Oceans Behavioral Hospital of Kentwood

“Multiple Occupancies - Contiguous Non-Health CFR(s): NFPA 101 Multiple Occupancies - Contiguous Non-Health Care Occupancies Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than two hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served. 18.1.3.4.1, 19.1.3.4.1 This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to assure the construction of a two hour fire barrier occupancy separation wall. The wall is required to be continuous and properly protected from penetrations and gaps. The rated doors are required to self closing, self latching, rated window, rated window frame and rated door frame within specifications of the rated fire barrier. Unprotected penetrations would permit the movement of smoke/fire rapidly from one compartment to the other within the facility. The deficient practice has the potential to affect sixteen patients of sixteen patients. Findings: During the facility tour on April 10, 2026 between the hours of 7:45 a.m. to 11:00 a.m. a portion of the Hospital building is abandoned with a two hour fire barrier separation. The two hour fire barrier above the suspended ceiling lacked a properly constructed two hour fire barrier. The interview with the Maintenance Director revealed the facility was not aware that the building’s ninety minute fire barrier was was not properly constructed above the suspended ceiling.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48050 Based on record review and interview the facility failed to ensure consent to treatment was documented according to hospital policy. The deficient practice is evidenced by: 1) failure to include 2 witness signatures when consent is obtained verbally in 1 (#15) of 30 records reviewed; and 2) failure to complete the informed consent document per hospital policy in 6 (#3, #4, #5, #9, #10, #17) of 30 records reviewed. Findings: 1) Failure to include 2 witness signatures when consent is obtained verbally in 1 (#15) of 30 records reviewed. Review of the hospital’s policy # RTS11 titled, “Informed Consent, Care Decisions, and Conflicts Resolution”, last revised on 11/01/2024 revealed in part: “PURPOSE: To outline the responsibility of the facility in establishing a mutual understanding between the patient/patient’s family/ representative and the facility about patient services received. To involve patients and significant others, when appropriate, in care decisions, conflict resolution, and the informed consent process. POLICY: The facility recognizes the benefit and the need to involve patients and significant others, when appropriate, in care, treatment and service decisions, conflict resolution, and to ensure that appropriate informed consent is obtained as outlined by the State, Federal and other regulatory bodies. PROCEDURE: Informed Consent: 3. The facility will, during the admission process, obtain signature on informed consent forms. Patient signatures may be obtained by handwritten signature or digitized signature which is an electronic image of an individual’s handwritten signature reproduced using a signature pad. If the patient is unable to sign due to physical impairments, verbal consent can be obtained and documented with two witnesses.” Review of the medical record for Patient #15 revealed admission on 02/11/2026 under a Physician’s Emergency Certificate with a diagnosis of aggressive behavior. Review of the consent for treatment revealed verbal consent was given by the patient’s guardian but was witnessed by only one staff member. In interview on 03/25/2026 at 1:56 PM, S7IC verified the consent should have had 2 signatures. 2) Failure to complete the informed consent document per hospital policy in 6 (#3, #4, #5, #9, #10, #17) of 30 records reviewed Review of the hospital’s policy #HIM.HIP AA-02.10 titled, “Uses and Disclosures Requiring Authorization”, revealed in part: “PURPOSE: To outline the organization’s policy regarding the use and disclosure of protected health information (PHI). III. Authorization Contents: To be valid, an authorization must include the following: * A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion. * Name or specific identifications of the person or persons who can make the requested use of disclosures. * Name or specific identification of the person or persons who may receive the requested use or disclosures.” Review of the medical record for Patient #3 revealed admission on 02/26/2026 under a Formal Voluntary Admission with a diagnosis of Major Depressive Disorder, Generalized Anxiety, Benzodiazepine dependency, and Cannabis Dependency. Review of the consent for treatment revealed incomplete sections for Consent & Authorization for Alcohol and Substance Use and Consent for Involvement in Treatment. In an interview on 03/25/2026 at 1:15 PM, S4ADON verified the information mentioned above. Review of the medical record for Patient #4 revealed admission on 02/06/2026 under a Physician’s Emergency Certificate with a diagnosis of Bipolar Disorder, Opioid Use Disorder, and Cocaine Use Disorder. Review of the consent for treatment revealed Patient #4 authorized the organization to acknowledge presence and to discuss treatment plan with the individual(s), but date, name of contact, relationship, phone number, and revoke was left blank. In an interview on 03/25/2026 at 1:45 PM, S4ADON verified the information mentioned above. Review of the medical record for Patient #5 revealed admission on 01/22/2026 under a Formal Voluntary Admission with a diagnosis of Bipolar Disorder, Autism Spectrum Disorder, Obsessive Compulsive Disorder, and Cannabis Abuse. Review of the consent for treatment revealed Patient #5 authorized the organization to acknowledge presence and to discuss treatment plan with the individual(s), but date, name of contact, relationship, phone number, and revoke was left blank. In an interview on 03/25/2026 at 2:15 PM, S4ADON verified the information mentioned above. Review of the medical record for Patient #9 revealed admission on 03/19/2026 under a Physician’s Emergency Certificate with a diagnosis of Psychosis and Polysubstance Dependence. Review of the consent of treatment revealed Patient #9 authorized the organization to acknowledge presence and to discuss treatment plan with the individual(s), but date, name of contact, relationship, phone number, and revoke was left blank. In an interview on 03/25/2026 at 2:45 PM, S4ADON verified the information mentioned above. Review of the medical record for Patient #10 revealed admission on 03/20/2026 under a Physician’s Emergency Certificate with a diagnosis of Bipolar Disorder and Depression. Review of the consent of treatment revealed Patient #10 authorized the organization to acknowledge presence and to discuss treatment plan with the individual(s), but date, name of contact, relationship, phone number, and revoke was left blank. In an inteview on 03/25/2026 at 3:15 PM, S4ADON verified the information mentioned above. Review of the medical record for Patient #17 revealed admission on 03/19/2026 under a Physician’s Emergency Certificate with a diagnosis of Major Depressive Disorder. Review of the consent of treatment revealed Patient #17’s POA authorized the organization to acknowledge presence and to discuss treatment plan with the individual(s), but date, name of contact, relationship, phone number, and revoke was left blank. In an interview on 03/25/2026 at 4:00 PM, S4ADON verified the information mentioned above.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 48050 Based on record review and interview, the psychiatric hospital failed to ensure the patient’s rights for privacy. This deficient practice is evidence by sharing patient information after a patient requested not to disclose information regarding treatment. Findings: Review of the medical record of Patient #7 revealed admission on 03/18/2026 under a Physician’s Emergency Certificate with a diagnosis of Bipolar Disorder, Cannabis Use Disorder, PTSD, and Anxiety. Review of the Admission packet revealed consent for involvement in treatment that Patient #7 checked “I do not authorize family/significant other involvement” for the portion titled family/significant other consent & authorization of disclosure of treatment portion of the form. Review of Patient 7’s medical record revealed social worker progress notes dated 03/25/2026 at 9:52 AM which documented the social worker contacted Patient #7’s aunt and informed her that Patient #7 would be discharged the following day. Social Worker documented that she disclosed information regarding Patient #7’s hospitalization to the aunt including aftercare options and recommendations to maintain stabilization. In an interview on 03/25/2026 at 11:00 AM, S4ADON verified Patient #7 did check on the consent form “I do not authorize family/significant other involvment” for the portion titled family/sigificant other consent & authorization of disclosure of treatment portion of the form. S4ADON further verified the social worker had a discussion with Patient #7’s aunt on 03/25/2026 at 9:52 AM regarding Patient #7’s hospitalization/treatment.”

“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: 50453 Based on record review and interview, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficient practice is evidenced by failure to self-report an incident involving a potential allegation of abuse/neglect within 24 hours to the Department of Health and Hospitals. Findings: Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: “4. Self-Reporting: In the interest of providing information that will indicate the facility’s compliance with CMS Regulation 482.13(c) (3) regarding abuse, neglect, and harassment, as well as La R.S. 40:2009.20, the following processes have been developed. It should be noted that a facility’s decision to self-report does not eliminate the possibility of an onsite investigation being conducted in response to allegations and/or relevant information received. Although LA R.S. 40:2009.20 requires a facility to report knowledge of incidents of abuse, within twenty-four hours, to either the local law enforcement agency or LDH (or the Medicaid Fraud Unit as applicable), many facilities find it beneficial to self-report to LDH, even if they have notified law enforcement. It is important to note that contacting law enforcement on behalf or at the request of the patient/complainant (e.g. to press charges, etc.) does not satisfy the statute’s intent regarding facility notification. 8: Initial Report (within 24 hours of knowledge): NOTE: Patient-to-patient assaults should be categorized as “Neglect” in relation to “Patient-to-Patient Physical Assault” or “Patient-to-Patient Sexual Assault.” From a LDH standpoint, the issue under review is to determine whether the facility failed to take prudent action to prevent, and/or respond to, the (alleged) occurrence. These incidents should be assessed as alleged “Neglect” (i.e. the hospital’s failure to act with due diligence). Also indicate what the allegation of neglect involves (i.e. sexual assault, physical assault, elopement, death, or other). The requirement (per statute) is that potential abuse or neglect be reported within 24 hours of knowledge (awareness) of the allegation, suspicion, or occurrence. 12. Special Settings and Considerations: This document describes the type of information needed by the HSS to conduct a thorough review of a hospital’s actions in relation to an allegation that abuse and/or neglect has occurred within the facility. In certain settings, including, but not limited to behavioral health facilities, pediatric units, and geriatric units, incidents involving physical or emotional abuse or sexual acting out between patients may be reportable, as the facility has specific responsibilities relative to providing adequate supervision to prevent these occurrences. Minors below the age of consent, psychiatric patients of any age, and cognitively impaired individuals (such as those with dementia or mental retardation) are not considered capable of consenting to sexual activity in a facility. As a result, sexual acts involving patients that fit these categories cannot be categorized as “consensual” even if both parties engage in the act voluntarily, and are reportable, as are occurrences indicating that the facility may have failed to adequately provide safety for the type of patient being treated.” Review of hospital policy #: AS-18, titled “Assessment and Reporting of Abuse, Neglect, Exploitation,” last revised 02/23/2026, revealed in part: “PURPOSE: To protect patients from harm and meet compliance standards set by state and federal guidelines and other regulatory or accreditation bodies, or contractual obligations regarding the assessment and reporting of suspected cases of abuse, neglect, and exploitation. POLICY: The facilities prohibit abuse, neglect, and exploitation oof patient/clients and/or participants. The facilities shall promptly and properly respond to allegations of abuse, neglect or exploitation and shall comply with all reporting obligations, including, but not limited to those set by the following: Federal: CMS (Centers for Medicare and Medicaid Services); Louisiana: The Louisiana Department of Health. PROCEDURE: The facility shall send the Self-Report on the Hospital Abuse and Neglect Self-Reporting form Louisiana to the email address listed above. Initial Report must be submitted within 24 hours a staff member or contract worker becoming aware that an incident of abuse or neglect has been alleged, witnessed or is suspected.” Review of the Incident Log revealed in part: 02/27/2026: Patient #12, Incident Category: Suicide Attempt/Gesture. Review of Patient #12’s medical record revealed Patient #12 was admitted on 02/27/2026 at 5:15 PM with a diagnosis of Major Depressive Disorder and Suicidal Ideation. Further review of Patient #12’s medical record failed to reveal documentation of the Suicide Attempt/Gesture that occurred on 02/27/2026 or any interventions that occurred following the event. Review of the incident report involving Patient #12 revealed in part: Incident date/time: 02/27/2026 at 10:30 PM. Category: Suicide Attempt/Gesture. As Mental Health Tech (MHT) was doing his rounds he found the patient with his shirt around his neck, trying to tighten it. MHT removed shirt from around the patient neck. The patient was brought to the day room with his mattress so that he could be watched more closely. MD notified and gave an order for line of sight observation. In an interview on 3/24/2026 at 4:02 PM, S3DON confirmed the above-mentioned incident involving Patient #12 was not self-reported.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 44495 Based on record review and interview the hospital failed to document a face to face interview with the patient within one hour of the use of a restraint in 1 (#17) of 3 (#14, #15, #17) reviewed medical records where restraints were used. Findings: Review of the medical record for Patient #17 revealed admission on 12/31/2025 under a Physician’s Emergency Certificate with a diagnosis of psychosis and major depressive disorder. Further review of the record revealed on 01/07/2026 the nurse documented “there was an altercation with another peer who apparently said something she did not appreciate and she lashed out physically. The altercation was quickly resolved and MD ordered Zyprexa 10 mg. There were no injuries as a result of this altercation.” The record failed to reveal documentation of a face to face evaluation within one hour of the chemical restraint. In interview on 03/25/2026 at 3:08 PM, S7IC verified restraint documentation should have been opened but the nurse failed to do so. There was no documentation of a face to face interview within one hour of the use of the restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iii) [there must be documentation in the patient’s medical record of] Alternatives or other less restrictive interventions attempted (as applicable); This Standard is not met as evidenced by: 44495 Based on record review and interview the hospital failed to document the use of alternative methods before a chemical restraint was administered in 1 (#17) of 3 (#14, #15, #17) reviewed medical records where restraints were used. Findings: Review of the medical record for Patient #17 revealed admission on 12/31/2025 under a Physician’s Emergency Certificate with a diagnosis of psychosis and major depressive disorder. Further review of the record revealed on 01/07/2026 the nurse documented “there was an altercation with another peer who apparently said something she did not appreciate and she lashed out physically. The altercation was quickly resolved and MD ordered Zyprexa 10 mg. There were no injuries as a result of this altercation.” The record failed to reveal documentation of use of alternative methods prior to the use of the restraint. In interview on 03/25/2026 at 3:08 PM, S7IC verified restraint documentation should have been opened but the nurse failed to do so. There was no documentation in the other notes of the use of de-escalation or other techniques prior to administration of the chemical restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 50453 Based on policy review, record review and interview, the hospital failed to ensure the nurse documented the debriefing for the use of seclusion according to hospital policy. Findings: Review of hospital policy #: NSG-71, titled “Seclusion and Restraints- LA/MS/OK/ID/AZ/NM/OH/PA,” last revised: 05/01/2025, revealed in part: “PURPOSE: To define guidelines for safe and therapeutic use of seclusion and/or restraints that supports the health, welfare, safety, rights, and personal dignity of the patient. PROCEDURE: 8. Release/Renewal Procedure: Debrief with patient/patient’s family/staff as applicable, according to debriefing guidelines of the flow sheet. 9. Debriefing: Identify what led to the episode and what could have been handled differently. Identify strategies to prevent future restraint or seclusion, taking into considerations suggestions from the patient or patient’s representative. Ascertain whether the patient’s physical well-being, psychological comfort, including trauma, and right to privacy were protected/addressed. Counsel the patient in relation to any trauma that may have resulted from the episode. When indicated, identify appropriate modifications to the patient’s treatment plan.” Review of Patient #12’s medical record revealed Patient #12 was admitted on 02/27/2026 at 5:15 PM with a diagnosis of Major Depressive Disorder and Suicidal Ideation. Further review of Patient #12’s medical record revealed Patient #12 was placed in seclusion on 03/01/2026 and 03/05/2026. Review of Patient #12’s Seclusion and Restraint Packet dated 03/01/2026 revealed in part the following documentation: Debriefing: -Reviewed what led to seclusion/restrain and what could have been done differently: Patient started having behaviors in his room, climbing shelves, cursing at staff when told to get down, being defiant. Patient started to threaten staff and wouldn’t calm down so waws put in seclusion. Patient continued to threaten/tried to fight staff. Psychiatrist was contacted and PRN injection was given. Patient was taken out of seclusion and into room. POC will be updated and continued. DON and Emergency Contact notified. -Assess/Review any trauma experienced by patient: Patient started having behaviors in his room, climbing shelves, cursing at staff when told to get down, being defiant. Patient started to threaten staff and wouldn’t calm down so waws put in seclusion. Patient continued to threaten/tried to fight staff. Psychiatrist was contacted and PRN injection was given. Patient was taken out of seclusion and into room. POC will be updated and continued. DON and Emergency Contact notified. Further review of the seclusion debriefing documentation on 03/01/2026 failed to reveal documented evidence of the following, per hospital policy: -What could have been handled differently. -Identify strategies to prevent future restraint or seclusion, taking into considerations suggestions from the patient or patient’s representative. -Counsel the patient in relation to any trauma that may have resulted from the episode. In an interview on 03/24/2026 at 2:30 PM, S3DON confirmed the above-mentioned findings. Review of Patient #12’s Seclusion and Restraint Packet dated 03/05/2026 revealed in part the following documentation: Debriefing: -Reviewed what led to seclusion/restrain and what could have been done differently: Patient was arguing with a few of his peers, began to stand on top of dining room table and threaten staff and peers. Patient was not redirectable and taken to seclusion room. Patient began spitting at, hitting and kicking staff. Patient was given a PRN IM injection. DON, psych physician and emergency contact notified. POC will be continued and updated. -Review any alterations in comfort, physical well-being, or privacy experienced: N/A -Assess/Review any trauma experienced by patient: N/A Further review of the seclusion debriefing documentation on 03/05/2026 failed to reveal documented evidence of the following, per hospital policy: -What could have been handled differently. -Identify strategies to prevent future restraint or seclusion, taking into considerations suggestions from the patient or patient’s representative. - Ascertain whether the patient’s physical well-being, psychological comfort, including trauma, and right to privacy were protected/addressed. -Counsel the patient in relation to any trauma that may have resulted from the episode. In an interview on 03/24/2026 at 2:47 PM, S3DON confirmed the above-mentioned findings.”

“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: 44495 Based on record review and interview, the facility failed to ensure the registered nurse supervised the care of each patient according to hospital policy. The deficient practice is evidenced by: 1) failure of the registered nurse to sign the observation sheets every two hours for 1 (#15) of 10 (#11-#20) reviewed medical records with manual documentation of patient observations; 2) failure of the nurse to document an incident involving Patient #12 per policy; 3) failure of the Registered Nurse to document an assessment each shift; 4) failure to ensure an initial nursing assessment was performed within 8 hours of the patient’s admission in 1 (#21) of 32 sampled medical records reviewed; 5) failure to ensure an active provider order for the monitoring of blood glucose via fingerstick with an active sliding scale insulin order in 1 (#21) of 2 medical records reviewed of diabetic monitoring; and 6) failure to ensure sliding scale insulin was administered per provider orders in 1 (#21) of 2 medical records reviewed of diabetic monitoring. Findings: 1) Failure of the registered nurse to sign the observation sheets every two hours for 1 (#15) of 10 (#11-#20) reviewed medical records with manual documentation of patient observations. Review of Policy Number CS-23, “Level of Observations,: revised 03/01/2023, revealed in part, “RN makes observations at least every 2 hours during the shift and initials the RN observations on the close observation sheet.” Review of the medical record for Patient #15 revealed admission on 02/11/2026 under a Physician’s Emergency Certificate with a diagnosis of aggressive behavior. Review of the “Observation Check Sheet,” revealed the patient was on fifteen minute observation by the MHT and the registered nurse was to verify the observations every two hours. Review of the documentation revealed the nurse failed to sign the sheet on 02/13/2026 at 9:00 PM, 02/13/2026 at 11:00 PM, 02/14/2026 at 1:00 AM, 3:00 AM, and 5:00 AM. Further review revealed on 02/16/2026 the patient was on the same levels of observation and the nurse failed to sign the sheet as required at 1:00 AM. In interview on 03/25/2026 at 2:21 PM, S7IC verified the missing observations by the registered nurse. 2) Failure of the nurse to document an incident involving Patient #12 per policy. Review of hospital policy number NSG-02, titled “Documentation,” last revised 01/01/2023, revealed in part: “PURPOSE: To maintain a comprehensive and chronologically continuous account of treatment delivered to a patient by nursing staff. Routine: 1. RN and/or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) documents all extraordinary occurrences and special needs (i.e. falls, etc.) in the multidisciplinary progress notes and documents any notifications or issues reported to the physician or non-physician practitioner (NPP), as applicable. 3. Documents the implementation and execution of physician and NPP orders. 4. Documents pertinent and factual information including assessment, interventions, education, and outcome.” Review of Patient #12’s medical record revealed Patient #12 was admitted on 02/27/2026 at 5:15 PM with a diagnosis of Major Depressive Disorder and Suicidal Ideation. Review of the Incident Log revealed in part: 02/27/2026: Patient #12, Incident Category: Suicide Attempt/Gesture. Review of the incident report involving Patient #12 revealed in part: Incident date/time: 02/27/2026 at 10:30 PM. Category: Suicide Attempt/Gesture. As Mental Health Tech (MHT) was doing his rounds he found the patient with his shirt around his neck, trying to tighten it. MHT removed shirt from around the patient neck. Review of Patient #12’s medical record failed to reveal documentation of the Suicide Attempt/Gesture that occurred on 02/27/2026. Further review of Patient #12’s medical record failed to reveal a documented assessment of Patient #12 following the incident by the nurse or documented evidence that the provider was notified of the incident. In an interview on 03/24/2026 at 2:22 PM, S3DON confirmed the above-mentioned findings. S3DON also confirmed that the incident on 02/27/2026 was not documented per policy in Patient #12’s medical record. 3) Failure of the Registered Nurse to document an assessment each shift. Review of hospital policy number NSG-02, titled “Documentation,” last revised 01/01/2023, revealed in part: “PURPOSE: To maintain a comprehensive and chronologically continuous account of treatment delivered to a patient by nursing staff. POLICY: Inpatient nursing personnel document patient’s progress every 12-hour shift, incorporating the elements of the nursing process and patient’s treatment goals and progress within the patient’s medical record. Daily: The Registered Nurse (RN) documents or reviews the LPN/LVN documentation on the Nursing Shift Assessment a minimum of once per shift.” Review of Patient #12’s medical record failed to reveal a nursing shift assessment for day shift for the following dates: -02/28/2026 -03/01/2026 In an interview on 03/24/2026 at 2:27 PM, S3DON confirmed the above-mentioned findings. 4) Failure to ensure an initial nursing assessment was performed within 8 hours of the patient’s admission in 1 (#21) of 32 sampled medical records reviewed. A review of facility policy, “Assessment Process: Inpatient,” policy number: AS-01, effective date: 01/11/2026 and last revised: 02/01/2026, revealed in part: “POLICY: An Intake Screening and Assessment, Nursing Admission Assessment, Psychosocial Assessment, Recreation/leisure Assessment, Psychiatric Evaluation, and a History & Physical Examination are performed on all inpatient admissions in order to effectively identify patient symptomology and formulate an individualized plan specific to the patient’s presenting problems. PROCEDURE: Intake/Admitting RN: 6. Interviews and assess patient within 8 hours of admission to complete the Admission Nursing Assessment.” A review of Patient #21’s medical record revealed an admission on 02/24/2026 at 4:29 AM with a diagnosis of unspecified dementia with behavioral disturbances. Review of the document titled, “Admit Nursing Assessment - Inpatient,” revealed the document being uncompleted. The assessment was signed by S23RN on 02/24/2026 at 6:41 AM as completed. In an interview on 03/24/2026 at 2:00 PM, S20RDON confirmed the above-mentioned findings 5) Failure to ensure an active provider order for the monitoring of blood glucose via fingerstick with an active sliding scale insulin order in 1 (#21) of 2 medical records reviewed of diabetic monitoring. A review of facility policy, “GLUCOMETER METHOD FOR OBTAINING CBGs,” policy number: NSG-26, effective date: 01/11/2026 and last revised: 09/01/2025, revealed in part: “POLICY: CBGs [capillary blood glucose levels] will be performed with physician orders by licensed nursing staff and mental health techs (MHTs) who are deemed competent to perform the procedure.” A review of Patient #21’s medical record revealed a medical history of diabetes mellitus. A review of the electronic medical records vital sign log revealed the results of glucose readings being obtained as follows: 02/25/2026 at 9:05 PM as “165 mg/dl”; 02/27/2026 at 10:02 PM as “208 mg/dl”; 02/27/2026 at 10:02 PM as “214 mg/dl”; 02/28/2026 at 9:15 PM as “170 mg/dl”; 03/02/2026 at 9:39 PM as “207 mg/dl”; 03/02/2026 at 10:39 PM as “203 mg/dl”; and 03/03/2026 at 6:36 AM as “203 mg/dl”. A review of the provider orders failed to reveal an order to obtain a capillary blood glucose reading. In an interview on 03/24/2026 at 2:00 PM, S20RDON confirmed the above-mentioned findings 6) Failure to ensure sliding scale insulin was administered per provider orders in 1 (#21) of 2 medical records reviewed of diabetic monitoring. A review of Patient #21’s medical record revealed a medical history of diabetes mellitus. A review vital sign log revealed the results of glucose readings being obtained as follows: -02/25/2026 at 9:05 PM as “165 mg/dl”; -02/27/2026 at 5:57 AM as “208 mg/dl”; -02/27/2026 at 10:02 PM as “214 mg/dl”; -02/28/2026 at 9:15 PM as “170 mg/dl”; -03/02/2026 at 9:39 PM as “207 mg/dl”; -03/02/2026 at 10:39 PM as “203 mg/dl”; and -03/03/2026 at 6:36 AM as “203 mg/dl”. A review of the provider orders and the document titled, “Medication Administration Record” revealed order #47: “Insulin Lispro (HumaLOG) 100/ML, subcutaneously Before Meals and Bedtime PRN - SEE SLIDING SCALE PER LONG TERM CARE FACILITY: Indication: type 2 diabetes mellitus Blood Sugar [From 0-60 SEE ABOVE] [From 61 - 200 = 0 Units] [From 201 to 250 = 3 Units]”. Further review of the medical record and the “Medication Administration Record” failed to reveal insulin being administered for the following blood glucose readings above 200 mg/dl and the required insulin administration per sliding scale order: -03/02/2026 at 9:39 PM for a blood glucose of “207 mg/dl”; -03/02/2026 at 10:39 PM for a blood glucose of “203 mg/dl”; and -03/03/2026 at 6:36 AM for a blood glucose of “203 mg/dl”. In an interview on 03/24/2026 at 2:00 PM, S20RDON confirmed the above-mentioned findings. 48051 50453”

