting to hide on the side of Patient #2’s bed with no pants on naked from the waist down. On further observation, Patient #2 was discovered to not be wearing any bottoms, also naked from the waist down. Review of statement taken from Patient #2 on 12/19/2024 revealed the following: “Mood stabilizer-I did not want to take it but she made me take it to sleep. “Just take it, so you can go to sleep.” Wrong answer. I was knocked out. I came to and he was on top of me. He was already having intercourse with me. He said, “the door is locked.” I then could hear the nurse’s voice yelling. I don’t know what staff was in there, it was a lot, but I heard the night nurse’s voice. Next thing I knew, I felt her hand grab the blanket off of me and I was exposed. I could tell because when I woke up the next morning, my pants were stuck around my ankles. Did they come back to check on me? I don’t even think they came back to check on me! Please pull the tapes to check if they came back and check on me. I haven’t even taken a shower since it happened! Please don’t let me see him get arrested, let me be in my room. This should not have happened in any situation. No one should have been in anyone’s room.” A review of Master Treatment Plan last updated on 12/19/2024 at 4:03 PM, failed to reveal active problems pertaining to events involving sexual assault occurring on 12/18/2024. Continued review failed to reveal active problems pertaining to hypokalemia, a medical problem requiring intervention. During an interview on 12/26/2024 at 1:49 PM, S2DON and S3ADON verified Patient #2’s Master Treatment Plan was last updated on 12/19/2024 and failed to reveal active problems pertaining to hypokalemia. S2DON and S3ADON confirmed the treatment plan had not been revised and updated following the events of sexual assault occuring on 12/18/2024. Patient #3 Review of Patient #3’s medical record revealed an admission date of 12/10/2024 with admitting diagnosis of brief psychotic disorder. Further review revealed Patient #1 had nicotine dependency, emesis, hypoglycemia, and low TSH. A review of psychiatric hospital document titled “Louisiana Department of Health Hospital/Licensed Provider Abuse/Neglect Initial Report” dated 12/17/2024 and submitted on 12/18/2024, revealed in part: Patient #3 woke up yelling, “Someone came into my room and put their fingers in my ass!” The patient was sent to the ER for evaluation. A physician from ER called the psychiatric hospital and stated that due to the patient’s current psychiatric mentality, the patient cannot give consent for a forensic evaluation. He did state that his lab results showed an acute kidney injury and that they will hydrate patient and return the patient to the psychiatric hospital.” A review of Master Treatment Plan last updated on 12/12/2024 failed to reveal active problems pertaining to events occurring on 12/17/2024. Continued review failed to reveal active problems pertaining to acute kidney injury, nicotine dependency, emesis, hypoglycemia, and low TSH, all medical problems requiring intervention. During an interview on 12/26/2024 at 1:12 PM, S2DON and S3ADON verified Patient #3’s Master Treatment Plan was last updated on 12/12/2024 and failed to reveal active problems pertaining to acute kidney injury, nicotine dependency, emesis, hypoglycemia, and low TSH. S2DON and S3ADON confirmed the treatment plan had not been revised and updated following the events of 12/17/2024.”

“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: 48051 Based on observation and interview, the hospital failed to ensure the condition of the physical plant and the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients were assured. This deficient practice is evidenced by failure to ensure the surfaces of the ventilation vents and the interior door frame of Room “u” were free of brown, rough and irregular surfaces creating an infection control issue. Findings: Observations during a walk-through of the hospital’s offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed Room “u” with ventilation vents and the interior door frame containing brown, rough and irregular surfaces resembling rust which created an infection control issue. In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mentioned findings.”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to ensure there was proper ventilation in all appropriate areas. This deficient practice was evidenced by the hospital failing to ensure Room “u” was properly ventilated. Findings: Observations during a walk-through of the hospital’s offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed Room “u” with a damp floor, water beading on the exterior windows, a pungent smell, and a warm, humid feel. Observation failed to reveal indication of air circulating as felt by hand or movement of paper next to the vents and no obvious noise of an exhaust ventilation system functioning within this room. In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mention findings.”

“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: 48051 Based on observation and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failing to have a clean and sanitary environment. Findings: Observations during a walk-through of the hospital’s offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed Room “u” with an adhesive medical bandage stuck to the wall of shower stall #1 and saturated toilet paper around the rim of the toilet. In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mentioned findings.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47397 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: 1) failure of the hospital to provide continuous line of sight and 1:1 supervision as ordered by the physician for 3 (#2, #7 and #R3) of 3 (#2, #7 and #R3) psychiatric patients with physician orders for line of sight and 1:1 supervision (See findings under A-0144); 2) failure to provide a focused assessment on Patient #1 following a claim of sexual assault (See findings under A-0145); 3) failure to ensure patients did not have access to items that could cause harm to themselves (See findings under A-0144); 4) failure to test glucometer controls to meet the safety needs of the patients (See findings under A-0144); 5) failure to ensure each patient received an armband for accurate identification per hospital policy (See findings under A-0144); and 6) failure to ensure the patient /patient representative was included in the development and implementation of the patient’s plan of care for 5 (#1, #3-#6) of 5 (#1, #3-#6) patients reviewed for care plan participation. (See findings under A-0130).”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice is evidenced by failure to report and investigate the case of a threat against a nurse involving a firearm. Findings: Pursuant to LA RS 40:2199.16 acts of workplace violence at licensed healthcare facilities reporting required. A. Each regulated entity shall report to the proper authority, as required by the entity’s workplace violence prevention plan, any instance of workplace violence that occurs on its property. B. If an instance of workplace violence at a regulated entity’s facility results in injury, involves the use of a firearm or other dangerous weapon, or presents an urgent or emergent threat to the welfare, health, or safety of facility personnel, the regulated entity shall report the incident within twenty-four hours. Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. On 12/03/2024 at 3:10 p.m., a request was made for the psychiatric hospital’s policy on workplace violence prevention and reporting requirements. S1DON indicated that the hospital did not have a policy on work place violence and required reporting. Review of hospital document titled “Case: 990-Internal Incident/Unusual Occurrence Form/Workplace Violence and Safety: Aggressive/Violent Behavior by Patient”, initiated on 11/08/2024, revealed in part: On 11/08/2024 at 1:00 p.m., Patient #R1 was demanding to see MD. When informed that MD was not in the hospital, he began threatening staff and pounding on partition surrounding nurses’ station. PRN medication was administered. Patient #R1 then stated that he would “call his people” and “catch the nurse in the parking lot”. Patient #R1 made threatening statements that he would shoot S7RN when he was discharged and “leave him on a stretcher”. In an interview on 12/02/2024 at 3:05 p.m., S1DON indicated she did not submit a self-report for this incident because no harm came to S7RN. S1DON confirmed the hospital did not call the police regarding this threat made to S7RN. S1DON stated there was no need for further analysis of the situation “because patients threaten to shoot nurses everyday”.”