“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 the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients. Findings: Observations during a tour on 03/23/2026 from 8:48 AM - 10:08 AM of Facility A revealed the following: -Room ‘a’: cabinet shelf has peeling laminate with a brown/reddish stain to the bottom of the shelf. -Hole in wall outside nurse station of hallway ‘A’ with exposed sheet rock. -Peeling paint on wall between Room ‘b’ and Room ‘c’. -Room ‘d’: ceiling vent covered in white/gray substance. -Room ‘e’: Bottom section of wall padding not secured to the wall. During the facility tour, S5NS confirmed the above-mentioned 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: 50453 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 tour on 03/23/2026 from 8:48 AM - 10:08 AM of Facility A revealed the following: -Room ‘a’: brown/reddish stain to the bottom of the shelf. -Room ‘c’: soiled towels on the floor. During the facility tour, S5NS confirmed the above-mentioned findings.”

“Neurological Examination CFR(s): When indicated, a complete neurological examination must be recorded at the time of the admission physical examination. This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to ensure admitted psychiatric patients had a full neurologic examination as part of the physical examination. The deficient practice is evidenced by failure to document a neurologic examination in 3 (#14, #15, #26) of 30 reviewed inpatient records. Findings: Patient #14 Review of the medical record for Patient #14 revealed admission on 02/17/2026 under a Physician’s Emergency Certificate with a diagnosis of Oppositional Defiant Disorder. Review of the history and physical revealed the patient refused to participate in the examination attempted on 02/18/2026. Further review revealed the patient did participate in the history and physical examination on 02/25/2026 but a neurologic examination was not documented at that time. In interview on 03/25/2026 at 12:10 PM, S7IC verified a neurologic examination was not documented in the record. Patient #15 Review of the medical record for Patient #15 revealed admission on 02/11/2026 under a Physician’s Emergency Certificate with a diagnosis of aggressive behavior. Review of the history and physical attempted on 02/12/2026 revealed the patient refused to participate in the examination. Further review revealed the patient was compliant and the history and physical was completed on 02/16/2026 but a neurologic examination was not performed. In interview on 03/25/2026 at 2:01 PM, S7IC verified a neurologic examination was not documented in the patient’s record. Patient #26 Review of the medical record for Patient #26 revealed admission on 12/29/2026 under a Physician’s Emergency Certificate with a diagnosis of depression. Review of the history and physical attempted on 12/30/2026 revealed the results documented under all components of the neurological exam and cranial nerve assessment as, “UTA, patient refuses to participate.” Further review revealed the patient had a physical exam performed per medical progress notes dated: 01/01/2026, 01/02/2026, 01/03/2026, 01/04/2026, 01/05/2026, 01/07/2026, 01/08/2026, 01/09/2026, 01/10/2026, and 01/11/2026, and a neurological exam, including a cranial nerve assessment, was not performed during these physical exams. In an interview on 03/26/2026 at 8:55 AM, S4ADON verified a neurologic examination was not documented in the patient’s record. 48051”

“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: 48050 Based on record review and interview, the psychiatric hospital failed to ensure each patient had an individualized and comprehensive treatment plan for 1 (#4) of 13 (#1-#10, #17, #19, #20) 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 the hospital’s policy #CS-02 titled, “Treatment Planning: Integrated/ Multidisciplinary”, last revised date of 05/01/2025 revealed in part: PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of the patient’s treatment to promote positive patient outcomes. POLICY: The multi-disciplinary treatment team shall develop an integrated written, comprehensive treatment plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. The treatment plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient’s involvement, throughout the course of treatment. Review of Patient #4’s medical record revealed Patient #4 was admitted on 02/06/2026 for Bipolar Disorder, Opioid Use Disorder, and Cocaine Use Disorder. Further review of Patient #4’s medical record revealed a psychiatric evaluation done on 02/06/2026 at 7:02 PM which revealed in part the following: Patient #4 reports that she has been at a Residential Treatment Program for IV heroin use, which began at the age of nineteen, as well as crack cocaine use that started last year. Further review of Patient #4’s medical record revealed a Care Plan/Problem List with the following issues: Risk for Seizures, Risk for Violence, Altercation in Health Maintenance, and Altercation in Thought Processes which does not address Patient #4’s substance abuse issues. In an interview on 03/24/2026 at 3:15 PM, S4ADON verified Patient #4 has a history of substance abuse and was currently in a residential treatment program prior to hospitalization. S4ADON further verified that substance abuse should have been addressed on Patient #4’s Care Plan/Problem List.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 48050 Based on record review and interviews, the hospital failed to ensure all patient treatments were within compliance of particular aspects of the patients’ individual treatment program as evidenced by failure to have a signed master treatment plan by all members of the treatment team for 10 (#3, #4, #5, #6, #7, #10, #12, #17, #19, #20) of 16 (#1-#13, #17, #19, #20) patients’ treatment plans reviewed for the sample. Findings: Review of the hospital’s policy #CS-02 titled, “Treatment Planning: Integrated/ Multidisciplinary”, last revised date of 05/01/2025 revealed in part: “PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of the patient’s treatment to promote positive patient outcomes. POLICY: The multi-disciplinary treatment team shall develop an integrated written, comprehensive treatment plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. The treatment plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient’s involvement, throughout the course of treatment. Procedure: 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient’s medical record.” Patient #3 Review of Patient #3’s Interdisciplinary Treatment Plan Update Sheet dated 03/05/2026 failed to reveal staff signatures from the therapist. In an interview on 03/24/2026 at 2:20 PM, S4ADON verified the above information mentioned. Patient #4 Review of Patient #4’s Interdisciplinary Treatment Update Sheet dated 02/12/2026 failed to reveal staff signatures from the RN and therapist. In an interview on 03/24/2026 at 3:22 PM, S4ADON verified the above information mentioned. Patient #5 Review of Patient #5’s Interdisciplinary Treatment Update Sheet dated 01/29/2026 failed to reveal the patient’s signature indicating participation in treatment planning. In an interview on 03/24/2026 at 4:26 PM, S4ADON verified the above information mentioned. Patient #6 Review of Patient #6’s Interdisciplinary Treatment Plan Master Sheet dated 03/20/2026 failed to reveal Patient #6’s signature and staff signatures from the MD, RN, or Recreational Therapist. In an interview on 03/25/2026 at 9:28 PM, S4ADON verified the above information mentioned. Patient #7 Review of Patient #7’s Interdisciplinary Treatment Plan Master Sheet dated 03/18/2026 failed to reveal the staff signature from the MD. In an interview on 03/25/2026 at 9:29 AM, S4ADON verified the above information mentioned. Patient #10 Review of Patient #10’s Interdisciplinary Treatment Plan Master Sheet dated 03/20/2026 failed to reveal Patient #10’s signature and the staff signature from the MD. In an interview on 03/25/2026 at 11:37 AM, S4ADON verified the above information mentioned. Patient #12 Review of Patient #12’s Interdisciplinary Treatment Plan Master Sheet dated 02/27/2026 failed to reveal the Patient or Patient Legal Representatives signature indicating participation in the treatment planning. In an interview on 03/24/2026 at 3:29 PM, S3DON confirmed the above-mentioned findings. Patient #17 Review of Patient #17’s Interdisciplinary Treatment Plan Update Sheet dated 03/24/2026 failed to reveal the staff signatures from the RN and Therapist. In an interview on 03/25/2026 at 3:50 PM, S4ADON verified the above information mentioned. Patient #19 Review of Patient #19’s Interdisciplinary Treatment Plan Master Sheet dated 03/18/2026 failed to reveal the staff signatures from the Therapist and the Recreational Therapist. Review of Patient #19’s Interdisciplinary Treatment Plan Update Sheet dated 03/24/2026 failed to reveal the staff signatures from the RN, Therapist, and Recreational Therapist. In an interview dated 03/25/2026 at 2:55 PM, S4ADON verified the above information mentioned. Patient #20 Review of Patient #20’s Interdisciplinary Treatment Plan Master Sheet dated 03/08/2026 failed to reveal the staff signatures from the MD, Nurse, Therapist, and Recreational Therapist. Patient #20’s Interdisciplinary Treatment Plan Update Sheet dated 03/10/2026 failed to reveal the staff signature from the RN. Patient #20’s Interdisciplinary Treatment Plan Update Sheet dated 03/17/2026 failed to reveal the staff signature from the MD. Patient #20’s Interdisciplinary Treatment Update Sheet dated 03/24/2026 failed to reveal the staff signatures from RN and Therapist. In an interview on 03/25/2026 at 2:22 PM, S3ADON verified the above mentioned information. 50453”

“Discharge Summary CFR(s): The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient’s hospitalization… This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility failed to ensure the discharge summary was inclusive of the recapitulation of the patient’s hospitalization and/or the extent to which goals established in patient’s treatment plan were met in 2 (#21, #26) of 32 sampled patients’ medical record reviewed. Findings: A review of facility policy, “Patient’s Discharge Summary,” policy number: HIM-01.12, effective date: 01/11/2026 and last revised: 01/01/2024, revealed in part: “POLICY: The discharge summary should provide a synopsis of the patient’s history and their examination, care, treatment experience and post treatment plan. The basis for the discharge summary is the patient’s clinical assessments, treatment plan, and progress notes. PROCEDURE: 5. The discharge summary includes the following information: c. Course and progress in the hospital - Care treatment and services provided which may include mental status at admission, target symptoms, address treatment modalities utilized, response to treatment, adverse or unexpected results of treatment, special treatment procedures used, and the patient’s role in the treatment process. e. Conditions and disposition at discharge - mental status at discharge, justification for discharge patient’s behavior at discharge; problems & issues yet to be worked on, etc. f. Prognosis/level of risk at discharge - includes a risk assessment of danger to self or others Final diagnosis (admission “rule out” diagnoses should be noted by status as either “ruled out” or confirmed)”. A review of medical records revealed the following: Patient #21 Patient #21’s medical record revealed a nursing note entry on 03/03/2026 indicating the patient was transferred to a higher level of care (Provider A) on 03/03/2026 related to an unwitnessed fall. The patient was subsequently discharged from Oceans Hospital Kentwood on 03/03/2026. A review of the hospital document: “Form: Discharge Summary (EMR)” completed by S19NP on 03/03/2026 at 9:14 PM, failed to reveal the patient’s course and progress related to his last 2 days of admission in Oceans Hospital Kentwood and the precipitating factors related to his transfer to Provider A. Patient #26 Patient #26 medical record revealed an admission date of 12/29/2025 and a discharge date of 01/12/2026. A review of the hospital document, “Form: Discharge Summary (EMR)” completed by S17MD on 01/12/2026 at 7:37 PM, failed to reveal the patient’s course and progress in the hospital related to care treatment and services provided which may include mental status at admission, target symptoms, address treatment modalities utilized, response to treatment, adverse or unexpected results of treatment, special treatment procedures used, and the patient’s role in the treatment process; Conditions and disposition at discharge related to mental status at discharge, justification for discharge patient’s behavior at discharge; problems & issues yet to be worked on, etc.; and prognosis/level of risk at discharge including a risk assessment of danger to self or others. In an interview 03/25/2026 at 9:00 AM and assisting with electronic medical record navigation, S20RDON confirmed the above-mentioned findings”

“Discharge Summary - Recommendations CFR(s): … and recommendations from appropriate services concerning follow-up or aftercare This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility failed to ensure the discharge summary included recommendations from appropriate services concerning follow-up or aftercare in 1 (#26) of 32 sampled patients’ medical record reviewed. A review of facility policy, “Patient’s Discharge Summary,” policy number: HIM-01.12, effective date: 01/11/2026 and last revised: 01/01/2024, revealed in part: “POLICY: The discharge summary should provide a synopsis of the patient’s history and their examination, care, treatment experience and post treatment plan. The basis for the discharge summary is the patient’s clinical assessments, treatment plan, and progress notes. PROCEDURE: g. prognosis for follow-up care”. A review of Patient #26’s medical record revealed an admission date of 12/29/2025 and a discharge date of 01/12/2026. A review of the hospital document, “Form: Discharge Summary (EMR)” completed by S17MD on 01/12/2026 at 7:37 PM, failed to reveal the patient’s prognosis for follow-up and aftercare at discharge. In an interview 03/25/2026 at 9:00 AM and assisting with electronic medical record navigation, S20RDON confirmed the above-mentioned findings.”

“Social Services Staff Responsibilities CFR(s): Social service staff responsibilities must include, but are not limited to, participating in discharge, planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital. This Standard is not met as evidenced by: 48051 50453 Based on record review and interview, the hospital failed to ensure social services staff completed all designated responsibilities. The deficient practice is evidenced by failure of the social services staff to complete a psychosocial assessment in 3 (#12, #21, #23) of 32 sampled medical records reviewed. Findings: Review of hospital policy number AS-01, titled “Assessment Process: Inpatient,” last revised 02/01/2026, revealed in part: “POLICY: An Intake Screening and Assessment, Nursing Admission Assessment, Psychosocial Assessment, Recreation/Leisure Assessment, Psychiatric Evaluation, and a History & Physical Examination are performed on all inpatient admissions in order to effectively identify patient symptomology and formulate an individualized treatment plan specific to the patient’s presenting problems. The Social Worker/Therapist or Case Manager: Initial Contact: 1. Reviews information gathered. Introduces self to patient and makes initial patient contact within the first 24 hours of admission. 2. Psychosocial Assessment is completed within 72 hours of admission by a licensed professional counselor, licensed master social worker, licensed social worker, or licensed marriage and family therapist. If the assessment is completed by a licensed professional counselor, licensed social worker, or licensed marriage and family therapist, the assessment will be reviewed and co-signed by a licensed master social worker.” Patient #12 Review of Patient #12’s medical record revealed Patient #12 was admitted on 02/27/2026 at 5:15 PM with a diagnosis of Major Depressive Disorder and Suicidal Ideation. Review of the psychosocial assessment revealed that it was signed on 03/03/3036 at 12:55 PM. Further review of Patient #12’s medical record failed to reveal that the documentation of the psychosocial assessment was completed within 72 hours of admission. In an interview on 03/24/2026 at 3:32 PM, S3DON confirmed the above-mentioned findings. Patient #21 Review of the medical record for Patient #21 revealed admission on 02/24/2026 at 4:29 AM with a diagnosis of unspecified dementia with behavioral disturbances. Review of the psychosocial assessment revealed the document being approximately 95% uncompleted. The assessment was signed by S21RSW on 02/25/2026 at 1:18 PM as completed. Patient #23 Review of the medical record for Patient #21 revealed admission on 02/28/2026 at 4:29 PM with a diagnosis of bipolar disorder. Review of the psychosocial assessment revealed the document being approximately 95% uncompleted. The assessment was signed by S22LMSW on 03/03/2026 at 1:15 PM as completed. In an interview on 03/24/2026 at 4:00 PM, S20RDON confirmed the above-mentioned findings.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital’s governing body failed to ensure the quality of care provided to patients as evidenced by failure of the admitting physician to review and reconcile current medications on admission per hospital policy for 3 (#1-#3) of 3 (#1-#3) patient records reviewed. Findings: Review of psychiatric hospital’s policy #MM-14 titled “Medication Management” last revised on 02/01/2021, revealed in part: “Procedure: 4. Physicians shall review the current medications with the admitting nurse and reconcile the medications that are to be continued and provide orders for the medications to the nurse. The physician/NPP will make any additions, deletions or corrections to the patient’s medication orders using the physician’s order sheet or the electronic medical record (EMR) order entry process. The physician/NPP will document orders for continued medications, changes, or stops on the Admission Medication Reconciliation Order form, or via EMR order entry as applicable, and authenticate. The nurse will scan all inpatient admission medication orders to pharmacy to be verified and uploaded to the patient’s MAR, unless an EMR is utilized. 5. If the physician provides the above orders verbally, the nurse will document the medication orders on the Admission Medication Reconciliation Order form and indicates the medications have been reconciled with the physician/NPP. 6. The physician/NPP authenticates the verbal orders within the required States timeframe. 7. Orders are sent to the hospital pharmacist for dispensing of the medications for inpatient. The pharmacist reviews the medications for contraindications and communicates any indications to the nurse and physician/NPP.” Review of psychiatric hospital’s policy #RTS-01 titled “Patient Rights” last revised on 02/01/2021, revealed in part: “Policy: The organization supports the patient’s right to care, treatment, and services within its mission. Treatment: You have the right to medically appropriate treatment.” Patient #1 Review of medical record revealed an admission date of 07/29/2025 at 8:30 PM with diagnoses of psychosis, hypertension, cirrhosis, pancytopenia, Monoclonal Gammopathy of Undetermined Significance, and hyponatremia and discharged on 08/07/2025 at 5:00 PM. Continued review revealed the following home medications: Carvedilol (for hypertension), clonidine (for hypertension), Xifaxin (for hepatic encephalopathy), Benadryl (for pruritus of the skin), Ketoconazole (for skin rash), pantoprazole (for gastroesophageal reflux disease), Melatonin (for insomnia), trazodone (for sleep) and Vistaril (for anxiety). Review of Medication Administration Record dated 07/29/2025 through 07/31/2025 revealed Patient #1 did not receive his carvedilol, Xifaxan, clonidine, Melatonin, and Trazodone until 07/30/2025 at 9:00 PM. Further review revealed Patient #1 did not receive his pantoprazole, until 07/31/2025 at 9:00 AM. Continued review failed to reveal the admitting physician reviewed Patient #1’s current medications with the admitting nurse and reconciled the medications that were to be continued and to provide orders for the medications to the nurse. During an interview on 09/23/2025 at 2:11 PM, S2QD confirmed Patient #1 was not administered his home medications for over 24 hours from time of admission. S2QD verified the admitting physician failed to review Patient #1’s current medications with the admitting nurse and reconcile the medications that were to be continued and to provide orders for the medications to the nurse. Patient #2 Review of medical record revealed Patient #2 was admitted from a nursing home on 08/11/2025 at 6:00 PM with diagnosis of aggression and discharged as deceased on 8/12/25 at 4:58 AM. Continued review revealed the following home medications: Ativan (for anxiety), Donepezil (for memory), Memantine (for memory), Metoprolol (for hypertension), Montelukast (for allergies), Pravastatin (for hyperlipidemia), Sertraline (for depression), Trelegy Ellipta (for Chronic Obstructive pulmonary Disease), and Trospium Chloride (for overactive bladder). Continued review of medical record failed to reveal Patient #2 was seen by a physician from admission until deceased. Review of Medication Administration Record dated 08/11/2025 through 08/12/2025 failed to reveal Patient #2 received any medications from time of admission on 08/11/2025 at 6:00 PM until patient found deceased at 4:58 the next morning. Continued review failed to reveal the admitting physician reviewed Patient #2’s current medications with the admitting nurse and reconciled the medications that were to be continued and to provide orders for the medications to the nurse. During an interview on 09/23/2025 at 11:36 AM, S2QD confirmed Patient #2 was not administered any medications from admission until he was found deceased. S2QD verified the admitting physician failed to review Patient #2’s current medications with the admitting nurse and reconcile the medications that were to be continued and to provide orders for the medications to the nurse. Patient #3 Review of medical record revealed Patient #3 was admitted on 07/08/2025 at 5:45 PM with diagnosis of bipolar disorder, pituitary adenoma, ventriculoperitoneal shunt, high blood pressure, hypothyroid, and hyponatremia, discharged on 07/19/2025 at 9:00 AM. Continued review revealed the following home medications: Abilify (for bipolar), Lexapro (for depression), Cortef (for adrenocortical insufficiency) Synthroid (for hypothyroid), Lisinopril (for hypertension), Meloxicam (for rheumatoid arthritis), pantoprazole (gastroesophageal reflux disease). Review of Medication Administration Record dated 07/08/2025 through 07/10/2025 revealed Patient #3 did not receive his Synthroid until 07/10/2025 at 6:30 AM. Patient #3 did not receive his Cortef, Lisinopril, Meloxicam, and pantoprazole until 07/10/2025 at 9:00 AM. Continued review failed to reveal the admitting physician reviewed Patient #3’s current medications with the admitting nurse and reconciled the medications that were to be continued and to provide orders for the medications to the nurse. During an interview on 09/23/2025 at 12:58 PM, S2QD confirmed Patient #3 was not administered his home medications from admission on 07/08/2025 at 5:45 PM until 07/10/2025 at 6:30 AM over 24 hours from time of admission. S2QD verified the admitting physician failed to review Patient #3’s current medications with the admitting nurse and reconcile the medications that were to be continued and to provide orders for the medications to the nurse. During an interview on 09/23/2025 at 1:19 PM, S1DON stated the nurses have the ability to call the provider to notify them about the home medications although the orders are triggered to the physician when put in the EMR system for him to sign and and are available for the provider to address the home medications at that time.”