“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: 47397 Based on record review and interview, the psychiatric hospital failed to ensure the patient /patient representative’s right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient’s plan of care for 5 (#1, #3-#6) of 6 (#1- #6) patients reviewed for care plan participation. Findings: Review of the psychiatric hospital’s policy titled “Patient Rights “, Revised: 03/21/2018, revealed in part: “Policy: ...In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: ...7. Participate in the development and implementation of his or her plan of care”. Review of Patient #1’s medical record revealed an admission date of 10/30/2024 with diagnosis of bipolar, schizophrenia, homicidal ideations, auditory hallucinations, visual hallucinations and urinary tract infection. Review of Patient #1’s medical document titled “Master Treatment Plan” initiated on 10/30/2024, failed to reveal evidence of Patient #1’s signature or Patient #1 representative’s signature indicating participation in her plan of care. Review of Patient #3’s medical record revealed an admission date of 11/06/2024 with diagnosis of bipolar disorder, current episode manic severe with psychotic features. Review of Patient #3’s medical document titled “Master Treatment Plan” initiated on 11/06/2024, failed to reveal evidence of Patient #3’s signature or Patient #3 representative’s signature indicating participation in his plan of care. Review of Patient #4’s medical record revealed an admission date of 11/01/2024 with diagnosis of suicidal ideations. Review of Patient #4’s medical document titled “Master Treatment Plan” initiated on 11/01/2024, failed to reveal evidence of Patient #4’s signature or Patient #3 representative’s signature indicating participation in his plan of care. Review of Patient #5’s medical record revealed an admission date of 11/02/2024 with diagnosis of bipolar disorder, current episode depressed, severe, with psychotic features and adverse effect of amphetamines, sequela. Review of Patient #5’s medical document titled “Master Treatment Plan” initiated on 11/02/2024, failed to reveal evidence of Patient #5’s signature or Patient #3 representative’s signature indicating participation in his plan of care. Review of Patient #6’s medical record revealed an admission date of 11/01/2024 with diagnosis of bipolar disorder, current episode depressed, severe, with psychotic features, depression, and suicidal ideations. Review of Patient #6’s medical document titled “Master Treatment Plan” initiated on 11/01/2024, failed to reveal evidence of Patient #6’s signature or Patient #3 representative’s signature indicating participation in his plan of care. During an interview on 12/03/2024 at 3:00 p.m., S1DON confirmed the Master Treatment Plans for Patients #1, and #3-#6 failed to reveal patient/patient representative signatures indicating participation in the plans of care.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting as evidenced by: 1) failure to provide continuous line of sight and 1:1 supervision as ordered by the physician for 3 (#2, #7 and #R3) of 3 (#2, #7 and #R3) psychiatric patients with physician orders for line of sight and 1:1 supervision; 2) failure to ensure patients did not have access to items that could cause harm to themselves. 3) failure to test glucometer controls to meet the safety needs of the patients; and 4) failure to ensure each patient received an armband for accurate identification per hospital policy. Findings: Review of psychiatric hospital’s policy titled “Patient Rights”, revised 03/21/2018, revealed in part: “Policy, in part: In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to, in part: 19. Receive care in a safe setting.” 1) Failure to provide continuous line of sight and 1:1 supervision as ordered by the physician for 3 (#2, #7 and #R3) of 3 (#2, #7 and #R3) psychiatric patients with physician orders for line of sight and 1:1 supervision. Review of psychiatric hospital’s policy titled “Levels of Observation”, revised 06/13/2024, revealed in part: “Policy, in part: The safety of patients is a priority during hospitalization. Beacon Behavioral Hospital’s inpatient program ensures patient safety through a level of monitoring and observation matched to patient’s need and assessed risk. In the inpatient setting, surveillance of common areas (such as hallways, dayrooms, etc.) may be monitored via camera (i.e., video surveillance). At no time is this type of surveillance to be used as a replacement of the levels of observation for any patient, who must be directly observed, in-person, according to prescriber orders. Procedure, in part: Line of Sight: Observation is defined as always maintaining visual observation of a patient. One-to-One (1:1): Observation is maintained when a patient is considered at high risk and requires observation by a staff member dedicated only to that patient (One staff member to Obne patient). The staff member assigned to 1:1 cannot be assigned any other patients or tasks during that period. Assessment and Determination of Needs, in part: 6. Patient rounds will be assigned to specific staff members on each shift by the Charge RN. “ Review of psychiatric hospital document titled “Daily Nursing Assignment Sheet”, dated 10/26/2024 PM shift, revealed S11MHT was assigned to Patients #R4-#R9 and #R20. Continued review revealed S3MHT was assigned only to Patient #R3 who was on observation level 1:1. Review of psychiatric hospital document titled “Daily Nursing Assignment Sheet”, dated 10/26/2024 PM shift, revealed Patients #R4-#R10, #R17 and #R20 were assigned to Hallway ‘A’. Patients #7, #R1, #R11, #R13 and #R21 were assigned to Hallway ‘B’. Patients #R3, #R10, #R12, #R14, #R15, #R16, #R18, and #R22 were assigned to Hallway ‘C’. Review of psychiatric hospital document titled “Daily Nursing Assignment Sheet”, dated 11/09/2024 PM shift, failed to reveal patients were assigned a mental health technician. Patient #2 Review of psychiatric hospital document titled “Hospital / Licensed Provider Abuse/Neglect Initial Report”, submitted 11/17/2024, revealed documented video observations dated 11/09/2024 detailing the following: 8:30 p.m.