“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 record review and interview, the hospital failed to ensure the patient right to be free from all forms of neglect as evidenced by failure to ensure discharged Patient #1 arrived safely to Shelter ‘A’. Findings: Review of psychiatric hospital’s policy #RTS-01 titled “Patient Rights” last revised on 02/01/2021, revealed in part: “Exhibit A: Rights of Persons Suffering from Mental Illness and Substance Abuse Summarized in Layman Terms. Abuse, Neglect, Exploitation, Harassment: You have the right to be free from neglect.” Review of Patient #1’s medical record revealed an admission date of 07/29/2025 at 8:30 PM with diagnoses of psychosis, hypertension, cirrhosis, pancytopenia, Monoclonal Gammopathy of Undetermined Significance, and hyponatremia, discharged on 08/07/2025 at 5:00 PM. Review of Patient #1’s Progress Note dated 07/30/2025 at 10:23 AM revealed S11SW spoke with his sister and a representative at the nursing home from which he was admitted. Patient no longer lived at the nursing home per his request. The nursing home stated he was not appropriate, and that he could live independently. It was reported patient was at a previous recovery center and left the program early. Patient #1’s sister reported he previously lived at Shelter ‘A’ for years and that he was familiar with that facility. Patient did not have any income as reported by the sister and the nursing home. Review of Patient #1’s Multidisciplinary Progress note dated 08/07/2025 at 5:05 PM per S12RN revealed the patient was discharged from Ocean’s Hospital in Hammond. Patient was discharged to Shelter ‘A’ in baton Rouge. Patient was escorted off unit by staff. Patient left the facility at 5:00 PM via Ride Share ‘B’. Review of Shelter ‘A’s website revealed hours open from 8:00 AM-4:00 PM. During an interview on 09/23/2025 at 2:32 PM, S2QD verified Shelter ‘A’ was open from 8:00 AM until 4:00 PM per the website. During an interview on 09/24/2025 at 8:11 AM, a representative from Shelter ‘A’ stated the shelter accepted intakes on a first-come, first-served basis starting at 8:30 AM. Intakes stop at 3:30 PM and the office closes at 4:00 PM. An individual who arrived after 3:30 PM would have to return at an earlier time the next day, and based on first-come, first-served basis, would be provided a bed. During an interview on 09/23/2025 at 2:51 PM, S5DCS stated the psychiatric hospital did not have a blanket procedure for post-discharge follow-up and depended on the situation, whether or not the patient was aware and independent versus cognitively declined especially if they were using a different transportation other than family. S5DCS said she was not aware Patient #1 discharged to Shelter ‘A’ via Ride Share ‘B’. S5DCS stated initially Transport ‘C’ was supposed to arrive on 08/07/2025 at 9:00 in AM to bring Patient #1 to Shelter ‘A’. S5DCS reported that the transportation change should have been communicated to the treatment team and she was not sure why that did not happen. There was no note as to why this changed. S5DCS reported the treatment team should have discussed the timing for discharge based on the shelters’ hours in order for the patient to arrive safely. S5DCS verified the psychiatric hospital did not know if Patient #1 arrived safely to Shelter ‘A’ on 08/07/2025.”

“Social Service Records CFR(s): The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history. This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital failed to ensure the medical record included the accurate necessary steps for safe discharge to occur. This deficient practice is evidenced by failure to organize, document and facilitate specificities regarding transport and timing changes for Patient #1’s discharge to Shelter ‘A’. Findings: Review of psychiatric hospital’s policy #PC-18 titled “Discharge planning: Transition Record” last revised on 10/01/2024, revealed in part: Procedure: 3. Discharge planning should encompass the following areas: Review of community resources needs of patient post-discharge and availability of same. 4. Social Services/Case management personnel shall: Participate/facilitate discharge planning and develops mechanisms for exchanging information with service providers outside the facility. Contact the post-discharge referral source to ascertain the suitability of placement, schedule any appointments and to facilitate coordination of transfer. Coordinates transportation arrangements. 6. The treatment Team members will complete a crisis safety plan, if applicable, and document the final discharge plans on the Transition Record. This information shall include at a minimum: 24 hours/7-day contact information including physician for emergencies related to the inpatient stay. 7. The Transition Record and any other documentation to support the continuum of care shall be transmitted to the next level of care provider within 24 hours of discharge and documented in the patient’s medical record. Review of Patient #1’s medical record revealed an admission date of 07/29/2025 at 8:30 PM with diagnoses of psychosis, hypertension, cirrhosis, pancytopenia, Monoclonal Gammopathy of Undetermined Significance, and hyponatremia, discharged on 08/07/2025 at 5:00 PM. Review of Patient #1’s medical record failed to reveal discharge documentation related to the following: 1) information between the psychiatric hospital and Shelter ‘A’, specifically the suitability of placement and the hours of operation including time of expected arrival in order for Patient #1 to participate in the shelter’s intake process; 2) transportation changes from Transport ‘C’ scheduled for 9:00 AM on 08/07/2025 to Ride Share ‘B’ at 5:00 PM on 08/07/2025 that was noted by the treatement team; 3) accurate final discharge plans on the Transition Record that included 24 hours/7-day contact information including physician for emergencies related to the inpatient stay; and 4) continuum of care information transmitted to Shelter ‘A’ within 24 hours of discharge. During an interview on 09/23/2025 at 2:51 PM, S5DCS confirmed the above and stated she could not locate documentation as to why Patient #1 discharged to Shelter ‘A’ via Ride Share ‘B’. S5DCS stated that initially Transport ‘C’ was supposed to arrive on 08/07/2025 at 9:00 in AM to bring Patient #1 to Shelter ‘A’. S5DCS reported that the transportation change should have been communicated to the treatment team and she was not sure why that did not happen. There was no note as to why this changed. S5DCS reported the treatment team should have discussed and documented the timing for discharge based on the shelters’ hours.”

“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: 48050 Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by 1)failure of the staff to perform observations as ordered by the physician in 3(#1-#3) of 3 (#1-#3) reviewed patient records; and 2)failure of the staff to ensure precautions and increased observation levels post incident in 2 (#1, #2) of 3 (#1-#3) reviewed patient records Findings: Review of hospital policy number CS-23, titled “Level of Observations,” last revised 03/01/2023, revealed in part: “PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. POLICY: Observation Levels: Every 15 minutes- the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. PROCEDURE: 3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. The observing staff initials the 15-minute increments on the form to indicate the patient was observed. The staff member signs the signature line at the bottom of the form to validate their initials and credentials.” 1)failure of the staff to perform observations as ordered by the physician in 3(#1-#3) of 3 (#1-#3) reviewed patient records Patient #1 Review of Patient #1’s medical record revealed Patient #1’s observation level was every 15 minutes rounding by the Mental Health Technician (MHT). The Rounding Form dated 08/09/025 revealed the MHT rounding at 2:42 AM then again at 3:14 AM which is 32 minutes between patient rounding. An interview on 09/09/2025 at 1:35 PM, S1QD verified the above information. Patient #2 Review of Patient #2’s medical record revealed Patient #2’s observation level was every 15 minutes rounding by the Mental Health Technician (MHT). The Rounding Form dated 08/07/025 revealed the MHT did not round on Patient #2 from 4:00 AM to 7:45 AM which is 3 hours and 45 minutes between patient rounding. An interview on 09/09/2025 at 1:35 PM, S1QD verified the above information. Patient #3 Review of Patient #3’s medical record revealed Patient #2’s observation level was every 15 minutes rounding by the Mental Health Technician (MHT). The Rounding Form dated 09/07/025 revealed the MHT rounded on Patient #3 at 5:21 AM, 5:39 AM, and 6:18 AM which is 18 and 39 minutes between patient rounding. An interview on 09/08/2025 at 2:55 PM, S1QD verified the above information. 2)failure of the staff to ensure precautions and increased observation levels post incident in 2 (#1, #2) of 3 (#1-#3) reviewed patient records Review of hospital policy number CS-44, titled “Sexual Acting Out (SAO) Precautions,” last revised on 09/01/2025, revealed in part: “PURPOSE: To provide staff with a framework for identifying patients who are at risk for exhibiting sexually inappropriate behavior and to provide guidance for the implementation of precautions to ensure the safety of all patients. To define actions to take in response to reports or allegations of sexual behavior or sexual acting out between patients. Criteria: 5. Patients found to be at risk for sexual behaviors will be placed on 1:1 observation or Line of Sight (LOS) until a face-to-face assessment is completed by the Physician to ensure appropriate level of precaution. PROCEDURE: Management of Sexual Incident (Inpatient Services) 1. Immediately separate patients involved in the alleged incident. Patients are either placed immediately on separate units if possible or on opposite sides of the same unit with increased observations for the alleged perpetrator until the investigation is completed and provider has completed evaluation. 4. Based on the incident, place the alleged perpetrator on 1:1 or LOS until the Provider completes a face-to-face evaluation of the patient to determine if the patient’s activities or behaviors are appropriate for a lower level of observation. Patients with alleged and observed sexual acting out behaviors will be assessed daily by the Physician to ensure appropriate level of care. Review of Patient #1’s medical record revealed Patient #1 was admitted on 08/04/2025 with Major Depression Disorder. On 08/13/2025 at 7:26 PM, Patient #1 was found in bathroom with a female patient reporting consensual sex occurred. Hospital staff made notifications to provider and Patient #1’s family, but did not place Patient #1 on SAO precautions until 08/14/2025 at 1:56 AM and did not increased observation level to LOS until 08/14/2025 at 10:00 AM. In an interview on 09/09/2025 at 12:55 PM, S1QD verified above information did not follow hospital policies/procedures. Review of Patient #2’s medical record revealed Patient #2 was admitted on 08/06/2025 with Depression and Anxiety. On 08/13/2025 at 7:26 PM, Patient #2 was found in bathroom with male patient reporting consensual sex occurred. Hospital staff made notifications to provider and Patient #2’s family, but did not place Patient #2 on SAO precautions until 08/14/2025 at 1:55 AM and did not increased observation level to LOS until 08/14/2025 at 10:00 AM. In an interview on 09/09/2025 at 9:15 AM, S1QD verified above information did not follow hospital policies/procedures.”

“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: 48050 Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. The deficient practice is evidenced by: 1)failure of the Registered Nurse to follow provider orders in 3 (#1-#3) medical records reviewed; and 2)failure of the Registered Nurse to document patient observations every 2 hours per hospital policy in 2 (#1, #2) of 3 (#1-#3) medical records reviewed. Findings: 1)Failure of the Registered Nurse to follow provider orders in 3 (#1-#3) of 3 (#1-#3) medical records reviewed. Review of Patient #1’s medical record revealed that Patient #1 was involved in sexual incident with a female patient on 08/13/2025 at 7:26 PM. Further review of Patient #1’s medical record revealed the provider ordered the following labs Gonorrhea/Chlamydia on 08/13/2025, 08/14/2025, 08/16/2025, 08/19/2025, and 08/20/2025. The lab Gonorrhea/Chlamydia was never collected from Patient #1 before discharge on 08/21/2025 at 4:00 PM. An interview on 09/09/2025 at 12:55 PM, S1QD verified the Gonorrhea/ Chlamydia labs were never collected while Patient #1 was hospitalized. Review of Patient #2’s medical record revealed that Patient #2 was involved in sexual incident with a male patient on 08/13/2025 at 7:26 PM. Further review of Patient #2’s medical record revealed the provider ordered a repeat urinary pregnancy test (UPT) to be done on 08/19/2025 at 5:30 AM. Patient #2 was discharged from the hospital before repeat UPT was done. An interview on 09/09/2025 at 9:20 AM, S1QD verified the UPT was never collected while Patient # 2was hospitalized. 2)Failure of the Registered Nurse to document patient observations every 2 hours per hospital policy in 2 (#1, #2) of 3 (#1-#3) medical records reviewed. Review of hospital policy number CS-23, titled “Level of Observations,” last revised 03/01/2023, revealed in part: “PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. PROCEDURE: 3. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form.” Patient #1 Review of Patient #1’s medical record revealed Patient #1’s observation level was every 15 minutes rounding by the Mental Health Technician (MHT) and every 2 hours by the RN. The Rounding Forms dated with following times the RN missed rounding on the patient every 2 hours: 08/05/2025 at 7:00 AM; 08/07/2025 at 7:00 PM; 08/10/2025 at 7:00 AM; 08/11/2025 at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, AND 7:00 PM; 08/13/2025 at 7:00 PM, 08/15/2025 at 7:00 PM; AND 08/20/2025 at 7:00 AM. In an interview on 09/09/2025 at 1:40 PM, S1QD verified the RN missed rounding every 2 hours on Patient #1 as mentioned above. Patient #2 Review of Patient #2’s medical record revealed Patient #1’s observation level was every 15 minutes rounding by the Mental Health Technician (MHT) and every 2 hours by the RN. The Rounding Forms dated 08/13/2025 at 7:00 PM the RN missed every 2 hours rounding on Patient #2. In an interview on 09/09/2025 at 10:06 AM, S1QD verified the RN missed rounding every 2 hours on Patient #2 as mentioned above.”

“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: 48050 Based on record review and interview, the nursing staff failed to develop and update an individualized plan of care for each patient. This deficient practice was evidenced by failing to update the care plan following an incident for 2 (#1, #2) of 3 (#1-#3) patient records reviewed. Findings: Review of hospital policy number CS-02 titled “Treatment Planning; Integrated/ Multidisciplinary”, last revised 05/01/2025,revealed in part: “PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. POLICY: The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient’s involvement, throughout the course of treatment. PROCEDURE: 2. The admitting nurse is responsible for the following: Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths, and limitations, and physician’s orders. Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 08/04/2025 with Major Depression Disorder. Patient #1 exhibited violent behaviors on 08/11/2025, 08/14/2025, and 08/17/2025 which required PRN medications to be administered. Further review of Patient #1’s medical record revealed no update to Patient #1’s treatment plan. In an interview on 09/09/2025 at 1:50 PM, S1QD verified the above mentioned information. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 08/06/2025 with Depression and Anxiety. Patient #2 exhibited violent behaviors on 08/17/2025 requiring administration of PRN medication. Further review of Patient #2’s medical record revealed no update to Patient #2’s treatment plan. In an interview on 09/09/2025 at 9:30 AM, S1QD verified the above mentioned information.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48050 Based on record reviews and interview, the hospital failed to ensure that each patient’s medical record contained all documentation. The deficient practice is evident by failing to ensure discharge instructions contained all pertinent information needed for post hospital care in 1 (#1) of the 3 (#1-#3) patients’ medical records reviewed. Findings: Review of the hospital policy number PC-18 titled “Discharge Planning: Transition Record”, last revised 10/01/2024, revealed in part: “PURPOSE: To establish guidelines for assisting patients to the appropriate level of psychosocial/physical care, treatment, and services for post-treatment placement, follow- up, and/or transfer. PROCEDURE: 5. The Nurse shall: Upon discharge, provide the patient recommendations for anticipated continuing care, treatment, and services and discharge medication interventions. Review of Patient #1’s medical record revealed Patient #1 was discharge on 08/21/2025 at 11:48 AM. Further review of Patient #1’s medical record revealed the discharge instructions didn’t contain the following information: who Patient #1 was released to upon discharge, who received the discharge instructions, and follow-up care after hospitalization resulting in an incomplete document. In an interview on 09/09/2025 at 2:05 PM, S1QD verified Patient #1 did not have follow up care on the discharge instructions.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to establish an appropriate discharge plan for each patient. This deficient practice was evidenced by failing to provide 2 (#1, #2) of 3 (#1-#3) patients’ with a discharge plan that included discharge instructions/education for STI. Findings: Review of hospital policy PC-18, “Discharge Planning: Transition Record,” revised 10/01/2024 revealed in part,” PURPOSE: To establish for assisting patients to the appropriate level of psychosocial/physical care, treatment and services for post-treatment placement, follow-up, and/or transfer. PROCEDURE: 3. Discharge planning should encompass the following areas: Orders for continuing care to meet physical and psychosocial needs for discharge or transfer. Review of Patient #1’s medical record revealed that Patient #1 was involved in sexual incident with a female patient on 08/13/2025 at 7:26 PM. Further review of Patient #1’s medical record revealed the provider ordered the following labs on 08/13/2025 a Sexually Transmitted Infection (STI) panel ordered which consisted of HIV, Hepatitis, RPR, and Gonorrhea/Chlamydia. Further review of the Patient #1’s discharge plan did not reveal follow-up or education for STI. In an interview on 09/09/2025 at 2:05 PM, SIQD verified the above information. Review of Patient #2’s medical record revealed that Patient #1 was involved in sexual incident with a male patient on 08/13/2025 at 7:26 PM. Further review of Patient #1’s medical record revealed the provider ordered the following labs on 08/13/2025 a Sexually Transmitted Infection (STI) panel ordered which consisted of HIV, Hepatitis, RPR, UPT, and Gonorrhea/Chlamydia. Further review of the Patient #2’s discharge plan did not reveal follow-up or education for STI. In an interview on 09/09/2025 at 9:45 AM, SIQD verified the above information.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 50453 Based on record review and interview, the facility failed to ensure the medical record contained documented evidence of patient notification of their rights. This deficient practice was evidenced by failing to have the patient/patient representative sign the statement of Patient Acknowledgment of Rights for 1 (#3) of 3 (#1-#3) patients reviewed. Findings: Review of the hospital policy number RTS-01 titled, “Patient Rights Louisiana,” last revised 09/01/2023, revealed in part: “PURPOSE: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient’s rights if deemed necessary. Every patient shall receive a written copy of their rights and responsibilities as a patient as part of the Patient Handbook and shall sign an acknowledgement that they are aware of their rights. The written copy shall include all applicable state and federal rights protections afforded to the patient. PROCEDURE: 1. The patient is to be given a copy of the Patient’s Rights as part of the Patient Handbook that is reviewed at the time of admission by a program staff member. The patient acknowledges receipt of their written statement of rights by signing the Statement of Patient Acknowledgement which becomes part of the medical record. 5. If the patient is a minor, the rights shall be reviewed orally with the patient parent/guardian, when applicable, and have the patient sign the “acknowledgement of Rights” form and document verbal acknowledgement from the parent/guardian. Review of Patient #3’s medical record revealed an admission date of 05/30/2025 under a Physician Emergency Certificate (PEC). Patient #3’s medical record failed to reveal documented evidence that Patient #3 or their parent/guardian were notified of all patient rights. Further review failed to reveal a signed acknowledgement of rights form in the medical record. In an interview on 06/03/2025 at 9:20 AM, S1ADON confirmed the medical record failed to reveal evidence Patient #3 or his parent/guardian were given the opportunity to acknowledge that they were aware of all patient rights. S1ADON also confirmed that there was no signed acknowledgement of rights form in the medical record for Patient #3.”

“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: 50453 Based on record review and interview, the hospital failed to ensure the patient/patient representative’s right to participate in the development and implementation of his or her plan of care. This deficient practice is evidenced by failing to document the reason the patient did not participate in the treatment plan for 1 (#3) of 3 (#1-#3) patient treatment plans reviewed. Findings: Review of the hospital policy number RTS-01 titled, “Patient Rights Louisiana,” last revised 09/01/2023, revealed in part: “Treatment: You have the right too an individualized treatment plan and periodic reviews to determine your progress. You have the right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. Rights of Minors: Q. A minor patient admitted to a treatment facility has the right to an individualized treatment plan and periodic review to determine his progress.” Review of the hospital policy number CS-02 titled, “Treatment Planning; Integrated/Multidisciplinary,” last revised 05/01/2025, revealed in part: “PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. POLICY: The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient’s involvement, throughout the course of treatment. PROCEDURE: 4. If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient’s medical record.” Review of Patient #3’s medical record revealed an admission date of 05/30/2025 with a diagnosis of Major Depressive Disorder (MDD) and Bipolar. Review of Patient #3’s medical document titled “Interdisciplinary Treatment Plan Master Sheet” initiated on 05/30/2025, revealed the patient signature line was signed “verbal” by the nurse, but no additional documentation stating the reason that Patient #3 was unable and/or unwilling to sign was provided. In an interview on 06/03/2025 at 9:47 AM, S1ADON confirmed the nurse signed verbal on the patient signature line, but did not provide any documentation as to why Patient #3 was unable and/or unwilling to sign the treatment plan.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure the patient/representative was provided information about his/her health status, diagnosis, and prognosis in order to make “informed” decisions regarding his/her care. This deficient practice was evidenced by failing to have a signed consent for treatment form by the patient/representative for 1 (#3) of 3 (#1-#3) patients reviewed for signed consents. Findings: Review of hospital policy number RTS-11, titled “Informed Consent, Care Decisions, and Conflicts Resolution,” last revised 11/01/2024, revealed in part: “PURPOSE: To outline the responsibility of the facility in establishing a mutual understanding between the patient/patient’s family/representative and the facility about patient services received. To involve patients and significant others, when appropriate, in care decisions, conflict resolution, and the informed consent process. POLICY: The facility recognizes the benefit and the need to involve patients and significant others, when appropriate, in care, treatment and service decisions, conflict resolution, and to ensure that appropriate informed consent is obtained as outlined by the State, Federal and other regulatory bodies. PROCEDURE: Informed Consent: 1. The Governing Body/Administration dictates that informed consent is mandatory on those procedures, care, treatment, and services normally requiring informed consent and mandates that all staff responsible for the delivery of care, treatment and services educate patients/patient’s family/representative to allow for informed decision making as to participate in the care, treatment, and services being delivered. 3. The facility will, during the admission process, obtain signature on informed consent forms. If the patient is unable to sign due to physical impairments, verbal consent can be obtained and documented with two witnesses. In the case of involuntary commitment, the facility will follow the policies of the organization related to involuntary admission. 4. Specific informed consent is required in the following circumstances: Facility treatment programming/admission.” Review of Patient #3’s medical record revealed an admission date of 05/30/2025 under a Physician Emergency Certificate (PEC). Patient #3’s medical record failed to have documented evidence that Patient #3 or his representative signed an informed consent for treatment. In an interview on 06/03/2025 at 9:20 AM, S1ADON confirmed that there was no signed informed consent for treatment in the medical record for Patient #3.”

“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. This deficient practice was evidenced by failure of the staff to prepare for a scheduled power outage and ensure 12 (#3, #R1-#R11) of 12 (#3, #R1-#R11) patients were monitored according to the physician’s orders including special precautions and documented the care provided in real time according to accepted standards and hospital policy. Findings: Review of hospital policy number IS-03, titled “Electronic Medical Record (EMR) Downtime Procedures,” effective date 07/01/2023, revealed in part: “PURPOSE: To mitigate the risk associated with planned and unplanned downtimes related to the Electronic Medical Record (EMR) and to outline the processes for access to patient information for the purposes of documentation of patient care during those downtime periods. POLICY: The facility recognizes that interruptions in the availability of the EMR may occur which can be planned or unplanned and outlines a process for ensuring the care delivered during a period of EMR downtime is appropriately documented. PROCEDURE: 1. Notification will be sent out to all employees for planned downtime. When possible and deemed necessary, timing of planned downtime shall be coordinated with the facility and pharmacy. 11. All documentation requirements and related policies and procedures shall remain in effect for the period of downtime.” Review of hospital policy number CS-23, titled “Level of Observations,” last revised 03/01/2023, revealed in part: “PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. POLICY: Observation Levels: Every 15 minutes- the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. PROCEDURE: 3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. The observing staff initials the 15-minute increments on the form to indicate the patient was observed. The staff member signs the signature line at the bottom of the form to validate their initials and credentials.” Review of hospital policy number AS-19, titled “Suicide/Homicide Risk Assessment,” last revised 11/01/2023, revealed in part: “PURPOSE: The purpose of this policy is to ensure an effective method for suicide/homicide screening, assessment, monitoring, and treatment of patients at risk for suicide/homicide. POLICY: Prevention techniques will be accomplished by a comprehensive approach that identifies and mitigates process and system level issues contained within the hospital environment that can contribute to self-harm. Direct Care Staff who conduct suicide screening, assessment, or re-assessment will be trained and successfully pass competency test on the screening and/or assessment process and screening/assessment tools as part of new hire orientation and annually thereafter. PROCEDURE: Inpatient: 3. All direct care staff needs to be aware of suicidal/homicide/violence risks. Suicide, homicide, and/or violence precautions will be noted in the medical record. 5. The following Risk Levels and Interventions will be used in the assessment to mitigate any suicide/homicide/violence risk: Levels of risk and appropriate interventions (Inpatient): Suicidal Risk Stratification: HIGH Suicide Risk: Suicidal ideation with intent or intent with plan in the last month or suicidal behavior within the past 3 months. Suicidal Intervention: HIGH Suicide Risk: Stay patient, initiate 1:1 observation, and notify provider to obtain order. Patient may be placed on lower level of observation based on clinical judgement of the Medical Staff and the documented justification. Initiate a “Potential for Self-Harm” treatment plan. Maintain a SAFE environment & evaluate personal belongings for ligature risk. Develop Safety Plan with suicide resources for discharge planning. Notify multidisciplinary team of patient’s “high suicide risk” status. Suicidal Risk Stratification: MODERATE Suicide Risk: Suicidal ideation with method, WITHOUT plan, intent or behavior in the past month Or Suicidal behavior more than 3 months ago Or Multiple risk factors and few protective factors. Suicidal Intervention: MODERATE Suicide Risk: Implement q15 min observation. Place patient close to nurses’ station with roommate, if possible. Initiate a “Potential for Self-Harm” treatment plan. Maintain a SAFE environment & evaluate personal belongings for ligature risk. Develop Safety Plan with suicide resources for discharge planning. Notify multidisciplinary team of patient’s “moderate suicide risk” status. Suicidal Risk Stratification: LOW Suicide Risk: Wish to die or Suicidal Ideation WITHOUT method, intent, plan, or behavior Or Modifiable risk factors and strong protective factors Or No reported history of Suicidal Ideation or Behavior. LOW Suicide Risk: Implement q15 min observation. Continue to monitor for changes in suicidal ideation or behavior.” Review of hospital policy number CS-04, titled “Elopements,” last revised 01/01/2025, revealed in part: “PURPOSE: To identify those at risk for elopement and to prevent the occurrence. PROCEDURE: 2. For patients who are screened or assessed to be at risk for elopement, the physician is notified and an order for elopement precautions is obtained. The prescribed level of observation is implemented immediately. 5. Elopement prevention strategies and interventions include, but not limited to: Initiate 1:1 or Line of sight observation level. Limit/restrict outdoor privileges (requires physician order which must be renewed every 24 hours). Ensure all staff practice door safety by ensuring all doors on and off the unit are closed and appropriately latched/locked before leaving the door area. Redirect patients away from immediate proximity of doors. Staff vigilance during outdoor time by walking the inside perimeter of fencing to stay between patients and fence. Always having two or more staff present when patients are off the locked unit within the facility. Ensure no items such as chairs, benches, garbage cans, etc. are in the outdoor courtyard that could be used to leverage patient over fencing. Direct patients away from fence during outdoor times.” Review of hospital policy number CS-44, titled “Sexual Acting Out (SAO) Identification and Precautions,” effective date 12/19/2022, revealed in part: “PURPOSE: To provide staff with a framework for identifying patients who are at risk for exhibiting sexually inappropriate behavior and to provide for the implementation of precautions to ensure the safety of all patients. POLICY: Definitions: Sexual Precautions: Sexual Precautions are defined as intensified levels of staff awareness and attention to patient safety/security related to sexual acting out behaviors. Sexual Precautions require varying levels of observing patients and the initiation of specific protocols and supplemental documentation, when warranted. PROCEDURE: 4. The RN/LVN/LPN ensures all patient orders for SAO Precautions are recorded and posted. 5. The RN ensures the SAO Precaution level is communicated on the hand off report and all staff are aware of the SAO Order. Sexual Acting Out (SAO) Precautions: 1. LOS or 1:1 or 15 minute observation based on clinical assessment; 2. Assess location of patient rooms based on vulnerability of the patient population in particular at-risk patients; 3. Determine if level of SAO risk requires that a patient requires his/her patient room; 4. Room visible from the nurses’ station or patient lounge when possible; 5. Door open when patient is his/her room; 8. Ensure all staff members are aware of SAO behavior (including volunteers, students); 9. Ensure two staff members are present when the patient needs assistance in his/her room or isolated areas; 10. Monitor relationships, interactions, not passing, whispering, etc., among patients. 11. Screen reading materials, ensure appropriate media is viewed on the unit; 12. Visitor restrictions if appropriate.” In an interview during the entrance conference on 06/02/2025 at 8:25 AM, S1ADON stated there would be a scheduled power outage around 10:00 AM - 11:00 AM. Per S1ADON, the outage is to install a new part on the generator. S1ADON confirmed at that time that staff working had been made aware of the power outage and that staff would be documenting patient care on paper forms during the electrical power downtime. Observations during a tour on 06/02/2025 from 10:53 AM - 11:15 AM revealed all 12 patients were in the secured outdoor area playing while being observed by 2 nurses and 2 MHT’s. Review of the Observation Check Sheet for Patient #3 and Patients #R1-#R11 revealed that observations were initiated for each patient on paper at 10:45 AM. Review of the Observation Check Sheets for Patient #3 and Patients #R1-R11 failed to reveal an assigned observation level checked per physician order by the Registered Nurse, the ordered precaution level, or the date the observations were being performed. Review of the bedboard for 06/02/2025 revealed Patient #3 and Patients #R1-R11 were all on Q15 minute observations. Further review revealed the following ordered precaution levels: Patient #3- Suicide, Violence, and Sexually Acting Out Patient #R1, #R2- Violence Patient #R3, #R8- Homicide, Violence Patient #R4, #R10, #R11- Suicide Patient #R5- Suicide, Homicide, Violence Patient #R6- SAO, Violence Patient #R7- SAO, Suicide, Violence Patient #R9- Elopement In an interview on 06/02/2025 at 11:08 AM, S7MHTconfirmed that she is unable to verify which precaution level each patient was on without a copy of the bedboard, which they use as a reference. S1ADON and S7MHT confirmed that the staff observing the patients did not have a copy of the bedboard with them at this time, which jeopardized their safety and well-being. Additional review of the Observation Check Sheets for 8 (#3, #R1-#R7) of the 12 (#3, #R1-#R11) patients failed to reveal staff initials by the observing staff for 10:45 AM or 11:00 AM to indicate the patient was being observed. In an interview on 06/02/2025 at 11:11 AM, S1ADON confirmed the above mentioned findings. S1ADON further confirmed that staff should have been prepared since this was a scheduled downtime. In an interview on 06/02/2025 at 11:25, S3RCEO confirmed the Observation Check Sheets should have been appropriately filled out because staff has been “aware for hours” that this was going to happen.”

“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 failure to accurately self-report an incident which involved an alleged patient to patient sexual assault. Findings: Review of hospital policy number QAPI-004, titled “Incident Reporting,” last revised 08/01/2024, revealed in part: “PURPOSE: To document any potential or adverse incident within the facility or on the facility grounds/property/vehicle, with the facts available at the time, recorded by persons involved, either in the incident or in the discovery of the incident. Information to Provide in the Incident Report: 1. The Incident Report shall be limited to factual statements (who, what, where, and when) related to the patient safety incident and any interventions take to reduce the risk of future incidents and promote safety.” Review of Patient #1’s medical record revealed Patient #1 was a 12 year old male admitted on 05/02/2025 with a diagnosis of Major Depressive Disorder (MDD). On the night of 05/04/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with his roommate, Patient #2. Further review revealed after Patient #1 was evaluated by the provider, he was transferred on 05/05/2025 to the ER for an evaluation at which point the Patient #1 was discharged into the care of his mother. Review of Patient #2’s medical record revealed Patient #2 was a 17 year old male admitted on 05/02/2025 with a diagnosis of Major Depressive Disorder (MDD). On the night of 05/04/2025, Patient #2 was involved in an alleged patient to patient sexual assault incident with his roommate, Patient #1. Further review revealed Patient #2 was discharged on 05/04/2025 at 10:48 PM into police custody. Review of the Nursing Assignment Sheet dated 05/04/2025 7a-7p and 7p-7a shift revealed a census of 15 patients. Further review revealed that Patient #R12 was on Line of Sight Observations. Review of the Hospital/Licensed Provider Abuse/Neglect Initial Report finalized on 05/05/2025 revealed in part the following documentation: Incident Type: Alleged Sexual Abuse (Patient to Patient Sexual Assault) Date/Time of Incident: 05/04/2025; exact time unknown, only reported time is known Shift of incident: 7p-7a Date/Time of Discovery: 05/04/2025 at 9:10 PM Patient Information documented on report included: Patient #1 as Victim Patient #2 as Aggressor Incident details revealed in part: Patient #2 reported that he forced Patient #1 to perform oral sex on him while in their room the evening of 05/04/2025. Both patients were on a PEC status. Both patients were close observation (every 15 minute) monitoring. Census on the unit was 15, no elevated observation at time of the incident. Staffing was 1 RN, 1 LPN, 2 MHT’s. The report failed to reveal that at the time of the incident Patient #R12 was on Line of Sight observations. In an interview on 06/03/2025 at 8:55 AM, S1ADON confirmed that information included in the self-report was not reported accurately. S1ADON further confirmed that at the time of the incident involving Patient #1 and Patient #2, the unit had a patient who was on an elevated observation level. S1ADON verified the Nursing Assignment Sheet for 05/04/2025 7P-7A revealed Patient #R12 was on Line of Sight observations.”

“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 failure of the Registered Nurse to document a provider notification for an alleged patient to patient sexual assault in 1 (#1) of 3 (#1-#3) patient medical records reviewed. Findings: Review of hospital policy number CS-44, titled “Sexual Acting Out (SAO) Identification and Precautions,” effective date 12/19/2022, revealed in part: “PURPOSE: To provide staff with a framework for identifying patients who are at risk for exhibiting sexually inappropriate behavior and to provide for the implementation of precautions to ensure the safety of all patients. To define actions to take in response to reports or allegations of sexual behavior or sexual acting out between patients. Criteria: 2. If it is suspected, reported, or observed that there has been sexual contact between patients, the attending provider or designee, the Charge Nurse, Hospital Administrator or Administrator on-call, Director of Nursing (DON), will be notified immediately.” A review of the incident report involving Patient #1 revealed in part that Patient #1 was identified as the alleged victim of a patient to patient sexual assault that was reported on 05/04/2025 at 9:10 PM. Review of Patient #1’s medical record revealed Patient #1 was admitted on 05/02/2025 with a diagnosis of Major Depressive Disorder (MDD). Further review failed to reveal documented evidence by the nurse that the attending provider was immediately notified that Patient #1 was an alleged victim of a sexual assault. In an interview on 06/02/2025 at 2:05 PM, S1ADON confirmed that there was no documentation in the medical record by the nurse that the provider was notified of the sexual assault incident involving Patient #1.”

“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: 50453 Based on record review and interview, the nursing staff failed to develop and update an individualized plan of care for each patient. This deficient practice was evidenced by failing to update the care plan following an incident for 1 (#2) of 3 (#1-#3) patient records reviewed. Findings: Review of hospital policy number CS-44, titled “Sexual Acting Out (SAO) Identification and Precautions,” effective date 12/19/2022, revealed in part: “PURPOSE: To define actions to take in response to reports of allegations of sexual behavior or sexual acting out between patients. PROCEDURE: 15. Update treatment plan for each patient.” Patient #2 Review of incident report involving Patient #2 revealed the following: Date of Incident: 05/04/2025, time of discovery: 9:10 PM, Type of occurrence: Alleged Patient to Patient Sexual Abuse. Review of Patient #2’s medical record revealed Patient #2 was placed on Sexually Acting Out precautions on 05/04/2025 at 9:40 PM. Further review failed to reveal evidence that Patient #2’s care plan was updated to include Sexually Acting Out precautions. In an interview on 06/03/2025 at 9:01 AM, S1ADON confirmed that the plan of care for Patient #2 was not updated to include Sexually Acting Out precautions.”

“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: 50453 Based on observation, record review, and interview, the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with hospital policy and the patient’s needs. This deficiency is evidenced by failing to ensure a Registered Nurse completed patient care assignments at the beginning of shift for 12 (#3, #R1-#R11) of 12 (#3, #R1-#R11) patients on the census. Findings: Review of hospital policy number NSG-05, titled “Nursing Assignments,” last revised 06/01/2023, revealed in part: “POLICY: It is the charge nurse’s responsibility to complete the nursing assignment sheet at the onset of every shift. All nursing staff members are held accountable for duties assigned. Charge nurses will supervise assignments and ensure completion of all delegated duties. PROCEDURE: In-Patient: 1. The charge nurse will determine the nursing care assignments for that shift based on patient acuity, and capabilities and scope of practice of available staff. Every patient will be assigned to a specific person.” Observations during a tour on 06/02/2025 from 10:53 AM - 11:15 AM revealed the 7A-7P Nursing Assignment Sheet, dated 06/02/2025. Review of the Nursing Assignment Sheet revealed the only information completed was the date, shift, census number, and name of charge nurse. Further review of the Nursing Assignment Sheet failed to reveal staff or patient assignments. In an interview on 06/02/2025 at 11:00 AM, S1ADON confirmed the above mentioned findings. S1ADON also confirmed that the Nursing Assignment Sheet should have been completed at the beginning of the shift.”

“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: 50453 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 tour on 06/03/2025 from 8:35 AM - 8:50 AM revealed Room “a” with soiled towels on the floor and 2 used bottles of mouth wash on the sink. In an interview on 06/03/2025 during the tour, S1ADON confirmed the above mentioned findings.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 50453 Based on record review and interviews, the hospital failed to ensure all patient treatments were within compliance of particular aspects of the patients’ individual treatment program as evidenced by failure to have a signed master treatment plan by the social worker/therapist and attending physician for 1 (#3) of 3 (#1-#3) patient treatment plans reviewed. Findings: Review of the hospital’s policy number CS-02 titled, “Treatment Planning; Integrated/Multidisciplinary,” last revised on 05/01/2025, revealed in part: “PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. POLICY: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessments process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient’s involvement, throughout the course of treatment. PROCEDURE: 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT).” Review of Patient #3’s medical record revealed he was admitted on 05/30/2025 at 1:13 AM for Major Depressive Disorder (MDD) and Bipolar. Review of Patient #3’s Interdisciplinary Treatment Plan Master Sheet dated 05/30/2025 failed to reveal staff signatures from the therapist or physician. In an interview on 06/03/2025 at 9:47 AM, S1ADON confirmed there was no signature for the therapist or the physician on the Master Treatment Plan for Patient #3. S1ADON further confirmed there should have been signatures for the therapist and physician on the Master Treatment Plan for Patient #3.”