-8:34 p.m.-Patient #1 and Patient #2 observed in the dayroom (lights off with limited visual). Close in proximity. 8:34 p.m.-8:36 p.m.-S3MHT, who was assigned to Patient #2 for Line of Sight observations, entered dayroom standing in the doorway as Patient #1 and Patient #2 approached him in conversation. (No audio). S3MHT then walked out of the dayroom. Patient #1 and Patient #2 danced in the entryway. Patient #2 hands on waist turned Patient #1 and hugged her from behind as they continued dancing. They then walked down towards the smoke break area. 9:02 p.m.-Patient #1 and Patient #2 are seen shuffling quickly down Hallway ‘B’ entering Patient #1’s assigned room. Patient #2 remained in her room for 30 seconds and then exited. He is seen running down the hall back to his assigned room. Review of psychiatric hospital document titled “Line of Sight Close Observation Form”, dated 11/09/2024 for Patient #2, failed to reveal observations completed between 7:15 p.m. and 6:45 a.m. In an interview on 12/03/2024 at 9:48 a.m., S1DON confirmed the above findings. Patient #7 Review of psychiatric hospital document titled “Behavioral Health-Patient Observation Sheet”, dated 10/26/2024 revealed Patient #7 was on Line of Sight (LOS) observations. S11MHT observed Patient #7 (on Hallway ‘B’) at 7:34 p.m., 7:43 p.m., 7:58 p.m., 8:12 p.m., 8:23 p.m., 8:33 p.m., 8:43 p.m., 8:53 p.m., 9:04 p.m., 9:16 p.m., 9:27p.m., 9:36 p.m., 9:46 p.m. and 9:58 p.m. S3MHT observed Patient #7 at 10:13 p.m., 10:22 p.m., 10:35 p.m., 10:49 p.m., 11:02 p.m., 11:16 p.m., 11:31 p.m., 11:46 p.m., 11:57 p.m., 12:12 a.m., 12:27 a.m., 12:40 a.m., 12:54 a.m., and 1:07 a.m. Review of psychiatric hospital document titled “Behavioral Health-Patient Observation Sheet”, dated 10/26/2024 revealed S11MHT also observed Patient #R10 (on Hallway ‘C’) at 7:30 p.m., 7:40 p.m., 7:55 p.m., 8:09 p.m., 8:25 p.m., 8:35 p.m., 8:46 p.m., 8:53 p.m., 9:04 p.m., 9:19 p.m., 9:31 p.m., 9:44 p.m. and 9:57 p.m. while on line of sight observation duty for Patient #7. S3MHT observed Patient #R10 at 10:11 p.m., 10:21 p.m., 10:33 p.m., 10:48 p.m., 11:01 p.m., 11:15 p.m., 11:30 p.m., 11:45 p.m., 11:55 p.m., 12:11 a.m., 12:26 a.m., 12:39 a.m., 12:53 a.m., and 1:06 a.m. while on line of sight observation duty for Patient #7 and 1:1 observation duty for Patient #R3. Review of psychiatric hospital document titled “Behavioral Health-Patient Observation Sheet”, dated 10/26/2024 revealed S11MHT also observed Patient #R22 (on Hallway ‘C’) at 7:29 p.m., 7:39 p.m., 7:53 p.m., 8:08 p.m., 8:21 p.m., 8:34 p.m., 8:46 p.m., 8:53 p.m., 9:04 p.m., 9:13 p.m., 9:17 p.m., 9:31 p.m., 9:44 p.m. and 9:57 p.m. while on line of sight observation duty for Patient #7. S3MHT observed Patient #R22 (on Hallway ‘C’) at 10:11 p.m., 10:21 p.m., 10:33 p.m., 10:48 p.m., 11:01 p.m., 11:15 p.m., 11:30 p.m., 11:46 p.m., 11:45 p.m., 11:55 p.m., 12:11 a.m., 12:25 a.m., 12:39 a.m., 12:52 a.m., and 1:06 a.m. while on line of sight observation duty for Patient #7 and 1:1 observation duty for Patient #R3. Review of psychiatric hospital documents titled “Behavioral Health-Patient Observation Sheet”, dated 10/26/2024 revealed S11MHT also observed Patients #R4-#R9 and #R12-#R22 in the same time span as he was observing Patient #7 on LOS. Review of psychiatric hospital documents titled “Behavioral Health-Patient Observation Sheet”, dated 10/26/2024 revealed S3MHT also observed Patients #R4-#R9 and #R12-#R22 in the same time span as he was observing Patient #7 on LOS and Patient #R3 on 1:1. Patient #R3 Review of psychiatric hospital document titled “Close Observation Form”, dated 10/25/2024 revealed Patient #R3 (on Hallway ‘C’) was on observation level 1:1. Further review failed to reveal he was observed during the timeframe between 11:00 p.m. and 1:00 a.m. Review of psychiatric hospital document titled “Close Observation Form”, dated 10/26/2024 revealed Patient #R3 was on observation level 1:1. Further review revealed S3MHT initialed 1:1 observations every 15 minutes between 7:15 p.m.-6:45 a.m. Review of psychiatric hospital documents titled “Behavioral Health-Patient Observation Sheet”, dated 10/26/2024 revealed S3MHT also observed Patients #7, #R4-#R9 and #R12-#R22 in the same time span as he was observing Patient #R3 on a 1:1 level. In an interview on 12/02/2024 at 11:55 a.m., S1DON reported the hospital utilizes electronic system ‘D’ to keep track of patients and observations. The hospital is able to access the system and note when patients are observed. The system can track 1:1 and note when the patient is not being observed. All of the data is uploaded to a cloud and can be accessed at anytime. In an interview on 12/03/2024 at 9:45 a.m. and 10:30 a.m., S1DON confirmed the above findings indicating patient observations were not safely implemented per physician orders and hospital policy. S1DON stated the video for the 10/26/2024 timeline was no longer available. S1DON verified S3MHT had been terminated. 