“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: 48537 Based on record review and interviews, the hospital failed to ensure all alleged incidents of patient abuse and neglect were reported and analyzed to ensure the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital’s failure to report an allegation of neglect within 24 hours to the Department of Health and Hospitals for 1 (#3) of (#1 - #3) patients reviewed for abuse. Findings: Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed “Department” shall mean the Department of Health and Hospitals. “Unit” means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, “Abuse” is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report. 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 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. Review of the hospital’s policy number RTS-04 titled “Patient Grievance Process” last revised 09/01/2024 revealed in part: “Purpose To provide an internal process that establishes guidelines for: Submission of a patient and/or family’s grievance allegation to the facility; Timely review and investigation of the allegation; Provision of a response; and Timely referral to the appropriate external agency as deemed necessary. Policy: The Governing Body is responsible for the effective operation of the compliant/grievance resolution process. Each facility has identified an individual to serve as the facility’ Patient Advocate who is responsible for the follow up and response to grievances submitted by a patient or caregiver. This facility has adopted an internal grievance process in accordance with Title 42 CFR, §482.13 which provides for prompt resolution of patient and/or patient representative concern regarding violation of a patient’s rights, quality of care, and other complaints involving the patient’s treatment stay. Utilization of this grievance procedure is not a prerequisite to the pursuit of other remedies - at all times, patients have free and unrestricted access to the Mental Health Advocate organization in each state. Definitions: Complaint - An expression of dissatisfaction, however made, about the standard of service, actions or lack of action by staff or regarding the facility and is resolved by staff present at the time the complaint is made, requiring no further resolution. Grievance - A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient’s rights. Procedure: Grievance Procedures 1. The Patient Advocate logs the grievance allegation onto the “Complaint/Grievance Log” and contacts the patient, or patient representative, and opens an investigation to determine the validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. If the grievance is regarding an allegation of abuse or neglect, the appropriate state mandatory guidelines for reporting will be followed. Role of the Administrator 1. Ensure appropriate policies and procedures are followed for grievances alleging abuse and neglect of patients.” Review of Patient #3’s medical record revealed he was admitted to the hospital on 04/26/2025 at 1:30 PM from a nearby hospital for substance abuse. Review of the hospital incident report regarding Patient #3 dated 04/27/2025 at 3:15 AM by S10RN revealed in part: CASE INFORMATION: Occurrence Type: Incident Category: Aggression Severity: Unsafe Condition Location: Nursing Station Cause: N/A Length of Stay Prior to Occurrence: 1 day Notifications: S6MD - Attending Physician on 04/27/2025 at 3:24 AM S8DON - Director of Nursing on 04/27/2025 at 3:34 AM S4ACEO - Administrator on 04/27/2025 at 4:10 AM Other Witnesses: S12MHT S13MHT S11LPN INCIDENT REPORT INSTRUCTIONS: Category: Injury Brief factual description of the incident: 3:15 AM Patient #3 woke up from sleeping and came in the hallway cursing at staff and being aggressive. Staff asked Patient #3 what he needed and he said, “B*tch you know what I need.” Staff attempted to redirect but patient was undirectable. Another patient came in his face because she was upset about him causing a disturbance and called him a n*gga. He threatened to hit her so the medication nurse (S11LPN) opened the door and attempted to talk Patient #3 down, but he charged in the nursing station and started choking the medication nurse. Nurse and other staff ran out the nursing station from Patient #3 because he was too violent to control and would not leave. Police/DON/MD notified. Injury or Adverse Outcome: Other - Violent behavior/injury to staff Related Causes & Factors: Unprovoked act Actions Taken Post-Incident: MD notified, Supervisor notified, Discharged to Local Police Department Follow Up/Resolution (QD): MDN completed, MD notified, police contacted. Patient arrested. Follow Up/ Resolution (DON): On 04/27/2025, the medical record and video were reviewed collectively by S1COO; S2CLO; S3SVPO; S4ACEO and S5VPCO. Video review indicated patient rapidly escalated with no opportunity for staff to de-escalate. Staff retreated to nursing station for safety and continued attempts to verbally de-escalate the patient. The patient broke through the nursing station window and gained entrance into the nursing station through the window. The patient attempted to choke the LPN. 911 was called and law enforcement arrived to intervene. The patient began to fight with 5 law enforcement officers who finally arrested and removed the patient from facility. The physician was notified and provided AMA discharge orders for the patient. Two employees were sent to the emergency department for evaluation and treatment (LPN due to choked by patient and MHT who fell during event). During review of the incident, the individuals listed above analyzed and discussed reporting requirements and upon review of information provided in presentation at LHA meeting by LDH staff regarding self-reporting requirements and review of email clarification provided following the meeting, it was determined there was additional reporting requirement other that law enforcement related to workplace violence. Upon conclusion of incident review, it was determined there were no policy violations as the patient appropriately assessed for violence risk and was found to be a low risk requiring no violence related precautions and staff had no indication to expect the sudden, violent event that occurred. Following this review S8DON spoke with a patient witness who indicated the patient was unprovoked and there was no precipitating occurrence to this event and Patient #3 escalated rapidly without provocation. No additional actions required. Electronically Signed By: S10RN 04/27/2025 7:04 AM S5VPCO 04/28/2025 3:36 PM S7QD 04/29/2025 2:05 PM Review of the hospital’s Grievances & Complaints Log for 04/27/2025 revealed the following for Patient #3: Date Received: 04/27/2025 Type: Grievance Nature of Complaint/Grievance: Treatment, Patient #3’s mother filed regarding law enforcement being called on patient. Resolution: No actions deemed necessary. Date of Patient/Family Contact & Start of Investigation: 04/27/2025 Date Investigation Completed: 05/01/2025 Mail Date of Copy of Grievance Report/Letter to Patient/Family: 05/02/2025 Review of the Grievance Report Letter dated 05/02/2025 sent to the mother of Patient #3 following the investigation of her filed grievance revealed in part: “After you spoke with our administrator on 04/27/2025, we immediately began an investigation into your concerns. Based on your conversation via phone, the concerns you identified included feeling that your son was mistreated due to law enforcement being called during the incident with your son on 04/27/2025. You expressed feeling that law enforcement should not be involved due to this being a behavioral health facility.” No self-report was submitted related to the investigation of this grievance. On 05/05/2024 at 11:44 AM, a request was made to S7QD to review the video footage of the incident on 04/27/2025 at 3:15 AM, but it was no longer available to be viewed. Following, an interview was then conducted with S7QD regarding her viewing of the video footage. S7QD stated she viewed the video footage on 04/28/2025. She stated Patient #3 was seen on video coming out of his room and walking into dayroom B around 3:00 AM. She said it appeared like he had some paranoid behaviors because he was ripping the clipboard logs out of both of the MHT’s (S12MHT & S13MHT) hands who were seated in the day room. S7QD stated he was then seen talking with the nurse, S10RN who was also in the dayroom. S7QD stated there was no audio so she was unable to hear what was said, but it did appear he was yelling at S10RN. S7QD stated Patient #3 was then seen approaching the nurses’ station monitor box, where he began pounding on the window. S7QD stated inside the monitor box was the medication nurse, S11LPN and another MHT, S14MHT. S7QD stated S11LPN went to exit the monitor box in an attempt to deescalate Patient #3, but as soon as S11LPN opened the door, Patient #3 charged the Nurses’ station door gaining access to nurses’ station and began strangling S11LPN. S7QD stated she was unable to see inside the nurses’ station at the time Patient #3 had gained entry because there weren’t cameras in the monitor box, however she could see S10RN and the two MHTs (S12MHT &S13MHT) who were in the dayroom B run off the unit and into the lobby to call the local police department, DON and the MD about the situation. S7QD stated it wasn’t long after, S11LPN was seen exiting the nurses’ station with the S14MHT onto dayroom B and Patient #3 was seen exiting the nurses’ station through the opposite door placing himself on dayroom A. S7QD stated Patient #3 was then seen kicking the sliding window of the nurses’ station in and subsequently breaking it. Shortly after, S7QD stated 2 local police officers arrive to the facility and appear on camera entering the unit. Both officers attempt to take down Patient #3, but were unsuccessful. S7QD stated after multiple attempts and a struggle, Patient #3 was tased twice by the officers because the first time was unsuccessful resulting in him removing the taser darts immediately after being struck by them. S7QD stated in total the take down, struggle and tasing of Patient #3 with the officers took around 15-20 minutes before the local law enforcement officers were able to finally detain him safely and remove him from the facility, to which he was discharged and transported for booking to the local parish prison. S7QD stated she didn’t believe the incident was reported due to this being an incident where Patient #3 attacked staff unprovoked. On 05/05/2025 at 12:35 PM, an interview was conducted with S4ACEO, he stated based on an LDH presentation he had attended regarding work place violence submissions, he understood it to mean that if the patient initiated the violence towards the staff it is not to be reported and only law enforcement needed to be informed. He confirmed no self-report was submitted for potential abuse and/or neglect of the patient or for the grievance filed by Patient #3’s mother. On 05/06/2025 at 10:23 AM, an interview was conducted with S8DON. S8DDON stated she did not complete a self-report and was unaware if one was completed for this incident because she was not a part of the self-report process for the facility, but thought this would be the type of incident which would require a self-report.”

“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 provide a written letter describing the steps taken to investigate the patient’s claims for 1 (#1) of 1 reviewed patient records with an associated grievance (See Findings Tag A0123); 2) Failure to increase Patient #4’s observation level per hospital policy immediately following an incident where Patient #4 was the alleged perpetrator of a sexual assault (See Findings Tag A0144); 3) Failure to obtain a physician order for a physical hold and seclusion for Patient #1 (See Findings Tag A0154); and 4) Failure to document a one-hour face-to-face in 1 (#1) of 1 reviewed for restraint/seclusion initiation (See Findings Tag A0178).”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 50453 Based on policy review, record review, and interview, the hospital failed to provide the patient with a written notice of its decision regarding the resolution of a grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This deficient practice was evidenced by the failure to provide a written letter describing the steps taken to investigate the patient’s claims for 1 (#1) of 1 reviewed patient records with an associated grievance. Findings: A review of hospital policy No. RTS-04 titled, “Patient Grievance Process,” last revised 09/01/2024, revealed in part: “PROCEDURE: Grievance Procedures: 3. If the investigation is ongoing on the 7th day, an extension letter should be sent to the grievant with documentation confirming date of issuance. The extension letter should include the date the expected resolution will be completed and sent. 4. The Patient Advocate issues a final written response to the grievant by the 7th day, or no later than the date referenced on the extension letter, from the date of the grievance allegation, and will include: a. The name of the facility contact person. b. The steps taken on behalf of the person reporting to investigate the grievance. c. The results of the grievance process. d. The facility’s decision. e. The date of completion. f. The contact information to appeal the offered resolution. Role of the Administrator: 1. Ensure appropriate policies and procedures are followed for grievances alleging abuse and neglect of patients.” A review of the complaint and grievance log revealed a grievance listed involving Patient #1. The nature of the complaint/grievance revealed complaints from DCFS related to safety and treatment after Patient #1 was tased by a police officer while at facility. The grievance investigation was documented as completed on 01/30/2025. Review of the complaint and grievance log failed to reveal documentation that a written grievance letter was provided at the date of completion. In an interview on 03/25/2025 at 1:50 PM, S4DCS confirmed that a written grievance letter was not provided. S4DCS confirmed that she was “instructed not to send a written grievance letter by corporate quality because it was transparent” and the incident was reviewed in person with DCFS. S1DOQ confirmed that the hospital policy states a final written response is to be sent to the grievant.”

“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 record review and interview, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by failure to increase Patient #4’s observation level per hospital policy immediately following an incident where Patient #4 was the alleged perpetrator of a sexual assault. Findings: A review of hospital policy No. CS-44 titled, “Sexual Acting Out (SAO) Identification and Precautions,” effective date 12/19/2022, no last revision date, revealed in part: “PROCEDURE: Management of Sexual Incident: 1. Immediately separate patients involved in the alleged incident. Patients are either placed immediately on separate units if possible or on opposite sides of the same unit with increased observations for the alleged perpetrator until the investigation is completed and provider has completed evaluation. 4. Based on the incident, place the alleged perpetrator on 1:1 or LOS until the Provider completes a face to face evaluation of the patient to determine if the patient’s activities or behaviors are appropriate for a lower level of observation. Patients with alleged and observed sexual acting out behaviors will be assessed daily by the Physician to ensure appropriate level of care.” A review of the incident report involving Patient #4, revealed that Patient #4 was identified as the aggressor/perpetrator of a patient to patient sexual assault that occurred on 03/11/2025 at 2:00 PM. A review of Patient #4’s medical record revealed that the patient was admitted on 03/07/2025 and orders for Q15 minute observations were initiated. Patient #4’s medical record failed to reveal orders for increased observation levels following the sexual assault incident that occurred on 03/11/2025. Further review failed to reveal that a provider completed a face-to-face evaluation of Patient #4 after being identified as the alleged perpetrator in the sexual assault incident. Review of the Nursing Assignment Sheets revealed the following: 03/11/2025 for 7:00 AM-7:00 PM, both Patient #3 and Patient #4 assigned to the room a. 03/11/2025 for 7:00 PM-7:00 AM, Patient #3 remained assigned to room a and the second bed was marked as blocked. Patient #4 was reassigned to room b with female Patient #R1. 03/12/2025 for 7:00 PM-7:00 AM, Patient #4 was assigned to room b and the second bed was marked blocked. In an interview on 03/24/2025 at 1:30 PM, S3ADM confirmed that Patient #4 was identified as the aggressor/perpetrator in the sexual assault incident. S3ADM also confirmed that Patient #4 was moved to room with Patient #R1 with no additional precautions or interventions to prevent Patient #4 from also assaulting Patient #R1. In an interview on 03/24/2025 at 1:44 PM, S1DOQ confirmed that Patient #4 was placed in room b with Patient #R1 following the sexual assault incident. In an interview on 03/25/2025 at 2:34 PM, S1DOQ confirmed that there were no observation orders for 1:1 or LOS after Patient #4 was identified as the perpetrator of an alleged sexual assault as per policy. S1DOQ also confirmed that Patient #4 remained on Q15 minute observations until discharge on 03/13/2025.”

“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 patients had the right to be free from restraints. This deficient practice was evidenced by the hospital failing to obtain a physician order for a physical hold and seclusion for Patient #1. Findings: A review of hospital policy No. NSG-71, titled, “Seclusion and Restraints- LA/MS/OK,” last revised 05/01/2024, revealed in part: “Definitions: Restraint: Any manual method, physical 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. Physical Holding for Forced Medications: The application of force to physically hold a patient, in order to administer a medication against the patient’s wishes, is considered a restraint. The use of force in order to medicate a patient must have a physician’s order prior to the application of restraint (use of force). If physical holding for forced medication is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also apply. Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. PROCEDURE: 1. Initiation: The physician/NPP will be notified as soon as possible after the initiation of seclusion and/or restraint. The RN will document physician/NPP contact and physician order on Physician Order for Seclusion and Restraint Form. For facilities with electronic medical record (EMR), the physician or NPP will directly enter the physician’s order into the EMR. Any verbal orders for initiation of seclusion or restraint will be authenticated within the timeframe specified by state requirements.” Review of Patient #1’s medical record revealed an admission date of 01/17/2025 with an admitting diagnoses of Intermittent Explosive Disorder, ADHD, and Autism Spectrum Disorder/Intellectual Disability. Review of Patient #1’s Seclusion and Restraint Packet for 01/17/2025 revealed the following: Seclusion/Restraint Type: Physical Restraint: Date/Time In: 01/17/2025 at 4:20 PM; Date/Time Out: 01/17/2025 at 4:20 PM Seclusion: Date/Time In: 01/17/2025 at 4:30 PM; Date/Time Out: 01/17/2025 at 5:00 PM Review of Patient #1’s Seclusion and Restraint Packet for 01/18/2025 revealed the following: Seclusion/Restraint Type: Physical Restraint: Date/Time In: 01/18/2025 at 9:00 AM; Date/Time Out: 01/18/2025 at 9:00 AM Seclusion: Date/Time In: 01/18/2025 at 1:10 PM; Date/Time Out: 01/18/2025 at 1:30 PM Review of Patient #1’s medical record failed to reveal orders for a physical restraint initiated on 01/17/2025. Review of Patient #1’s medical record failed to reveal orders for seclusion initiated on 01/18/2025. In an interview on 03/25/3035 at 9:20 AM, S1DOQ confirmed the above mentioned findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50453 Based on record review and interview, the psychiatric hospital failed to ensure a one-hour face-to-face assessment was performed with the initiation of restraint/seclusion. The deficient practice is evidenced by failure to document a one-hour face-to-face in 1 (#1) of 1 reviewed for restraint/seclusion initiation. Findings: A review of hospital policy No. NSG-71, titled, “Seclusion and Restraints- LA/MS/OK,” last revised 05/01/2024, revealed in part: “Definitions: Restraint: Any manual method, physical 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. Physical Holding for Forced Medications: The application of force to physically hold a patient, in order to administer a medication against the patient’s wishes, is considered a restraint. The use of force in order to medicate a patient must have a physician’s order prior to the application of restraint (use of force). If physical holding for forced medication is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also apply. Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. PROCEDURE: 4. Face-to-Face Evaluation: A one-hour face-to-face patient evaluation must be conducted in person by a physician or other NPP, or trained RN in the absence of the physician or NPP. Conduct a one hour face-to-face, if trained to do so, even if patient is no longer in restraint/seclusion and physician is not present.” Review of Patient #1’s medical record revealed an admission date of 01/17/2025 with an admitting diagnoses of Intermittent Explosive Disorder, ADHD, and Autism Spectrum Disorder/Intellectual Disability. Review of Patient #1’s Seclusion and Restraint Packet for 01/17/2025 revealed the following: Physical Restraint: Date/Time In: 01/17/2025 at 4:20 PM Seclusion: Date/Time In: 01/17/2025 at 4:30 PM One Hour Face to Face Evaluation: Date/Time: 01/17/2025 at 6:00 PM Review of Patient #1’s Seclusion and Restraint Packet for 01/18/2025 revealed the following: Seclusion/Restraint Type: Physical Restraint: Date/Time In: 01/18/2025 at 9:00 AM Seclusion: Date/Time In: 01/18/2025 at 1:10 PM One Hour Face to Face Evaluation: Date/Time: 01/18/2025 at 2:30 PM In an interview on 03/25/3035 at 9:24 AM, S1DOQ confirmed the one-hour face-to-face evaluation was not completed within one hour of the initiation of restraint/seclusion on 01/17/2025 or 01/18/2025 for Patient #1.”

“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: 1) failure to accurately self-report an incident which involved 2 juvenile patients being tased by law enforcement; and 2) failure to accurately self-report the actions taken following the sexual assault of a patient. Findings: A review of hospital policy No. QAPI-004 titled, “Incident Reporting,” last revised 08/01/2024, revealed in part: “Information to Provide in the Incident Report: 1. The Incident Report shall be limited to factual statements (who, what, where, and when) related to the pateitn safety incident and any interventions take to reduce the risk of future incidents and promote safety.” 1) Failure to accurately self-report an incident which involved 2 juvenile patients being tased by law enforcement. Review of the medical record for Patient #1 revealed an admission date of 01/17/2025 with an admitting diagnoses of Intermittent Explosive Disorder, ADHD, and Autism Spectrum Disorder/Intellectual Disability. Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report finalized on 01/30/2025 revealed the following documentation: Incident type documented as: Workplace violence Date/Time Incident: 01/25/2025 at 10:30 AM Patient Information documented on report included: Patient #1 and Patient #2 documented as both being aggressor Video Surveillance information documented on report included: Video surveillance at incident site: yes What was revealed on video? Answer: Patient #1 came out of a room and entered another patient’s room. Patient #1 was redirected into the hallway by one of the MHT’s. Multiple staff members assisted in medicating the patient. Staff continued to attempt to maintain control of the patient in a safe manner unsuccessfully. Patient #1 then goes into her room briefly before attempting to enter another patient’s room. As Patient #1 was guided to the hallway, by multiple staff members, she began running at nurse and swinging her hands at nurse. Multiple staff members attempted to get control of Patient #1. Patient #1 is seen kicking, fighting and biting at staff. After an extended period of exchange, police arrived on the scene and assumed control of the situation with Patient #1. Incident details revealed in part: Law enforcement arrived at approximately 11:30 AM. Patient continued to attempt to attack officer, officer then tased Patient #1. Patient #1 went back down hall while officer was dealing with another peer. Patient transferred to ER for medical evaluation. Comments documented on report included: The hospital immediately initiated an investigation. The investigations included a review of video, medical records and interview of staff. The investigation found that the patient had made multiple attempts to harm the staff and other patients. Staff made every effort to maintain safe control of the patient despite Patient #1’s continuous refusal to comply or to behave safely. No policy violations were discovered and staff worked in accordance with Oceans’ workplace violence plan. Investigation Results: Was the allegation substantiated, unsubstantiated, or unable substantiate due to lack of evidence? Answer: N/A The report failed to reveal that Patient #2 was also tased by the officer. On 03/24/2025 at 1:51 PM, a review of video footage navigated by S1DOQ of the incident involving Patient #1 and Patient #2 on 01/25/2025 revealed in part: 11:22 AM- Officer enters unit. 11:23 AM- Patient #1 swinging arms at officer. 11:23:50 AM- Officer tases Patient #1. 11:24 AM- Patient #2 runs down hall to Patient #1 and starts removing taser prongs from Patient #1. 11:25 AM- Officer deploys his taser at Patient #2 at least 3-4 times. In an interview on 03/24/2025 at 2:10 PM, S1DOQ confirmed that the video footage revealed that both Patient #1 and Patient #2 were tased by the officer. S1DOQ also confirmed that the self-report was not reported “appropriately” and did not include all the details of the incident. 2) Failure to accurately self-report the actions taken following the sexual assault of a patient. Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report finalized on 03/17/2025 revealed the following documentation: Incident type documented as: Alleged Neglect: Patient to Patient Sexual Assault Date/Time Incident: 03/11/2025 at 2:00 PM Location of incident: Patient Room Patient Information documented on report included: Patient #3 as Victim Patient #4 as Aggressor Video Surveillance information documented on report included: Video surveillance at incident site: yes What was revealed on video? Answer: Video review revealed that the patients were in and out of their room numerous times during the time frame of alleged sexual abuse. Although we cannot determine the exact time of the alleged abuse occurring, or substantiate that the alleged abuse occurred, based on video review we can speculate that the alleged incident occurred between 2:11 PM (the time of the MHT round) and 2:22 PM (when Patient #4 exits the bedroom and goes to the bathroom). Incident details revealed in part: After the afternoon patient rest period, Patient #3 reported that while in their assigned room, Patient #4 pushed her against the wall and “fingered” her crotch at about 2:00 PM. Initial Actions Taken: Patients were separated, and rooms were blocked. Patient #3 was assessed for harm and patients involved in the incident were interviewed. Comments documented on report included: The hospital immediately initiated an investigation, which included a review of video, medical records and staff interviews. Based on video review, it was determined that the staff rounded on patients appropriately, based on their ordered level of observation. Medical record review did not indicate a history of sexually inappropriate behavior for either patient, nor did either score as “at risk” for sexually acting out on admission, but did indicate that Patient #4 has a history of reporting sexual abuse. However, Patient #4 is reported to be the aggressor in this case. Patients both maintain their original statements, in which Patient #3 alleged sexual abuse and Patient #4 reports consensual inappropriate sexual behavior. Investigation Results: Was the allegation substantiated, unsubstantiated, or unable substantiate due to lack of evidence? Answer: The allegation of abuse is unable to be substantiated due to lack of evidence. Review of the Nursing Assignment Sheets for 03/10/2025 - 03/12/2025 revealed the following: 03/11/2025 for 7:00 AM-7:00 PM, both Patient #3 and Patient #4 assigned to the room a. 03/11/2025 for 7:00 PM-7:00 AM, Patient #3 remained assigned to room a and the second bed was marked as blocked. Patient #4 was reassigned to room b with female Patient #R1. 03/12/2025 for 7:00 PM-7:00 AM, Patient #4 was assigned to room b and the second bed was marked blocked. The report failed to reveal that Patient #4 (the aggressor) was moved into a room with another female patient without additional measures to ensure the safety of the other occupant of the room, Patient #R1. In an interview on 03/24/2025 at 1:30 PM, S3ADM stated that they did not have the availability at the time of the incident to provide separate rooms for both Patient #3 and Patient #4. S3ADM confirmed that Patient #4 was identified as the aggressor in the incident, and confirmed that she was placed in another room with Patient #R1. In an interview on 03/24/2025 at 1:44 PM, S1DOQ stated the self-report was “misleading” and verified that it was documented in the self-report that the patients were separated and rooms were blocked. S1DOQ confirmed that Patient #4 was placed in room b with Patient #R1, and not in a blocked room as reported in the self-report.”

“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 a registered nurse (RN) supervised the care for each patient. This deficient practice is evidenced by failing to immediately address any clinical assessments on Patient #3 following a sexual assault. Findings: A review of hospital policy No. AS-18 titled, “Assessment and Reporting of Abuse, Neglect, Exploitations,” last revised 10/01/2024, revealed in part: “PROCEDURE: Procedure to Respond to Alleged or Suspected Abuse, Neglect, Exploitation by Facility staff (employed or contracted) or by another patient: 2. If the allegation involves another patient or an employed or contracted staff member of the facility, the Administrator/Administrator-on-Call are responsible to ensure a thorough investigation is performed and will respond immediately to address any clinical assessments and ensure the provision on any clinical interventions necessitated by the circumstances and perform an investigation to determine if the allegations are substantiated.” A review of hospital policy No. RTS-01 titled, “Patient Rights,” last revised 09/01/2023, revealed in part: “Rights of Minors: R. A minor patient admitted to a treatment facility has the right to have available such treatment as is medically appropriate to his condition. S. Each minor patient shall have the right to receive prompt and adequate medical treatment for any physical ailments and for the prevention of any illness or disability. Such medical treatment shall meet the standards of medical practice in the community.” A review of the incident report involving Patient #3, revealed that Patient #3 was identified as the victim of a patient to patient sexual assault that occurred on 03/11/2025 at 2:00 PM. A review of Patient #3’s medical record revealed that she was admitted on 03/05/2025. Patient #3 was placed on a PEC on 03/05/2025 and on 03/07/2025 a CEC was completed. Patient #3 was deemed as dangerous to self and gravely disabled. A review of Patient #3’s progress note from 03/11/2025 at 4:00 PM documented by S2ADON revealed in part the following: Patient #3 verbalized to S6MHT that her roommate (Patient #4) had sexually assaulted her. Patient #3 was brought to the Nurses desk for privacy to discuss this allegation. Patient #3 states, my roommate, “pushed me against the wall and fingered me.” Patient #3 further explains that she did not want this to happen and that she was discussing clothing with her roommate prior to this incident. Patient #3 has no contusions or abrasions and denies any injury. Patient #3 further denies pain or discomfort in any area of her body. Actions: Separated Patient #3 from Patient #4. Notified guardian who does not wish to press charges. Notified Nursing supervisors. Notified S13MD- no orders given. Patient #3 was discharged home on 03/12/2025 at 3:04 PM. Review of Patient #3’s medical record failed to reveal documentation that Patient #3 was evaluated by a provider prior to being discharged home following the sexual assault. In an interview on 03/25/2025 at 1:05 PM, S1DOQ confirmed that there was no documentation of an evaluation being completed by a provider following the sexual assault incident. S1DOQ also confirmed that there was no documentation by a provider regarding the sexual assault incident prior to discharge the following day. In an interview on 03/25/2025 at 1:35 PM, S2ADON confirmed that she was the nurse who cared for Patient #3 following the sexual assault on 03/11/2025. When asked if she visualized any contusions or abrasions as documented in her assessment, S2ADON stated that she did not remove Patient #3’s clothing to perform an assessment. S2ADON further stated “it was just 2 fingers.” S2ADON confirmed that she did not perform an assessment on Patient #3 following the sexual assessment and her findings were based on what she was told by Patient #3 while investigating the incident.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure the patient or his or her representative had the right to make informed decisions regarding his or her care. This was evidenced by: 1) failure to have signed consents for treatment and patient rights for 1 (#1) of 6 (#1-#6) patients reviewed for signed consents upon hospital admission; and 2) failure to have signed consents to transfer patient prior to leaving the hospital for higher level of care for 3 (#1, #2 & #4) of 3 (#1, #2 & #4) patients reviewed for signed transfer consents. Findings: Review of the hospital’s policy number RTS-11 titled “Informed Consent, Care Decisions, and Conflicts Resolutions” last revised on 11/01/2024 revealed in part: “Purpose: To outline the responsibility of the facility in establishing a mutual understanding between the patient/patient’s family/representative and the facility about patient services received. To involve patients and significant others, when appropriate, in care decisions, conflict resolution, and the informed consent process. Policy: The facility recognizes the benefit and the need to involve patients and significant others, when appropriate, in care, treatment and service decisions, conflict resolution, and to ensure that appropriate informed consent is obtained as outlined by the State, Federal and other regulatory bodies. Procedure: Informed Consent - 2. The facility will ensure that during the admission process and at any point, as necessary, in the patient’s stay each patient/patient’s family, if indicated will receive the following: - Explanation of care, services and treatment being offered. - Discussion of reasonable alternatives and the risks, benefits and side effects to such care. - Explanation of the relevant risks, potential benefits, and side effects of proposed care, including the possible results of not receiving care, treatment, and services. 3. The facility will, during the admission process, obtain signature on informed consent forms. Patient signatures may be obtained by handwritten signature or digitized signature which is an electronic image of an individual’s handwritten signature reproduced using a signature pad. If the patient is unable to sign due to physical impairments, verbal consent can be obtained and documented with two witnesses. In the case of involuntary admission, the facility will follow the policies of the organization related to involuntary admission.” Review of the hospital’s policy number NSG-24 titled “Transfer of a Patient to an Acute Care Facility” last revised on 10/01/2024, revealed in part: “Purpose: To maintain the continuity of patient care by communicating to the receiving facility with appropriate information. To comply with regulatory guidelines regarding patient transfer. Policy: If the Hospital is unable to adequately meet a patient’s needed, a physician may order a transfer to a more appropriate facility. It is a patient’s right to request transfer to another facility. Appropriate transfer and referrals are made if this facility cannot meet a patient’s needs and keeping the patient may jeopardize their well-being. This policy applies to patients transferred to another psychiatric hospital or short-term acute care facility.” 1) Failure to have signed consents for treatment and patient rights for 1 (#2) of 6 (#1-#6) patients reviewed for signed consents upon hospital admission. Review of Patient #2’s medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM from an outside referring hospital’s emergency department for Psychosis Aggression with secondary diagnoses of Mild Mental Retardation with an I.Q. of 50-70; Bipolar Type 1 Disorder; Dementia with Mood Disturbances; and Oppositional Defiant Disorder. Review of Patient #2’s admission packet revealed no signed consent for treatment or review of patient rights. There was also no documentation by staff Patient #2 had refused to sign or was unable to sign at the time of her admission. On 03/05/2025 at 1:45 PM, an interview was conducted with S5QA during patient chart review. She confirmed Patient #2 did not have a signed consent for treatment or review of patient rights in her chart along with no staff documentation Patient #2 had refused to sign or was unable to sign at the time of her admission. She further confirmed Patient #2 should have had these signed consents or staff documentation in their place. 2) Failure to have signed consents to transfer patient prior to leaving the hospital for higher level of care for 3 (#1, #2 & #4) of 3 (#1, #2 & #4) patients reviewed for signed transfer consents. Patient #1 Review of Patient #1’s medical record revealed she was admitted to the hospital on 12/10/2024 at 7:45 PM from an outside referring hospital’s emergency department for dementia with behavioral disturbances. Review of Patient #1’s consents revealed staff documentation on 12/10/2024 at 8:04 PM of “Patient Refused” to sign consent for treatment which included the consent to transfer for the duration of her admission to the facility. No additional consents for transfers were found in her chart. Review of Patient #1’s Physician’s Orders for December 2024 revealed in part: 12/14/2024 Transfer patient to local hospital emergency department s/p unwitnessed fall 12/15/2024 Transfer patient to local hospital emergency department s/p unwitnessed fall 12/17/2024 Transfer now for fall 12/18/2024 Transfer now Patient #1 had stitches seemingly break open Review of Patient #1’s Nursing and Medical Progress Notes dated 12/14/2024, 12/15/2024, 12/17/2024, and 12/18/2024 revealed no documentation of discussion with Patient #1 and/or representative of the need for being transferred, risk vs. benefits of being transferred and the possible outcome if not being transferred to a higher level of care for evaluation and possible treatment following a fall with head injury. Nurse documentation did reveal notification to representative of the transfer however. Patient #2 Review of Patient #2’s medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM from an outside referring hospital’s emergency department for Psychosis Aggression with secondary diagnoses of Mild Mental Retardation with an I.Q. of 50-70; Bipolar Type 1 Disorder; Dementia with Mood Disturbances; and Oppositional Defiant Disorder. Review of Patient #2’s consents revealed no signed consent for transfer to another facility. There was also no documentation by staff Patient #2 had refused to sign or was unable to sign at the time of her admission. Review of Patient #2’s Physician’s Orders for January 2025 revealed in part: 01/15/2025 Transfer patient to local hospital’s emergency room due to fall 01/20/2025 Patient transferred to local hospital’s emergency room due to decreased level of consciousness and possible aspiration Review of Patient #2’s Nursing and Medical Progress Notes dated 01/20/2025 revealed no documentation of discussion with Patient #2 and/or representative of the need for being transferred, risk vs. benefits of being transferred and the possible outcome if not being transferred to a higher level of care for evaluation and possible treatment following a fall with head injury. Patient #4 Review of Patient #4’s medical record revealed he was admitted to the hospital on 02/13/2025 at 8:15 PM from an outside referring hospital’s emergency department for Suicidal Ideations and Dementia. Review of Patient #4’s consents revealed he signed his consent for treatment, which included consent for transfer upon admission to the facility on 02/14/2025, but no time was documented. No additional consents for transfer were found in his chart. Review of Patient #4’s Nursing Note dated 02/14/2025 at 6:51 AM revealed “Notified S6NP to transfer to ER for evaluation.” Further review revealed nurse notified family member of incident and transfer to local hospital emergency department, however no documentation of discussion with Patient #4 and/or representative of the need for being transferred, risk vs. benefits of being transferred and the possible outcome if not being transferred to a higher level of care for evaluation and possible treatment following a fall with head injury was found. On 03/03/2025 at 11:51 AM, an interview was conducted with S1QD. She stated the consent for transfer was completed during the admission process to the facility, and no additional transfer consents were completed during a patient’s hospitalization if they were to require transfer to an outside acute care facility for further evaluation and/or additional treatment. She stated all transfers are considered emergent in nature which is why the patient is being transferred to a higher level of care.”

“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: 48537 Based on record review and interviews, the hospital failed to ensure initial reports of allegations of patient abuse/neglect of care were reported to Louisiana Department of Health within 24 hours of awareness of the allegation, as required by LDH-HSS, for 2 (#1 & #4) of 3 (#1, #2, & #4) patients reviewed for falls with injury requiring transfer to an outside facility for further evaluation and treatment. Findings: Review of the State law R.S. 40:2009.20 revealed “Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses’ aide, personal care attendant, respite worker, physician’s assistant, physical therapist, or any other healthcare giver having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within 24 hours, submit a report to the department or local law enforcement agency of such abuse or neglect.” Review of the hospital’s Self-Report Log for December 2024 to March 2025 revealed no self-reports for any patients with falls with injury requiring transfer to an outside facility for further evaluation and/or treatment and specifically did not reveal any reports for Patients #1 or #4. Patient #1 Review of the hospital’s Incident Reports revealed the following: On 12/15/2024 at 3:10 AM, Patient #1 sustained an unwitnessed fall in the common area which resulted in a laceration to the right side of her scalp with a hematoma and a hematoma and bruising to her right shoulder. Patient #1 was transferred by ambulance to outside facility for emergent evaluation and treatment. Review of Patient #1’s discharge paperwork dated 12/16/2024 from the outside facility she was transferred to for evaluation and subsequently admitted to the ICU for treatment of a traumatic subdural hemorrhage without loss of consciousness, a broken right clavicle bone and multiple bruises and contusions on her upper left and right extremities, right shoulder and right temporal/frontal scalp area with a laceration. Patient #1 was discharged and returned to this hospital via local ambulance transport on 12/16/2024 in stable condition. Patient #4 Review of the hospital’s Incident Reports revealed the following: On 02/14/2025 at 5:55 AM, Patient #4 sustained an unwitnessed fall in his room which resulted in an approximately 4 cm in length laceration to the middle of Patient #4’s forehead. Patient #4 was immediately transferred by ambulance to an outside facility for emergent evaluation and treatment. Review of Patient #4’s discharge paperwork dated 02/25/2025 from the outside facility he was transferred to for evaluation and subsequently admitted to for surgical intervention for placement of an odontoid screw for the treatment of a C2 odontoid fracture as a result of the fall. Patient #4 did not return to this hospital. On 03/05/2025 at 3:00 PM, an interview was conducted with S1QD. She stated both Patients #1 and #4 sustained injuries related to their falls while admitted. She stated it was not hospital practice to report falls with injury to LDH-HSS, however both incidents had internal RCA investigations ongoing. S1QD confirmed both Patient #1 and #4’s falls were unwitnessed which resulted in head injuries.”

“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: 48537 Based on record review and interview the facility failed to thoroughly analyze all adverse patient events and implement preventive actions. The deficient practice is evidenced by: 1) failure to accurately complete fall assessments upon admission to the hospital and post fall reassessments for 6 (#1-#6) of 6 (#1-#6) patients evaluated for admission and post fall (re)assessments; and 2) failure to re-educate staff on implementation of preventive measures and documentation of the use of those measures for each patient on fall precautions. Findings: Review of the hospital’s policy number AS-12 titled Fall Assessment/Re-Assessment and Precautions, last revised on 11/16/2022 revealed in part: “Purpose: To screen patient’s potential for falling and decrease the risk of injury. Policy: Inpatient 1. All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall, or change in mobility status, and/or every 7 days if identified as “at risk for falls”. 2. In the event of a fall occurrence, patients will be re-assessed and additional fall prevention interventions will be implemented. 3. The Registered Nurse (RN) utilizing the Fall Risk criteria on the Fall Risk Assessment Tool will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated. Procedure: Inpatient 1. The admitting RN shall complete an initial assessment within 8 hours of patient’s admission, evaluates patient’s ambulatory status and completes Fall Risk criteria. If a Fall Risk Score indicates the patient is “at risk for falls,” the immediate initiation of fall precautions will occur. 2. If a patient scores as “at risk for falls” during the initial nursing assessment, a Treatment Plan to address the risk for falls will be initiated by the RN. 3. Criteria may be used to determine fall risk: -Age; Mental Status; Elimination; Medications; Diagnoses; Ambulation/Balance/Mobility Devices/Use of Assistive Devices; Nutrition; Sleep Disturbances; History of falls 4. The patient shall be re-assessed by the RN for fall risk at a minimum of every 7 days, immediately after a fall, and as needed based on patient’s condition. 5. Interventions shall include: -Mandatory fall precautions - Interventions for “at risk for falls” (must implement ALL): *Apply yellow fall risk arm band *Provide nonskid slipper socks or ensure appropriate skid-proof footwear is used *Provide patient education *Initiate Fall Risk treatment plan -Additional fall precautions - (must select at least 2 additional interventions from list that are appropriate to the patient’s individual needs): *Bed alarm *Chair alarm *Ambulate with staff assistance *Ensure assistive devices (ex: eyeglasses, hearing aids) are available *Keep pathways clear *Line of Sight observation level *1:1 observation level *Reclining Chair *Assist with ADL’s 6. Post fall interventions shall include: -RN physical assessment of the patient; Obtain vital signs including pain assessment; Initiate neurological assessment if fall was unwitnessed or if fall resulted in head injury; Notify Physician/Non-physician practitioner (NPP) and ER orders as needed; Conduct a re-assessment of fall risk using the fall risk tool; Implement secondary fall prevention interventions from the additional precautions interventions list and update Fall Risk related Treatment Plan with individualized interventions; Complete Post-Fall Checklist 7. General Guidelines for Patient Safety: -Patient Bed/Room Measures: Keep bed in low position; Keep bed in locked position; Use bed alarms/chair alarms as appropriate; Provide bell at bedside; Leave bathroom light on; Use manufacturer low bed whenever possible. -Ambulation Safety Measures: Eliminate environmental hazards (remove wastebaskets, other items from the path between patient’s bed & doorways); Instruct patient to wear shoes with non-skid soles or provide patient with non-skid footwear; Instruct patient to ask for assistance if feeling weak, dizzy, or light-headed; Instruct patient to notify staff of any spills; Offer frequent toileting; Attempt to relocate patient near nurses’ station as appropriate (for fall or repeat fall); Keep ambulatory devices (walker, cane, wheelchair) within reach; Provide appropriate ROM exercises to include balancing and strengthening. 8. An incident report will be completed in its entirety and forwarded to the DON after every fall. 1) Failure to accurately complete fall assessments upon admission to the hospital and post fall reassessments for 6 (#1-#6) of 6 (#1-#6) patients evaluated for admission and post fall (re)assessments. Patient #1 Review of Patient #1’s medical record revealed she was admitted to the hospital on 12/10/2024 at 7:45 PM from an outside referring facility’s emergency department for Dementia with Behavioral Disturbances. Review of Patient #1’s Incident Reports revealed in part: Date/Time: 12/14/2024 at 7:10 PM Incident Type: Multiple unwitnessed falls in common area Injuries: Small skin tear to right elbow, bruising to left shoulder Post fall assessment was completed prior to transfer to an outside facility emergency department for further evaluation. Date/Time: 12/15/2024 at 3:48 AM Incident Type: Unwitnessed fall in common area Injuries: Laceration to right side of scalp and hematoma noted as well as hematoma and bruising noted to right shoulder No post fall assessment was completed prior to transfer to an outside facility emergency department for further evaluation. Date/Time: 12/17/2024 at 4:28 AM Incident Type: Unwitnessed fall from geri chair Injuries: Laceration to left forehead No post fall assessment was completed prior to transfer to an outside facility emergency department for further evaluation. Review of Patient #1’s Fall Risk Assessments revealed in part: Date/Time of Assessment: 12/10/2024 at 9:18 PM Type of Assessment: Admission Fall Assessment Mental Status: Confusion/Disorientation Elimination: Independent with control of bowel/bladder Medications: Cardiac Medications Diagnosis: Dementia/Delirium Ambulation/Balance: Unsteady/Requires Assist and Aware of Abilities History of Falls: No history of falls Assessment Total Score: 98 Electronically Signed by: S7RN Date/Time of Assessment: 12/14/2024 at 10:05 PM Type of Assessment: Post Fall Assessment Mental Status: Agitation/Anxiety; Confusion/Disorientation Elimination: Elimination with Assist; Altered elimination (incontinence, nocturia, frequency) Medications: Cardiac Medications; Psychotropic Medications (including benzodiazepines and antidepressants) Diagnosis: Dementia/Delirium Ambulation/Balance: Unsteady but Forgets Limitations History of Falls: History of falls in the last 3 months Assessment Total Score: 145 Electronically Signed by: S8RN Date/Time of Assessment: 12/17/2024 at 5:23 PM Type of Assessment: Post Fall Assessment Mental Status: Confusion/Disorientation Elimination: Altered elimination (incontinence, nocturia, frequency) Medications: Cardiac Medications; Psychotropic Medications (including benzodiazepines and antidepressants) Diagnosis: Dementia/Delirium Ambulation/Balance: Unsteady/Requires Assist and Aware of Abilities; Unsteady but Forgets Limitations History of Falls: History of falls in the last 3 months Assessment Total Score: 127 Electronically Signed by: S8RN On 03/06/2025 at 12:28 PM, an interview was conducted with S1QD. She confirmed post fall reassessments were not completed for Patient #1 after her fall on 12/15/2024 and 12/17/2024 and should have been. Patient #2 Review of Patient #2’s medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM for Psychosis Aggression with secondary diagnoses of Mild Mental Retardation with an I.Q. of 50-70; Bipolar Type 1 Disorder; Dementia with Mood Disturbances; and Oppositional Defiant Disorder. Review of Patient #2’s Incident Reports revealed in part: Date/Time: 01/15/2025 at 1:25 AM Incident Type: Fall Injuries: Patient #2 denies hitting her head and had no obvious injuries noted Post fall assessment was not completed. Date/Time: 01/15/2025 at 3:50 PM Incident Type: Fall Injuries: Small hematoma to posterior, left side Post fall assessment was not completed prior to transfer to outside facility emergency department for further evaluation. Date/Time: 01/16/2025 at 2:55 AM Incident Type: Fall Injuries: None Post fall assessment was not completed. Review of Patient #2’s Fall Risk Assessments revealed in part: Date/Time of Assessment: 01/15/2025 at 11:32 AM Type of Assessment: Admission Fall Assessment Mental Status: Agitation/Anxiety; Confusion/Disorientation Elimination: Elimination with Assist Medications: Psychotropic Medications (Including Benzodiazepines and antidepressants) Diagnosis: Major Depressive disorder Ambulation/Balance: Proper use of Assistive Devises (cane, walker, w/c) History of Falls: History of falls in the last 3 months Assessment Total Score: 94 Electronically Signed by: S10RN On 03/06/2025 at 12:30 PM an interview was conducted with S1QD. She confirmed post fall reassessments were not completed for Patient #2 after either fall on 01/15/2025 or the fall on 01/16/2025 and should have been. Patient #3 Review of Patient #3’s medical record revealed she was admitted to the hospital on 02/26/2025 at 12:00 AM from an outside referring emergency department for Major Depressive Disorder. Review of Patient #3’s Incident Reports revealed in part: Date/Time: 02/26/2025 at 4:00 PM Incident Type: Fall Injuries: None visible and/or reported Post fall assessment was not completed. Review of Patient #3’s Fall Risk Assessments revealed in part: Date/Time of Assessment: 02/26/2025 at 4:15 AM Type of Assessment: Admission Fall Assessment Mental Status: Agitation/Anxiety; Intermittently Confused Elimination: Altered elimination (incontinence, nocturia, frequency) Medications: Psychotropic Medications (Including benzodiazepines and antidepressants) Diagnosis: Major Depressive disorder Ambulation/Balance: Proper use of Assistive Devices (cane, walker, w/c) History of Falls: History of falls in the last 3 months Assessment Total Score: 111 Electronically Signed by: S11RN On 03/06/2025 at 12:22 PM an interview was conducted with S1QD. She confirmed a post fall reassessment was not completed for Patient #3 after a fall on 02/26/2025 and should have been. Patient #4 Review of Patient #4’s medical record revealed he was admitted to the hospital on 02/13/2025 at 8:15 PM from an outside referring facility emergency department for Suicidal Ideations and Dementia. Review of Patient #4’s Incident Reports revealed in part: Date/Time: 02/14/2025 at 5:50 AM Incident Type: Fall Injuries: 4cm Laceration to middle of forehead Post fall assessment was not completed prior to transfer outside facility emergency department for further evaluation. Review of Patient #4’s Fall Risk Assessments revealed in part: Date/Time of Assessment: 02/14/2025 at 1:34 AM Type of Assessment: Admission Fall Assessment Mental Status: Intermittently confused Elimination: Independent with control of bowel/bladder Medications: Cardiac Medications Diagnosis: Dementia/Delirium Ambulation/Balance: Proper use of Assistive Devices (cane, walker, w/c) History of Falls: No history of falls Assessment Total Score: 93 Electronically Signed by: S12RN On 03/06/2025 at 12:20 PM an interview was conducted with S1QD. She confirmed a post fall reassessment was not completed for Patient #4 after his fall on 02/14/2025 and should have been. Patient #5 Review of Patient #5’s medical record revealed he was admitted to the hospital on 02/24/2025 at 6:15 PM from his nursing home for Schizoaffective Disorder. Review of Patient #5’s Incident Reports revealed in part: Date/Time: 03/05/2025 at 8:40 PM Incident Type: Unwitnessed fall Injuries: Old skin tears to bilateral arms, elbows and top of hands opened and bleeding; no additional injuries noted Post fall assessment was completed inaccurately. Review of Patient #5’s Fall Risk Assessments revealed in part: Date/Time of Assessment: 02/24/2025 at 11:02 PM Type of Assessment: Admission Fall Assessment Mental Status: Agitation/Anxiety; Intermittently Confused Elimination: Independent with control of bowel/bladder Medications: Psychotropic Medications (Including benzodiazepines and antidepressants) Diagnosis: Bipolar/Schizoaffective Disorder Ambulation/Balance: Independent/Steady gait/Immobile History of Falls: History of falls in the last 3 months Assessment Total Score: 106 Electronically Signed by: S13RN Date/Time of Assessment: 03/05/2025 at 2:07 AM Type of Assessment: Post Fall Assessment Mental Status: Intermittently confused Elimination: Altered elimination (incontinence, nocturia, frequency) Medications: No medications Diagnosis: Dementia/Delirium Ambulation/Balance: Unsteady/Requires Assist and Aware of Abilities History of Falls: History of falls in the last 3 months Assessment Total Score: 103 Electronically Signed by: S14RN On 03/06/2025 at 12:20 PM an interview was conducted with S1QD. She confirmed a post fall reassessment was completed for Patient #5 after his fall on 03/05/2025, however it was completed inaccurately by not indicating the accurate medication types and diagnosis types for Patient #5. She confirmed by correctly indicating the proper medication types he had been receiving and his additional diagnosis of schizoaffective disorder which he was admitted with, it would have increased his total fall risk assessment score. Patient #6 Review of Patient #6’s medical record revealed she was admitted to the hospital on 02/24/2025 at 7:15 PM from an outside referring facility’s emergency department for Psychosis. Review of Patient #6’s Incident Reports revealed in part: Date/Time: 03/03/2025 at 10:30 AM Incident Type: Witnessed fall in day room Injuries: None reported Post fall assessment was completed inaccurately. Review of Patient #6’s Fall Risk Assessments revealed in part: Date/Time of Assessment: 02/25/2025 at 4:26 AM Type of Assessment: Admission Fall Assessment Mental Status: Agitation/Anxiety; intermittently confused Elimination: Altered elimination (incontinence, nocturia, frequency); Incontinent by ambulates independently Medications: Cardiac Medications; Psychotropic Medications (Includes benzodiazepines and antidepressants) Diagnosis: Bipolar/Schizoaffective Disorder; Substance Abuse/Alcohol Abuse Ambulation/Balance: Independent/Steady gait/Immobile History of Falls: History of falls in the past 3 months Fall Risk Score: 90 or above Assessment Total Score: 124 Electronically Signed by: S11RN Date/Time of Assessment: Type of Assessment: Post Fall Assessment Mental Status: Intermittently confused Elimination: Independent with control of bowel/bladder Medications: Psychotropic Medications (Including benzodiazepines and antidepressants) Diagnosis: Bipolar/Schizoaffective Disorder; Substance abuse/Alcohol abuse Ambulation/Balance: Unsteady/Requires Assist and Aware of Abilities History of Falls: History of falls in the past 3 months Fall Risk Score: 89 or below Assessment Total Score: 87 Electronically Signed by: S15RN On 03/06/2025 at 12:20 PM, an interview was conducted with S1QD. She confirmed a post fall reassessment was completed for Patient #6 after her fall on 03/05/2025, however it was completed inaccurately by not indicating the accurate medication types and including the addition of PRN psychotropic medications received within the last 24 hours for Patient #6. She confirmed by correctly indicating the proper medication types she had been receiving and including the addition of the PRN psychotropic medications she had received within the prior 24 hours, it would have increased her total fall risk assessment score. 2) Failure to re-educate staff on implementation of preventive measures and documentation of the use of those measures for each patient on fall precautions. Review of the incident log revealed on 02/14/2025 Patient #4 slipped while leaving the restroom. Patient #4 was taken to an acute care hospital and diagnosed with cervical spine fracture. Review of the medical record for Patient #4 revealed admission on 02/14/2025. Review of the admission orders revealed Patient #4 was placed on fall precautions. Further review of the medical record revealed the patient did receive the required yellow band, but there was no documentation of initiation of any of the other preventive measures. On 03/05/2025 at 3:50 PM, an interview was conducted with S5QA who confirmed there was no documentation by the nurse that the patient was told to put the non-skid socks on his feet. S5QA confirmed the non-skid socks are routinely placed in the bucket that was given to patients at the time of admission. On interview at 03/06/2025 at 2:10 PM, S1QD confirmed she had watched the video of the incident and Patient #4 was not wearing his non-skid socks at the time of the fall. S1QD confirmed the facility was in the process of educating the nursing staff about the fall precautions, but the education did not focus on the documentation of implementation of the measures.”