2) Failure to ensure patients did not have access to items that could cause harm to themselves. Review of psychiatric hospital’s policy titled, “Admission to an Inpatient Program”, revised on 05/01/2024 revealed in part: “Procedure, in part: Once the Patient is Accepted, in part: 6. A registered nurse meets with the patient (and accompanying individuals according to the patient’s preference and the registered nurse’s clinical judgement) in a room that affords privacy (not earshot of other patients and/or visitors and free of items that could cause harm to themselves or others) and conducts the Nursing Admission Assessment and obtains the patient’s signatures on consents and forms, as indicated. Review of psychiatric hospital’s policy titled, “Control of Contraband and Dress Code”, revised on 03/21/2018 revealed in part: “Policy, in part: Beacon Behavioral Hospital utilizes a number of methods for controlling the existence of Contraband, including, but not limited to, in part: Ensuring that patients do not have access to high-risk items. Contraband, in part: 1. Restricted items, in part: This category includes any items that a patient will be permitted to access during his hospitalization on a limited basis or with supervision. Items may be secured in a designated locked room or in the nurses’ station. Generally included in this category are, in part: a. Toiletries: Toothpaste and Toothbrush. 2. Prohibited Items, in part: This category includes any items that a patient will not be permitted to access at any time while on the unit. Beacon Behavioral Hospital makes every attempt to send these items home with family. If that disposition cannot be accomplished, these items should be secured in a manner that does not allow patient access to them. c. Items that may be used for Asphyxiation, in part: Plastic bags. On 12/02/2024 at 9:18 a.m., a shower chair made of PVC-type piping was observed unattended in the women’s shower room located on Hallway ‘B’. S12DM confirmed the finding stating the chair should not be left unattended in the shower room due to ligature risk and should be cleaned and bagged and placed in the equipment room after use. On 12/02/2024 at 9:23 a.m., a toothbrush and tube of toothpaste were observed on a shelf in patient room ‘c’. S12DM confirmed the findings and stated the items should be in a bucket with the patient’s name in a locked closet with the other patient buckets. On 12/02/2024 at 9:40 a.m., a shower chair made of PVC-type piping and linen cart also made of PVC-type piping were observed unattended in the men’s shower room located on Hallway ‘B’. S12DM confirmed the finding stating the unattended chair and linen cart should not be in the shower room due to ligature risk and should be cleaned and bagged and placed in the equipment room after use. On 12/02/2024 at 9:45 a.m., pieces of thick plastic approximately 4 feet long and bubble wrap with potential for ligature risk were observed hanging out of a box against the wall of the Intake Room accessible to patients who are newly admitted. S12DM confirmed the findings and stated the box with the long pieces of plastic and bubble wrap contained medical equipment that will eventually be installed on the wall but should be removed immediately in case of an admission. On 12/02/2024 at 9:48 a.m., a hard plastic toilet paper dispenser that was hanging open creating a ligature risk was observed in the shower room of Hallway ‘C’. S12DM confirmed the findings and stated the entire dispenser should be removed considering there is no commode in the shower room. On 12/02/2024 at 9:53 a.m., the nurses’ station door in the dayroom was observed open and unattended with 2 bottles of bleach cleaner in the entryway accessible to the 4 patients using the dayroom. S12DM confirmed the nurses’ station door was open and unattended and contained 2 bottles of bleach cleaner accessible to patients and should be locked in a cabinet to prevent patient access. S12DM verified the nurses’ station door in the dayroom should always be locked and attended when patients are using the dayroom. 3) Failure to test glucometer controls to meet the safety needs of the patients. On 12/02/2024 at 9:30 a.m., review of the hospital’s Glucometer Calibration and Control Logs located in the medication room failed to reveal documentation that quality controls were consistently performed. Review of psychiatric hospital document titled “Blood Glucose Daily Quality Control Log”, dated, December, failed to reveal documentation that quality controls were performed on 12/01/2024 and 12/02/2024. Review of psychiatric hospital document titled “Blood Glucose Daily Quality Control Log”, dated, November, failed to reveal documentation that quality controls were performed on 11/04/2024 thru 11/05/2024; 11/08/2024 thru 11/15/2024; and 11/17/2024 thru 11/27/2024. Review of psychiatric hospital document titled “Blood Glucose Daily Quality Control Log”, dated, October, failed to reveal documentation that quality controls were performed on 10/02/2024 thru 10/03/2024; 10/05/2024 thru 10/11/2024; 10/13/2024; 10/16/2024; 10/19/2024 thru 10/23/2024; and 10/27/2024 thru 10/31/2024. Review of psychiatric hospital document titled “Blood Glucose Daily Quality Control Log”, dated, September, failed to reveal documentation that quality controls were performed on 09/02/2024 thru 09/03/2024; 09/07/2024; 09/11/2024; 09/21/2024 thru 09/24/2024; and 09/27/2024 thru 09/30/2024. During an interview on 12/02/2024 at 9:30 a.m., S13LPN and S12DM confirmed the above findings. S13LPN stated the quality controls were to be perfomed every day. S13LPN verified she had several patients on the census requiring accuchecks. On 12/02/2024 at 9:30 a.m. surveyor requested a list of patients on the census requiring Accuchecks from S13LPN. On 12/02/2024 at 3:30 p.m. surveyor requested a list of patients on the census requiring Accuchecks from S1DON. On 12/03/2024 at 2:15 p.m. surveyor requested a list of patients on the census requiring Accuchecks from S1DON. Surveyor was not provided a list of patients on the census requiring Accuchecks as requested 3 times. 