“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: 48537 Based on record review and interviews, the hospital failed to ensure neuro checks were completed as ordered by the physician on 1 (#1) of 2 (#1 - #2) patients reviewed for a fall with head injury. Findings: Review of the hospital’s policy number NSG-02 titled, “Documentation” last revised on 01/01/2023, revealed in part: “Purpose: To maintain a comprehensive and chronologically continuous account of treatment delivered to a patient by nursing staff. To provide specific information regarding medications, treatments, and observations which reflects the care and progress of the patient. To increase communication among the various disciplines providing care to the patient. To provide concise and comprehensive information as a part of a legal document. Policy: Inpatient nursing personnel document patient’s progress every 12-hour shift, incorporating the elements of the nursing process and patient’s treatment goals and progress within the patient’s medical record. Nursing documents as a member of the multidisciplinary treatment team. Procedure: Inpatient - Routine 3. Documents the implementation and execution of physician and NPP orders.” Review of Patient #1’s medical record revealed she was admitted to the hospital on 12/10/2024 at 7:45 PM from an outside referring facility’s emergency room for dementia with behavioral disturbances. Review of Patient #1’s Physician’s Orders revealed in part: Neuro Checks Every Hour For 1 Day Start 12/17/2024 at 2:15 PM End 12/18/2024 at 1:15 PM Neuro Checks Every 2 Hours For 3 Days Start 12/19/2024 at 1:00 PM End 12/22/2024 at 11:00 AM Review of Patient #1’s Neurological Flow Sheets for 12/17/2024 to 12/22/2024 revealed in part: No neuro check documentation every hour from 12/17/2024 at 7:15 PM to 12/18/2024 at 1:15 PM. No neuro check documentation every two hours from 12/19/2024 at 1:00 PM to 12/20/2024 at 7:00 AM; from 12/20/2024 at 7:00 PM to 12/21/2024 at 7:00 AM; and from 12/21/2024 at 5:00 PM to 12/22/2024 at 11:00 AM. On 03/05/2025 at 11:50 AM, an interview was conducted with S5QA during patient record review. She confirmed Patient #1 had neuro checks ordered and were not completed during the above mentioned time frames and should have been.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needed. This deficient practice was evidenced by the failure to update the care plan of 1 (#2) of 6 (#1 - #6) patients reviewed for completed and updated care plans. Findings: Review of the hospital policy CS-02 titled, “Treatment Planning, Integrated/Multidisciplinary,” last revised on 07/01/2024 revealed in part: “Procedure: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. Policy: The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs and identified by the patient, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. Procedure: 2. The admitting nurse is responsible for the following: -Formulating the initial treatment plan based on physician’s orders/initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment, related measurement-based tools and family/significant other information within 24 of admit or sooner if patient’s needs warrants immediate action. -Implementing immediate treatment interventions for safety and stabilization of the patient. -Specifying and including at least one long or short-term individualized goal statement that identifies a specific and qualifying measurement-based tool that contributes directly to the patient’s plan of care and is directly related to the patient’s primary diagnosis. -Ensure that this preliminary plan of care addresses presenting needs. -Initiating individualizing treatment problem/nursing diagnosis list as identified in the assessment. -Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician’s orders. -Revising the plan based on changes in condition and physician’s orders. All physician’s orders will be incorporated into the Treatment Plan.” Review of Patient #2’s medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM from an outside referring facility’s emergency room with a primary diagnosis of psychosis aggression and secondary diagnoses of mild mental retardation (I.Q. 50-70); Bipolar Type 1; Dementia with Mood Disturbance and Oppositional Defiant Disorder. Review of Patient #2’s Physician’s Orders revealed the following medications in part: Depakote DR 500mg PO BID for Bipolar Lamictal 100mg PO BID for Bipolar Prozac 20mg PO Daily for anxiety Risperdal 3mg PO BID for Bipolar Seroquel 200mg PO BID for Bipolar Vistaril 50mg PO Q8H PRN for anxiety Review of Patient #2’s Medication Administration Record revealed Vistaril 50mg PO Q8H PRN for anxiety was administer on the following date and times: 01/16/2025 8:18 PM given; effectiveness documented at 01/16/2025 11:17 PM 01/17/2025 8:53 AM given; effectiveness documented at 01/17/2025 9:53 AM 01/17/2025 8:19 PM given; effectiveness documented at 01/17/2025 10:04 PM 01/18/2025 8:45 AM given; effectiveness documented at 01/18/2025 9:45 AM 01/18/2025 8:10 PM given; effectiveness documented at 01/18/2025 10:52 PM 01/19/2025 9:25 AM given; effectiveness documented at 01/19/2025 10:25 AM Review of Patient #2’s Complete Plan of Care revealed no documented care plan problems related to bipolar mood, anxiety or the number of psychotropic medications she was prescribed. On 03/05/2025 at 2:10 PM, an interview was conducted with S5QA during patient record review. She confirmed there were no care plan problems in Patient #2’s Complete Plan of Care related to her secondary diagnosis of Bipolar Type 1 or for her PRN anxiety or the number of other psychotropic medication she was prescribed and receiving while as patient in the hospital and there should have been.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure all patient treatments were within compliance of particular aspects of the patients’ individual treatment program as evidenced by failure to have a signed master treatment plan by the nurse and social worker/therapist for 1 (#2) of 6 (#1 - #6) patients’ treatment plans reviewed for the sample. Findings: Review of the hospital’s policy number CS-02 titled, “Treatment Planning; Integrated/Multidisciplinary” last revised on 07/01/2024, revealed in part: “Purpose: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. Policy: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessments process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient’s involvement, throughout the course of treatment. Procedure: 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient’s medical record.” Review of Patient #2’s medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM from an outside referring facility emergency room for psychosis aggression. Review of Patient #2’s Interdisciplinary Treatment Plan Master Sheet dated 01/15/2025 at 10:10 AM revealed the patient signature line was signed by S6SW, but no additional documentation stating Patient #2 was unable and/or unwilling to sign was provided. Further review revealed no staff signatures from the nurse, therapist or MD. On 03/05/2025 at 1:45 PM, an interview was conducted with S5QA during patient record review. While reviewing Patient #2’s Master Treatment Plan, she confirmed S6SW signed on the patient signature line, but did not provide any documentation as to why Patient #2 was unable and/or unwilling to sign. S6QA also confirmed There was no signature for the nurse and the therapist on the Master Treatment Plan and there should have been. She also confirmed there was no signature for the MD, but further stated there was ongoing open education related that from a prior survey citation.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview, the 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 ensure the patient /patient representative was included in the development and implementation of the patient’s plan of care for 1 (#2) of 3 (#1- #3) patients reviewed for care plan participation (see Findings Tag A0130); 2) Failure to monitor Patient #2 on 1:1 observation per physician order and hospital policy (see Findings Tag A0144); 3) Failure to monitor and observe 7 (#3, #R15, #R43 - #R47) of 14 (#3, #R15, #R42 - #R53) patients per Precautions ordered by the physician (see Findings Tag A0144); 4) Failure to monitor and observe patients as assigned by the Registered Nurse (see Findings Tag A0144); and 5) Failure to ensure 1 (S9MHT) of 4 (S7MHT, S8MHT, S9MHT, S10MHT) unlicensed direct care workers had a criminal background check performed by a Louisiana State Police approved vendor (see Findings Tag A0144).”