4) Failure to ensure each patient received an armband for accurate identification per hospital policy. Review of psychiatric hospital’s policy titled “Medication and Treatment Administration”, approved 01/25/2024, revealed in part: “Procedure-Inpatient, in part: 4. As each patient approaches the medication nurse, the nurse will identify the patient by the following methods, in part: c. Check the patient’s wristband.” On 12/02/2024 at 9:20 a.m., an armband was observed laying on a shelf in room ‘c’ with Patient #R23’s name. In an interview on 12/02/2024 at 9:21 a.m., Patient #R23 stated the armband was from the previous hospital she was admitted to before she was admitted to the psychiatric hospital. She stated she had not received a new armband since admission on 11/25/2024. Patient #R23 verified she was administered medications and was not asked to show her armband for identification purposes. In an interview on 12/02/2024 at 9:23 a.m., S12DM and S13LPN both verified the hospital had not used armbands for over a year. S13LPN reported the process to identify a patient for medication administration included the nurse writing the name of each patient on a Styrofoam cup. The nurse would look at the picture of the patient in the computer to identify the patient and then administer the medication in the Styrofoam cup. S12DM indicated the hospital should be using armbands and are in the process of implementing there use.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficiency is evidenced by failure to provide a focused assessment on Patient #1 following a claim of sexual assault. Review of psychiatric hospital’s policy titled “Ongoing Nursing Assessments”, revised 03/21/2018, revealed in part: “Policy, in part: In addition to the comprehensive assessment conducted on each shift, the registered nurse will conduct focused assessments in response to the patient, in part: Demonstrating or verbalizing indications that the patient has been assaulted or has engaged in high-risk behavior during hospitalization.” Review of Patient #1’s medical record revealed an admission date of 10/30/2024 with diagnosis of Bipolar, Schizophrenia, Homicidal ideations, Auditory hallucinations, Visual hallucinations and Urinary tract infection (UTI). Patient #1 noted with history of trauma involving sexual abuse as a child. Review of nursing note dated 11/10/2024 at 8:00 a.m., S5RN documented that Patient #1 was having a verbal altercation with male peer, accusing him of coming into her room and sexually assaulting her on the previous shift. Patient was interviewed to determine what actually happened and when. Patient #1 reported that the incident happened on the night of 11/09/2024 when the male peer went into her room. Patient #1 stated, “He flipped his dick out and because I am a meth addict, I sucked it.” She then stated, I want to report what he did and I want to press charges against him.” Psychiatry and Medical, along with DON notified of this incident. No new orders noted. Review of Patient #1’s medical record failed to reveal a focused assessment in response to the patient demonstrating and verbalizing indications that she had been assaulted during her hospitalization. During an interview on 12/03/2024 at 2:50 p.m., S1DON confirmed the medical record failed to reveal a focused assessment in response to Patient #1 demonstrating and verbalizing indications that she had been assaulted during her hospitalization.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to recognize patient safety issues through the Quality Assurance and Performance Improvement (QAPI) review process. The deficient practice is evidenced by: 1) failure to identify, discuss, create and implement an action plan to prevent sexual assault from occurring on site.; and 2) failure to identify, discuss, and create an action plan to ensure the assignment of a mental health technician to all patients on the census. Findings: Review of psychiatric hospital policy titled “Performance Improvement”, revised 01/23/2024, revealed, in part: “Purpose, in part: The purpose of the organizational Quality Assurance and Performance Improvement Plan at Beacon Behavioral is to ensure that he Governing Body, medical staff, and service staff (both professional and unlicensed) demonstrate the consistent delivery of safe, effective, optimal patient care and services in an environment of minimal risk. Goals of Quality Assurance and Performance Improvement, in part: Monitor/track the status of identified problems and action plans to assure sustained improvement and/or problem resolution; systematically and routinely evaluate unusual occurrences/incidents, the findings of QAPI activities, and any adverse patient events to detect trends, patterns of performance, or potential problems that affect at least one (1) department/service. Quality Assurance and Performance Improvement Team Scope of Activities, in part: Safety management; patient care and quality control activities in the following services are monitored, assessed, and evaluated, in part: Nursing services. Assessment of the performance of the following patient care and organizational functions are included, in part: Nursing, Provision of Care, Treatment and Services, Rights and Responsibilities of the Individual. Organization, in part: The QAPI Team is responsible for the implementation and monitoring of the effectiveness of Patient Safety Initiatives. The scope of such initiatives includes ongoing assessment, the use of internal and external knowledge and experience to prevent errors from occurrence, and maintaining and improving patient safety. Patient safety information, from aggregated data reports and individual incident occurrence reports, will be reviewed by the Committee of the Whole to prioritize organizational patient safety activity efforts. Included in the duties of the Committee of the Whole will be a review of these data reports. 1) Failure to identify, discuss, create and implement an action plan to prevent sexual assault from occurring on site. Review of psychiatric hospital document titled “Hospital/Licensed Provider Abuse/Neglect Initial Report”, submitted on 11/17/2024 revealed a substantiated allegation of patient-to-patient sexual abuse. The self-report indicated an action plan that included a locking case to be installed on the light switch in the dayroom by 11/22/2024 to prevent patient access. Review of psychiatric hospital document titled “Committee of the Whole Meeting Minutes and Agenda”, dated 11/20/2024 revealed in part: Topic-Sexual Assault onsite. [Occurences] 0. Action Plan: No action needed. Unsubstantiated claim. On 12/02/2024 at 9:56 a.m., observations of the light switch in the dayroom failed to reveal a locking case installed to prevent patient access as indicated on the self-report. In an interview on 12/02/2024 at 9:56 a.m., S12DM verified the light switch did not have a locking case installed to prevent patient access. 2) Failure to identify, discuss, and create an action plan to ensure the assignment of mental health technicians to all patients on every shift. Review of psychiatric hospital documents titled “Daily Nursing Assignment Sheet” for September 2024 failed to reveal patients were assigned a mental health technician on 5 shifts. Review of psychiatric hospital documents titled “Daily Nursing Assignment Sheet” for October 2024 failed to reveal patients were assigned a mental health technician on 14 shifts. Review of psychiatric hospital documents titled “Daily Nursing Assignment Sheet” for November 2024 failed to reveal patients were assigned a mental health technician on 17 shifts. Review of psychiatric hospital document titled “Committee of the Whole Meeting Minutes and Agenda”, dated 11/20/2024 failed to reveal the above safety issue was identified, discussed, and an action plan created to ensure the assignment of a mental health technician to all patients on the census. In an interview on 12/03/2024 at 3:45 p.m., S1DON reported the above issues would be addressed at the next meeting in December.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital failed to ensure a registered nurse developed a written assignment of nursing care for each patient to other nursing personnel in accordance with the patient’s needs. This deficiency is evidenced by failing to assign nursing personnel to each patient. Findings: Review of psychiatric hospital policy titled “Nursing Service”, revised 08/11/2023, revealed, in part: “Policy, in part: Inpatient Units, in part: The registered nurse develops a written assignment at the start of each shift. The assignment may be updated throughout the shift, as needed. The registered nurse assigns patient care to nursing staff members based on: The individualized needs of the patient; the training and skills of the staff member; the scope of practice of the staff member; and other issues, as applicable (e.g. identified transference, etc.).” Review of psychiatric hospital documents titled “Daily Nursing Assignment Sheet” for September 2024 failed to reveal patients were assigned a mental health technician on the following 5 shifts: 09/10/2024 AM shift. 09/13/2024 AM shift. 09/19/2024 AM shift. 09/19/2024 PM shift. 09/20/2024 AM shift. Review of psychiatric hospital documents titled “Daily Nursing Assignment Sheet” for October 2024 failed to reveal patients were assigned a mental health technician on the following 14 shifts: 10/07/2024 AM shift. 10/08/2024 PM shift. 10/09/2024 AM shift. 10/13/2024 AM shift. 10/14/2024 AM shift. 10/16/2024 PM shift. 10/17/2024 AM shift. 10/22/2024 AM shift. 10/26/2024 AM shift. 10/27/2024 AM shift. 10/27/2024 PM shift. 10/28/2024 AM shift. 10/31/2024 AM shift. 10/31/2024 PM shift. Review of psychiatric hospital documents titled “Daily Nursing Assignment Sheet” for November 2024 failed to reveal patients were assigned a mental health technician on the following 17 shifts: 11/01/2024 AM shift. 11/03/2024 AM shift. 11/05/2024 PM shift. 11/06/2024 AM shift. 11/08/2024 PM shift. 11/09/2024 AM shift. 11/09/2024 PM shift. (Of note, this is the date and shift when the incident involving patient #1’s sexual assault occurred). 11/10/2024 AM shift. 11/10/2024 PM shift. 11/19/2024 AM shift. 11/20/2024 AM shift. 11/24/2024 AM shift. 11/25/2024 AM shift. 11/28/2024 AM shift. 11/29/2024 AM shift. 11/29/2024 PM shift. 11/30/2024 AM shift. During an interview on 12/02/2024 at 12:02 p.m., S1DON indicated the mental health technicians determine which patients they are responsible for based on the completed assignment sheet provided to them by the registered nurse at the beginning of each shift. S1DON confirmed the above assignment sheets revealed patients without assigned mental health technicians.”

“VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(i) If verbal orders are used, they are to be used infrequently. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to ensure that verbal/telephone orders were used infrequently and were not a common practice as evidenced by the consistent use of verbal/telephone orders by the admitting physician for 7 (#1-#7) of 7 (#1-#7) records reviewed. Findings: Review of Patient #1’s Medical Record revealed admission date 10/30/2024 with verbal orders on the following dates: 10/30/2024 (admit orders), 11/01/2024, 11/02/2024, and 11/09/2024. Review of Patient #2’s Medical Record revealed admission date 11/04/2024 with verbal orders on the following dates: 11/04/2024 (admit orders), 11/05/2024, 11/08/2024, and 11/13/2024. Review of Patient #3’s Medical Record revealed admission date 11/06/2024 with verbal orders on the following dates: 11/05/2024 (admit orders), 11/06/2024 (admit orders), 11/07/2024, 11/11/2024, and 11/12/2024. Review of Patient #4’s Medical Record revealed admission date 11/01/2024 with verbal orders on the following dates: 11/01/2024 (admit orders), 11/03/2024, and 11/08/2024. Review of Patient #5’s Medical Record revealed admission date 11/02/2024 with verbal orders on the following dates: 11/02/2024 (admit orders), 11/03/2024, 11/04/2024 and 11/10/2024. Review of Patient #6’s Medical Record revealed admission date 04/01/2024 with verbal orders on the following dates: 04/01/2024 (admit orders). Review of Patient #7’s Medical Record revealed admission date 10/26/2024 with verbal orders on the following dates: 10/26/2024 (admit orders) and 10/27/2024. During an interview on 12/03/2024 at 11:33 a.m. S5RN stated that all admission orders are verbal orders for standing orders previously approved by the physicians. S5RN reported the nurses call the physician to approve the standing orders and medications but do not usually document that the physician was notified of the admission or that the verbal orders were confirmed. During an interview on 12/03/2024 at 12:18 p.m., S9PA and S10MD verified that all of the admit orders were verbal orders.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to ensure each patient had an individualized and comprehensive treatment plan for 3 (#1, #3, and #4) of 5 (#1, #3-#6) treatment plans reviewed. This deficiency is evidenced by failure to include all medical and psychiatric diagnoses as part of an individualized and comprehensive treatment plan. Findings: Review of hospital policy titled “Nursing Services”, revised 08/11/2023, revealed, in part: “Policy, in part: Throughout the assigned shift, it is the responsibility of the registered nurse to, in part: Develop or update treatment plans as per hospital policy.” Review of hospital policy titled “Assessment for Abuse, Neglect, and Domestic Violence”, revised 03/21/2018, revealed, in part: “Procedure, in part: 1. If, during an assessment or any other interaction, the patient discloses having been the victim or perpetrator of, or witness to, abuse, neglect, or domestic violence, the professional is expected to obtain as much information as possible without knowingly causing detriment to the patient. 5. The Multidisciplinary Treatment Plan will be updated as indicated. Patient #1 Review of Patient #1’s medical record revealed an admission date of 10/30/2024 with diagnosis of Bipolar, Schizophrenia, Homicidal ideations, Auditory hallucinations, Visual hallucinations and Urinary tract infection (UTI). Review of Patient #1’s Psychiatric Evaluation dated 10/31/2024 revealed patient #1 was withdrawing from methamphetamines with the diagnoses of schizoaffective disorder, bipolar type and methamphetamine use disorder. Review of History and Physical dated 10/30/2024 revealed Patient #1 complained she was withdrawing with a urine drug screen (UDS) positive for tetrahydrocannabinol (THC) and methamphetamine. Diagnoses included Bipolar/Schizophrenia with psychosis and homicidal ideations, THC and methamphetamine use, Hyperglycemia, Hypokalemia and UTI. Review of nursing note dated 11/10/2024 at 8:00 a.m., S5RN documented that Patient #1 was having a verbal altercation with male peer, accusing him of coming into her room and sexually assaulting her on the previous shift. Patient was interviewed to assess what actually happened. Patient #1 reported that the incident happened on the night of 11/09/2024 when the male peer went into her room. Patient #1 stated, “He flipped his dick out and because I am a meth addict, I sucked it.” She then stated, I want to report what he did and I want to press charges against him.” Psychiatry and Medical, along with DON notified of this incident. Review of Patient #1’s medical document titled “Master Treatment Plan” last reviewed on 11/04/2024, revealed the following “Active Problems”: 1) altered thought process related to chronic mental illness, substance abuse, severe anxiety as evidenced by impaired judgment; 2) substance abuse related to addiction as evidenced by positive drug scree, self disclosure, recent history of substance abuse; and 3) depression/hopelessness related to addiction, multiple stressors as evidenced by homicidal ideation. Continued review of “Master Treatment Plan” failed to reveal “Active Problems” related to the following: 1) sexual assault 2) withdrawal symptoms 3) urinary tract infection 4) hyperglycemia and 5) hypokalemia Patient #3 Review of Patient #3’s medical record revealed an admission date of 11/06/2024 with diagnosis of schizoaffective disorder. Review of Patient #3’s Psychiatric Evaluation dated 11/06/2024 revealed patient #3 was admitted for violent behavior, agitation and destroying property. Diagnoses included schizoaffective disorder, bipolar type and cannabis use disorder. Review of History and Physical dated 11/06/2024 revealed Patient #3 was diagnosed with bipolar 1 /depression with psychosis/aggression, THC abuse, nicotine dependency, leukocytosis, and seizures (orders for seizure precautions noted). Review of Patient #3’s medical document titled “Master Treatment Plan” last reviewed on 11/12/2024, revealed the following “Active Problems”: 1) altered thought process related to chronic mental illness as evidenced by psychotic symptoms; and 2) danger to others related to ineffective coping skills, impulsive as evidenced by threatening behavior, poor frustration tolerance, poor impulse control, irritability, and verbal outbursts. Continued review of “Master Treatment Plan” failed to reveal “Active Problems” related to the following: 1) seizures, 2) cannabis use disorder, 3) leukocytosis, and 4) nicotine dependency Patient #4 Review of Patient #4’s medical record revealed an admission date of 11/01/2024 with diagnosis of schizoaffective disorder and bipolar disorder. Review of Patient #4’s Psychiatric Evaluation dated 11/01/2024 revealed patient #4 was admitted for suicidal ideation with a plan and homicidal ideation without a plan. Diagnoses included schizoaffective disorder, bipolar type, suicidal ideation, homicidal ideation and alcohol dependence. Continued review revealed a medical history of hypertension, mixed hyperlipidemia and seizures. Review of Patient #4’s medical document titled “Master Treatment Plan” last reviewed on 11/06/2024, revealed the following “Active Problems”: 1) altered thought process related to chronic mental illness as evidenced by delusions, hallucinations, impaired judgment, psychotic symptoms; 2) depression/hopelessness related to isolation, homelessness, ineffective role performance, loss of a loved one, multiple stressors, inability to cope, negative life events as evidenced by decreased affect lack of motivation, suicidal ideation, and homicidal ideation; and 3) cardiac output, altered related to hypertension, hyperlipidemia as evidenced by acute symptoms and history of. Continued review of “Master Treatment Plan” failed to reveal “Active Problems” related to the following: 1) seizures and 2) alcohol dependence. During an interview on 12/03/2024 at 3:00 p.m., S1DON confirmed the treatment plans for Patients #1, #3-#6 failed to reveal individualized and comprehensive active problems related to the needs of each patient.”

“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: 44495 Based on record review and interview, the psychiatric hospital failed to ensure care in a safe setting. The deficient practice is evidenced by failure of nursing staff to monitor for signs of withdrawal as ordered for 1 (#1) of 1 reviewed patient records with orders for withdrawal assessments. Findings: Review of the medical record for Patient #1 revealed the patient was voluntarily admitted on 04/01/2024 with a diagnosis of bipolar disorder, suicidal ideations, and alcohol abuse. Review of the orders for Patient #1 revealed an order initiated on 04/02/2024 at 10:42 a.m. for “Complete CIWA (Clinical Institute Withdrawal Assessment). Every six hours. Request Type: Now. Comments: Give PRN Ativan CIWA. >8.” Further review of the order revealed the order duration was for 3 days starting on 04/20/2024 at 10:42 a.m. and ending on 04/05/2024 at 6:00 a.m. Review of the medical record revealed the assessment was completed as listed below: 04/03/2024 at 9:30 a.m. and at 3:30 p.m. 04/04/2024 at 12:01 a.m., 6:12 a.m., 3:12 p.m., and 5:08 p.m. 04/05/2024 at 12:00 a.m. and 5:54 a.m. In interview on 05/13/2024 at 12:03 p.m., S2DON verified the assessments were not performed every 6 hours as ordered.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to ensure all patients were protected and free from abuse. The deficient practice is evidenced by failure of the facility to restrict the access of 1 (#3) of 1 reviewed patient on Aggression/Violence Precautions after demonstrating violent tendencies towards another patient. Findings: Review of the policy titled “Nursing Service: Precautions,” revised 03/21/2018, revealed in part, “PRECAUTIONS: . . . A registered nurse may place a patient on Precautions, without a prior order from a licensed practitioner, to ensure the safety and security of the patient. If the registered nurse places a patient on Precautions, that nurse is required to contact the authorized licensed prescriber on duty to obtain a corresponding order as soon as possible. . . . Aggression/Violent Behavior Precautions are ordered when a patient, by behavior, verbalization, history, or by report presents a risk of violence towards other, regardless of the specific type of risk (i.e. fighting, homicide, sexual assault). The determination for ordering these Precautions may be made based on verbal threats, threatening behavior, reports, or history. The following are components of Aggression/Violent Behavior Precautions: . . . 10-foot Parameter- The patient is required to remain a minimum of 10 feet away from individuals that are identified as potential victims up to and including all peers. Orders indicate whether the 10-foot parameter will be observed during group therapy sessions.” Review of the medical record for patient #3 revealed admission on 04/21/2024 after the patient’s father requested an order of protective custody. Review of the Physician’s Emergency Certificate revealed in part, “OPC by father. Patient is not taking meds, acting bizarrely, wandering in other people’s yards, recently punched a stranger at a store.” Review of the self-reported incidents to the licensing authority in revealed two incidents between Patient #3 and Patient #R1. The first incident occurred on 04/30/2024 and the second incident occurred on 05/05/2024. Review of the incident from 04/30/2024 revealed at 9:30 p.m. both patients were on the patio when Patient #3, who was on aggression precautions, hit Patient #R1 with a closed fist. Both patients were on 15 minute observation at the time and it was reported there had been no previous altercations or aggression between the patients. Further review revealed after the event, Patient #3 was placed on line of sight observation and Aggression/ Violent Behavior Precautions were continued. The report documented Unit Restriction, Sharps Restriction, 10-foot Parameter, and No Roommate as components of the Aggression/Violent Behavior Precautions. Review of the incident from 05/05/2024 revealed both patients were on 15 minute observations. At 9:25 p.m. Patient #3, who was still on Aggression/ Violent Behavior Precautions, walked up to Patient #R1 in the dayroom and began hitting him in the face. Patient #R1 sustained a lactation above his right eyebrow and a black eye. Immediately after the incident Patient #R1 received neurological assessments every 2 hours. In interview on 05/13/2024 at 12:30 p.m., S2DON verified Patient #3 was not placed on distance precautions from Patient #R1 after the first incident even though it was listed in the report to the licensing authority. S2DON verified that the components listed in the report and in the hospital policy, including the 10-foot restrictions, required additional orders and were not automatically a part of the Aggression/ Violent Behavior Precautions. Patient #3 was placed on line of sight observation on the day of the incident and later on 1 to 1 observation which was discontinued the morning of 05/05/2024. S2DON verified the order for distance precautions was not requested because they did not feel Patient #R1 was a potential victim after the first unprovoked attack.”