“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: 50453 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. 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 1 (#2) of 3 (#1- #3) patients reviewed for care plan participation. Findings: A review of hospital policy # CS-02, titled “Treatment Planning; Integrated Multidisciplinary,” last revised 07/01/2024, revealed in part: “Policy: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient’s involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measureable goals and objectives based on assessed needs and identified by the patient, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. Procedure: 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient’s medical record.” Review of Patient #2’s medical record revealed an admission date of 02/04/2025 with Major Depressive Disorder and Suicidal Ideation. Review of Patient #2’s medical document titled “Interdisciplinary Treatment Plan Master Sheet” initiated on 02/04/2025, failed to reveal evidence of Patient #2’s signature or Patient #2 representative’s signature indicating participation in her plan of care. Further review also failed to reveal documentation why the patient did not participate in the treatment plan. In an interview on 02/06/2025 at 9:18 AM, S4LPNQ confirmed the Interdisciplinary Treatment Plan Master for Patient #2 failed to reveal patient/patient representative signatures indicating participation in their plan of care. S4LPNQ also confirmed there is no documentation about the reason Patient #2 did not participate in their treatment plan.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting. This deficient practice was as evidenced by: 1) Failure to monitor Patient #2 on 1:1 observation per physician order and hospital policy; 2) Failure to monitor and observe 7 (#3, #R15, #R43 - #R47) of 14 (#3, #R15, #R42 - #R53) patients per Precautions ordered by the physician; 3) Failure to monitor and observe patients as assigned by the Registered Nurse; and 4) Failure to ensure 1 (S9MHT) of 4 (S7MHT, S8MHT, S9MHT, S10MHT) unlicensed direct care workers had a criminal background check performed by a Louisiana State Police approved vendor. Findings: 1) Failure to monitor Patient #2 on 1:1 observation per physician order and hospital policy A review of the psychiatric hospital policy, “Levels of Observations,” Policy Number: CS-23, effective 01/11/2026 and last revised 03/01/2023, revealed in part: “Policy: Three levels of observation are utilized: every 15-minute (Q15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order. Observation Levels: one-to-one observation - The staff will ensure the patient is visually within sight and within arms -reach of a staff member at all times and in all circumstances. See Appendix A for more information. Procedure: 4. One-to-one Observations: Assigns a nursing staff to perform one-to-one and ensures staff have relief for all breaks. Ensures that staff members are in arms reach of a patient at all times. Appendix A: 1:1 Observation is defined as: keeping the patient under direct observation within one arm’s reach of the patient at all times. This includes use of bathroom and bathing. Protocol for 1:1 Observation: 1. Staff is to remain within arm’s length of patients at all times.” Observations during a walk-through of the hospital on 02/05/2025 from 8:45 AM to 10:00 AM revealed 2 MHT’s (S9MHT, S10MHT) sitting at a table along the exterior wall of Room “h.” The entry door to Room “h” was closed. It was identified by S4LPNQ that Patient #2 was assigned to Room “h” and currently on 1:1 observation. S9MHT and S10MHT were positioned in chairs facing Room “t” (dayroom) where Patient #2’s entry door is located and neither were in a position which would have allowed a visual observation of Patient #2 if the door was open. Patient #2 was laid in Bed B of Room “h” and appeared to be sleeping. An immediate review of S9MHT and S10MHT observation flowsheets, revealed S10MHT was currently monitoring and in possession of 7 (#2, #R28 - #R33) of 15 (#2, #R28 - #R41) patient’s Observation Check Sheet/Graphic Flowsheets. This included the 1:1 Observation patient #2. S9MHT was currently monitoring and in possession of 8 (#R34 - #R41) of 15 (#2, #R28 - #R41) patient’s Observation Check Sheet/Graphic Flowsheets. The reviewed Observation Check Sheet/Graphic Flowsheets revealed S10MHT was currently observing a 1:1 patient and 6 other patients which, per hospital policy is not protocol. This type of practice placed Patient #2 at risk for potential self-injurious behavior. A review of Patient #2’s medical record revealed physician orders for 1:1 Observation with a rationale of “Danger to Self.” Further, Patient #2’s prescribed precaution levels included, “Suicide/Self Harm Precautions.” In an interview on 02/05/2025 and present during this walk-through, S2DON and S4LPNQ confirmed the above mentioned findings and further confirmed, Patient #2 was not being observed and monitored per hospital policy. 2) Failure to monitor and observe 7 (#3, #R15, #R43 - #R47) of 14 (#3, #R15, #R42 - #R53) patients per Precautions ordered by the physician A review of the psychiatric hospital policy, “Elopements,” Policy Number: CS-04, effective 01/11/2016 and last revised 01/01/2025, revealed in part: “Purpose: To identify those at risk for elopement and to prevent the occurrence. Procedure: 2. For patients who are screened or assessed to be at risk for elopement, the physician is notified and an order for elopement precautions is obtained. The prescribed level of observation is implemented immediately. 5. Elopement prevention strategies and interventions include, but not limited to: Initiate 1:1 or Line of sight observation level. Limit/restrict outdoor privileges (requires physician order which must be renewed every 24 hours). Ensure all staff practice door safety by ensuring all doors on and off the unit are closed and appropriately latched/locked before leaving the door area. Redirect patients away from immediate proximity of doors. Staff vigilance during outdoor time by walking the inside perimeter of fencing to stay between patients and fence. Always having two or more staff present when patients are off the locked unit within the facility. Ensure no items such as chairs, benches, garbage cans, etc. are in the outdoor courtyard that could be used to leverage patient over fencing. Direct patients away from fence during outdoor times.” A review of the psychiatric hospital policy, “Fall Assessment/Re-Assessment and Precautions,” Policy Number: AS-12, effective 01/11/2016 and last revised 11/16/2022, revealed in part: “Purpose: To screen patient’s potential for falling and decrease the risk of injury. Procedure: 5. Interventions shall include: Mandatory fall precautions - Interventions for patients “at risk for falls” (must implement all below): Apply yellow fall risk arm band; Provide nonskid slipper socks or ensure appropriate skid-proof footwear is used; Provide patient education; Initiate Fall Risk treatment plan. Additional fall precautions - (must select at least 2 additional interventions from below that are appropriate to the patient’s individual needs): Bed alarm; Chair alarm; Ambulate with staff assistance; Ensure assistive devices (ex: eyeglasses, hearing aids) are available; Keep pathways clear; Line of Sight observation level; 1:1 observation level; Reclining chair, Assist with ADLs.” A review of the psychiatric hospital policy, “Suicide/Homicide Risk Assessment,” Policy Number: AS-19, effective 01/11/2016 and last revised 11/01/2023, revealed in part: “Purpose: The purpose of this policy is to ensure an effective method for suicide/homicide screening, assessment, monitoring, and treatment of patients at risk for suicide/homicide. Policy: Prevention techniques will be accomplished by a comprehensive approach that identifies and mitigates process and system level issues contained within the hospital environment that can contribute to self-harm. Direct Care Staff who conduct suicide screening, assessment, or re-assessment will be trained and successfully pass competency test on the screening and/or assessment process and screening/assessment tools as part of new hire orientation and annually thereafter. Procedure: Inpatient: 3. All direct care staff needs to be aware of suicidal/homicide/violence risks. Suicide, homicide, and/or violence precautions will be noted in the medical record. 5. The following Risk Levels and Interventions will be used in the assessment to mitigate any suicide/homicide/violence risk: Levels of risk and appropriate interventions (Inpatient): Suicidal Risk Stratification: HIGH Suicide Risk: Suicidal ideation with intent or intent with plan in the last month or suicidal behavior within the past 3 months. Suicidal Intervention: HIGH Suicide Risk: Stay patient, initiate 1:1 observation, and notify provider to obtain order. Patient may be placed on lower level of observation based on clinical judgement of the Medical Staff and the documented justification. Initiate a “Potential for Self-Harm” treatment plan. Maintain a SAFE environment & evaluate personal belongings for ligature risk. Develop Safety Plan with suicide resources for discharge planning. Notify multidisciplinary team of patient’s “high suicide risk” status. Suicidal Risk Stratification: MODERATE Suicide Risk: Suicidal ideation with method, WITHOUT plan, intent or behavior in the past month Or Suicidal behavior more than 3 months ago Or Multiple risk factors and few protective factors. Suicidal Intervention: MODERATE Suicide Risk: Implement q15 min observation. Place patient close to nurses’ station with roommate, if possible. Initiate a “Potential for Self-Harm” treatment plan. Maintain a SAFE environment & evaluate personal belongings for ligature risk. Develop Safety Plan with suicide resources for discharge planning. Notify multidisciplinary team of patient’s “moderate suicide risk” status. Suicidal Risk Stratification: LOW Suicide Risk: Wish to die or Suicidal Ideation WITHOUT method, intent, plan, or behavior Or Modifiable risk factors and strong protective factors Or No reported history of Suicidal Ideation or Behavior. LOW Suicide Risk: Implement q15 min observation. Continue to monitor for changes in suicidal ideation or behavior.” A review of the psychiatric hospital policy, “Sexual Acting Out (SAO) Identification and Precautions,” Policy Number: CS-44, effective 12/19/2022 and no revisions, revealed in part: “Purpose: To provide staff with a framework for identifying patients who are at risk for exhibiting sexually inappropriate behavior and to provide for the implementation of precautions to ensure the safety of all patients. Policy: Definitions: Sexual Precautions: Sexual Precautions are defined as intensified levels of staff awareness and attention to patient safety/security related to sexual acting out behaviors. Sexual Precautions require varying levels of observing patients and the initiation of specific protocols and supplemental documentation, when warranted. Procedure: 4. The RN/LVN/LPN ensures all patient orders for SAO Precautions are recorded and posted. 5. The RN ensures the SAO Precaution level is communicated on the hand off report and all staff are aware of the SAO Order. Sexual Acting Out (SAO Precautions: 1. LOS or 1:1 or 15 minute observation based on clinical assessment; 2. Assess location of patient rooms based on vulnerability of the patient population in particular at-risk patients; 3. Determine if level of SAO risk requires that a patient requires his/her patient room; 4. Room visible from the nurses’ station or patient lounge when possible; 5. Door open when patient is his/her room; 8. Ensure all staff members are aware of SAO behavior (including volunteers, students); 9. Ensure two staff members are present when the patient needs assistance in his/her room or isolated areas; 10. Monitor relationships, interactions, not passing, whispering, etc., among patients. 11. Screen reading materials, ensure appropriate media is viewed on the unit; 12. Visitor restrictions if appropriate.” A review of the psychiatric hospital policy, “Seizure Precautions,” Policy Number: NSG-40, effective 01/11/2016 and last revised 02/01/2023, revealed in part: “Purpose: To identify patients at risk for seizure activity, implement precautions to prevent injury, and provide immediate interventions for patients during seizure activity. Seizure Precautions (Inpatient): 4. Seizure precautions may include: Ensure patient showers instead of bath & utilize shower chair (always have personnel in near proximity in case assistance is needed); Assess room for hard edges, un-necessary furniture, etc. that may cause injury if seizure occurs (remove un-necessary furniture, consider padding hard edges); Include risk for seizures in shift report; include risk of seizures in multi-disciplinary treatment plan; Ensure suction equipment, airway management equipment, and oxygen are in proximity and available for use; Prevent individual patient’s known triggers once identified (i.e. bright lights, television, or specific foods).” A review of the before mentioned policies include patient interventions to be performed and/or monitored in relation to the prescribed Precaution level. Observations during a walk-through of the hospital on 02/05/2025 from 8:45 AM to 10:00 AM revealed S7MHT sitting at a table in Room “s.” S7MHT was currently monitoring and documenting observations on 8 (#3, #R15, #R42 - #R47) of 14 (#3, #R15, #R42 - #R43) patients’ Observation Check Sheet/Graphic Flowsheets. A review of these Observation Check Sheet/Graphic Flowsheets was performed with S7MHT. In an interview on 02/05/2025 at 9:00AM, S7MHT confirmed she was currently assigned to Patients #3, #R15 and #R42 - #R47. S7MHT further confirmed, she was unaware of the before mentioned patients having any ordered Precautions. In an interview on 02/05/2025 and present during this walk-through, S2DON and S4LPNQ confirmed the above mentioned findings. A review of Patients #3, #R15 and #R42 - #R47 medical records for physician ordered Precautions revealed: Patient #3: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 02/04/2025 1:00 PM, End Date: not avaialble; Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 02/04/2025 1:00 PM, End Date: not avaialble; and Suicide/Self Harm Precautions Continuous, Request Type: Routine, Status: Open, Start 02/04/2025 1:00 PM, End Date: not avaialble. Patient #R15: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/25/2025 12:00 PM, End Date: not avaialble; and Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/25/2025 12:00 PM, End Date: not avaialble. Patient #R42 no ordered Precautions. Patient #R43: Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/31/2025 5:00 PM, End Date: not avaialble; and Violence/Homicide Precautions Continuous, Request Type: Routine, Status: Open, Start 01/31/2025 5:00 PM, End Date: not avaialble. Patient #44: Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/29/2025 6:00 PM, End Date: not avaialble.. Patient #45: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/27/2025 3:00 PM, End Date: not avaialble.; Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/27/2025 3:00 PM, End Date: not avaialble; Suicide/Self Harm Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/27/2025 3:00 PM, End Date: not avaialble; and Violence/Homicide Precautions Continuous, Request Type: Routine, Status: Open, Start 01/27/2025 3:00 PM, End Date: not avaialble. Patient #45: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/28/2025 1:00 PM, End Date: not avaialble; and Patient #45: Violence/Homicide Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/28/2025 1:00 PM, End Date: not avaialble.. Patient #46: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/29/2025 4:00 PM, End Date: not avaialble; and Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/29/2025 4:00 PM, End Date: not avaialble. A review of the before mentioned medical records revealed orders for precautions on 7 (#3, #R15, #R43 - #R47) of 8 (#3, #R15, #R42 - #R47) medical records. S7MHT was unaware of the ordered Precautions on the patients she was observing and monitoring which jeopardized their safety and well-being. In an interview on 02/05/2025 at 1:30 PM S3DQ confirmed the above mentioned findings during medical record review and further confirmed the MHT’s should be aware of the patient’s Precautions. 3) Failure to monitor and observe patients as assigned by the Registered Nurse A review of the psychiatric hospital policy, “Levels of Observations,” Policy Number: CS-23, effective 01/11/2026 and last revised 03/01/2023, revealed in part: “Policy: Three levels of observation are utilized: every 15-minute (Q15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order. Observation Levels: one-to-one observation - The staff will ensure the patient is visually within sight and within arms -reach of a staff member at all times and in all circumstances. See Appendix A for more information. Procedure: 4. One-to-one Observations: Assigns a nursing staff to perform one-to-one and ensures staff have relief for all breaks. Ensures that staff members are in arms reach of a patient at all times. Appendix A: 1:1 Observation is defined as: keeping the patient under direct observation within one arm’s reach of the patient at all times. This includes use of bathroom and bathing. Protocol for 1:1 Observation: 1. Staff is to remain within arm’s length of patients at all times.” A review of the psychiatric hospital policy, “Nursing Assignments,” Policy Number: NSG-05, effective 01/11/2016 and last revised 06/01/2023, revealed in part: “Purpose: To ensure a safe, therapeutic milieu and delivery of quality care by designating specific duties to appropriate staff members. To ensure the assignment of nursing staff without regard to race, color, disability, or national origin of ether staff or patients. Policy: It is the charge nurse’s responsibility to complete the nursing assignment sheet at the onset of every shift. All nursing staff member are held accountable for duties assigned. Charge nurses will supervise assignments and ensure completion of all delegated duties. Procedure: In-Patient: 1. The charge nurse will determine the nursing care assignments for the shift based on patient acuity, and capabilities and scope of practice of available staff. Every patient will be assigned to a specific staff person. 2. All nursing staff team members will be notified of their assigned responsibilities and the shift assignment will be posted. 3. The charge nurse is involved with and responsible for supervising and evaluating the care of all patients. Patient care assignments area commensurate with the qualifications of the nursing staff member assigned. 5. Agency/contracted nursing personnel will receive training and competency assessment/documentation prior to receiving a patient care assignment.” Observations during a walk-through of the hospital on 02/05/2025 from 8:45 AM to 10:00 AM revealed 2 MHT’s (S9MHT, S10MHT) sitting at a table along the exterior wall of Room “h.” An immediate review of S9MHT and S10MHT observation flowsheets, revealed S10MHT was currently monitoring and in possession of 7 (#2, #R28 - #R33) of 15 (#2, #R28 - #R41) patient’s Observation Check Sheet/Graphic Flowsheets. This included the 1:1 Observation Patient #2. S9MHT was currently monitoring and in possession of 8 (#R34 - #R41) of 15 (#2, #R28 - #R41) patient’s Observation Check Sheet/Graphic Flowsheets. The reviewed Observation Check Sheet/Graphic Flowsheets revealed S10MHT was currently observing a 1:1 patient and 6 other patients which, per hospital policy is not protocol. A review of the hospital’s 7A-7P Assignment Sheet, dated 02/05/2025, revealed in part, S10MHT was assigned Patients #2 and #R34 - #R40 and S9MHT was assigned Patients #R41 and #R28 - #R33. The hospital’s 7A-7P Assignment Sheet, dated 02/05/2025 did not match the MHT/patient assignments being performed. The change in patient assignment without the charge nurse’s involvement could jeopardized the safety and well-being of patients. In an interview on 02/05/2025 and present during this walk-through, S2DON and S4LPNQ confirmed the above mentioned findings. In an interview on 02/05/2025 at 2:45 PM, S3DQ confirmed the above mentioned findings. In an interview on 02/06/2025 at 8:25 AM, S5RN confirmed the above mentioned findings and further confirmed she had made the assignment on 02/05/2025, however S9MHT and S10MHT had changed their assignments. 4) Failure to ensure 1 (S9MHT) of 4 (S7MHT, S8MHT, S9MHT, S10MHT) unlicensed direct care workers had a criminal background check performed by a Louisiana State Police approved vendor Pursuant to La. R.S. 40:1203.7, Authorized Agencies must be domiciled in the state of Louisiana and must be certified by the LA Secretary of State’s office. Authorized Agents must also be certified by the Bureau of Criminal Identification and Information (Bureau). Companies that perform background check services that are not domiciled in Louisiana nor certified through the Secretary of State’s office and the Bureau are not authorized to request or receive criminal history information stored in Louisiana Computerized Criminal History (LACCH) database. The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State’s designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau may only release criminal history information stored in LACCH for noncriminal justice purposes when authorized by law. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2 A review of hospital policy, “Selections of Employees,” Policy Number: HR 01.02, effective 01/11/2016 and revised 09/01/2024, revealed in part, “Purpose: To establish consistent recruiting, hiring and retention policies that comply with all federal, state, and local laws and/or regulation in order to attract and retain the most qualified employees. Procedure: Employee Background Checks: In addition to thorough reference checks, additional background checks are required utilizing an approved company vendor prior to extending an offer of employment. A review of personnel files revealed S9MHT’s prior to hire criminal background check being performed by an unapproved vendor - DISA. In an interview on 02/06/2025 at 9:15 AM, S12HR confirmed the above mentioned findings.”

“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 per hospital policy; 2) failure of the Registered Nurse to assign Observation Levels for 4 (Patient #1, R2-R4) of 28 (Patient #1, R1-R27) patient Observation Check Sheets reviewed; and 3) failure of the Registered Nurse to document the nursing shift assessment on 1 (#1) of 3 (#1-#3) patient’s medical records reviewed. Findings: Review of the hospital policy # CS-23, titled “Level of Observation,” last revised, 03/01/2023, revealed in part: “Observation Levels: -Every 15 minutes- The staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. -Line of Sight (Constant Observation)- The staff member will ensure the patient is visually within sight at all times. -One-to-one Observation- The staff will ensure the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. Procedure: 1. The initial patient observation level is determined and ordered by the physician upon patient admission. The decision to utilize one of the observation levels is made based on the patient’s needs and presenting symptomology. 3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. The observing staff initials the 15-minute increments on the form to indicate the patient was observed. This form or vital sign form will also be utilized for 1:1 monitoring when stricter level of monitoring is ordered and will be notated as such on the top of the form. The staff member signs the signature line at the bottom of the form to validate their initials and credentials. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form. Every 15 Minute Observation: RN assigns staff members to q15-minute observations, Line of Sight or one-to-one observation based on physician/NPP orders and assigns breaks and meal-time relief.” 1) Failure of the Registered Nurse to document patient observations every 2 hours per policy. Review of the Patient #1’s Observation Check Sheet dated 01/24/2025, revealed the Registered Nurse failed to review and sign that the patient observations were completed every 2 hours within the timeframes below: 01/25/2025 between 3:15 AM - 6:45 AM. In interview on 02/05/2025 at 2:00 PM, S4LPNQ confirmed that the RN did not document that observations were performed every 2 hours per hospital policy. Review of the Patient Observation Check Sheets dated 01/26/2025, revealed the Registered Nurse failed to review and sign that the patient observations were completed every 2 hours for 5 (Patient #1, R1-R3) of 28 (Patient #1, R1-R27) patient Observation Check Sheets reviewed within the timeframes below: Review of Patient #1’s Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM. Review of R1’s Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM. Review of R2’s Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM. Review of R3’s Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM. Review of R4’s Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM. In interview on 02/05/2025 at 2:05 PM, S4LPNQ confirmed that the RN did not document that observations were performed every 2 hours per hospital policy on the above mentioned patients. 2) Failure of the Registered Nurse to assign Observation Levels for 4 (Patient #1, R2-R4) of 28 (Patient #1, R1-R27) patient Observation Check Sheets reviewed. A review of the Patient Observation Check Sheet for Patient #1 dated 01/26/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. A review of the Patient Observation Check Sheet for R2 dated 01/26/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. A review of the Patient Observation Check Sheet for R3 dated 01/26/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. A review of the Patient Observation Check Sheet for R4 dated 01/26/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. In interview on 02/05/2025 at 2:05 PM, S4LPNQ confirmed that the RN did not document that observations were performed every 2 hours per hospital’s policy on the above mentioned patients. 3) Failure of the Registered Nurse to document the nursing shift assessment on 1 (#1) of 3 (#1-#3) patient’s medical records reviewed. A review of hospital policy # NSG-02, titled “Documentation,” last revised 01/01/2023, revealed in part: “Policy: Inpatient nursing personnel document patient’s progress every 12-hour shift, incorporating the elements of the nursing process and patient’s treatment goals and progress within the patient’s medical record. Inpatient: Daily: The Registered Nurse (RN) documents or review the LPN/LVN documentation on the Nursing Shift Assessment a minimum of once per shift. 1. All notes must be related to the patient’s problems on the treatment plan.” Review of Patient #1’s medical record failed to reveal a nursing shift assessment documented on 01/20/2025 for night shift. In an interview on 02/05/2025 at 3:31 PM, S4LPNQ confirmed that the nurse failed to document a shift assessment on the night of 01/20/2025 per hospital policy.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This deficient practice was evidenced by the MHTs changing their patient care assignments. Findings: A review of the psychiatric hospital policy, “Nursing Assignments,” Policy Number: NSG-05, effective 01/11/2016 and last revised 06/01/2023, revealed in part: “Purpose: To ensure a safe, therapeutic milieu and delivery of quality care by designating specific duties to appropriate staff members. To ensure the assignment of nursing staff without regard to race, color, disability, or national origin of ether staff or patients. Policy: It is the charge nurse’s responsibility to complete the nursing assignment sheet at the onset of every shift. All nursing staff member are held accountable for duties assigned. Charge nurses will supervise assignments and ensure completion of all delegated duties. Procedure: In-Patient: 1. The charge nurse will determine the nursing care assignments for the shift based on patient acuity, and capabilities and scope of practice of available staff. Every patient will be assigned to a specific staff person. 2. All nursing staff team members will be notified of their assigned responsibilities and the shift assignment will be posted. 3. The charge nurse is involved with and responsible for supervising and evaluating the care of all patients. Patient care assignments area commensurate with the qualifications of the nursing staff member assigned. 5. Agency/contracted nursing personnel will receive training and competency assessment/documentation prior to receiving a patient care assignment. A review of the psychiatric hospital policy, “Levels of Observations,” Policy Number: CS-23, effective 01/11/2026 and last revised 03/01/2023, revealed in part: “Policy: Three levels of observation are utilized: every 15-minute (Q15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order. Observation Levels: one-to-one observation - The staff will ensure the patient is visually within sight and within arms -reach of a staff member at all times and in all circumstances. See Appendix A for more information. Procedure: 4. One-to-one Observations: Assigns a nursing staff to perform one-to-one and ensures staff have relief for all breaks. Ensures that staff members are in arms reach of a patient at all times. Appendix A: 1:1 Observation is defined as: keeping the patient under direct observation within one arm’s reach of the patient at all times. This includes use of bathroom and bathing. Protocol for 1:1 Observation: 1. Staff is to remain within arm’s length of patients at all times.” Observations during a walk-through of the hospital on 02/05/2025 from 8:45 AM to 10:00 AM revealed 2 MHT’s (S9MHT, S10MHT) sitting at a table along the exterior wall of Room “h.” An immediate review of S9MHT and S10MHT observation flowsheets, revealed S10MHT was currently monitoring and in possession of 7 (#2, #R28 - #R33) of 15 (#2, #R28 - #R41) patient’s Observation Check Sheet/Graphic Flowsheets. This included the 1:1 Observation Patient #2. S9MHT was currently monitoring and in possession of 8 (#R34 - #R41) of 15 (#2, #R28 - #R41) patient’s Observation Check Sheet/Graphic Flowsheets. The reviewed Observation Check Sheet/Graphic Flowsheets revealed S10MHT was currently observing a 1:1 patient and 6 other patients which, per hospital policy is not protocol. A review of the hospital’s 7A-7P Assignment Sheet, dated 02/05/2025, revealed in part, S10MHT was assigned Patients #2 and #R34 - #R40 and S9MHT was assigned Patients #R41 and #R28 - #R33. The hospital’s 7A-7P Assignment Sheet, dated 02/05/2025 did not match the MHT/patient assignments being performed. The change in patient assignment without the charge nurse’s involvement could jeopardized the safety and well-being of patients. In an interview on 02/05/2025 and present during this walk-through, S2DON and S4LPNQ confirmed the above mentioned findings. In an interview on 02/05/2025 at 2:45 PM, S3DQ confirmed the above mentioned findings. In an interview on 02/06/2025 at 8:25 AM, S5RN confirmed the above mentioned findings and further confirmed she had made the assignment on 02/05/2025, however S9MHT and S10MHT had changed their assignments.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48051 50453 Based on record review and interview, the hospital nursing staff failed to administer medications in accordance with the accepted standards of practice. This deficient practice is evidenced by: 1) failure of the nursing staff to administer medications within the appropriate timeframe per physician order in 1 (#2) of 3 (#1-#3) patient medical records reviewed; and 2) failure of nursing staff to notify the physician of an abnormal blood pressure per hospital policy. Findings: 1) Failure of the nursing staff to administer medications within the appropriate timeframe per physician order in 1 (#2) of 3 (#1-#3) patient medical records reviewed. Review of hospital policy # MM-01, titled “Medications,” last revised: 12/01/2024, revealed in part: “Medication administration: Before administering a medication, the licensed independent practitioner or qualified individual administering the medication does the following: -Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.” Review of Patient #2’s medication administration record revealed the following order: Hydroxyzine Pamoate (Vistaril) 50mg (1 capsule) by mouth, every 8 hours, PRN: Anxiety. Further review of Patient #2’s medication administration record revealed the following dates/times of administration: 02/05/2025 at 4:18 PM 02/05/2025 at 10:03 PM Review of Patient #2’s medical record failed to reveal nursing documentation that the provider was notified or that the provider approved the administration of the medication to be given early. In an interview on 02/06/2025 at 9:03 AM, S4LPNQ confirmed the PRN medication was given early and not as prescribed by the provider. S4LPNQ also verified that there was no documentation by the nurse that the provider approved them to administer the medication early. At this time S3DQ also confirmed that the medication above was administered within 6 hours of each other and not within 8 hours as prescribed by the provider. 2) Failure of nursing staff to notify the physician of an abnormal blood pressure per hospital policy A review of hospital policy, “ Vital Signs Monitoring,” Policy Number NSG-34, effective 01/11/2016 and last revised 12/01/2022, revealed in part, “ Purpose: To ensure vital signs are accurately obtained and monitored as ordered by the physician/non-physician practitioner (NPP). Policy: It is the policy of the Hospital to effectively communicate all vital signs that fall outside of the “within normal limits” parameters in a timely manner to licensed and independent practitioners as established by acceptable nursing practice. Vital signs include Blood Pressure (B/P), Pulse (P), Respirations (R), and Temperature (T). Procedure: 4. Normal vital signs are: Blood Pressure: Adults - <120/80. 6. The RN will notify the physician or NPP of abnormal vital signs and assessments based on nursing judgement and critical thinking. Parameters and patient’s baseline are used as a guide in judgement and assessment on reporting of vital signs to physician/NPP. Reporting ranges may vary according to symptomology and history of individual’s baseline. A review of Patient #2’s medical record revealed a History and Physical performed by S11FNP on 02/01/2025 at 1:15 pm and indicated a prior medical history of hypertension, vascular dementia, cerebral vascular accident, heart failure, coronary artery disease and Stage 3 chronic kidney disease. A review of Patient #2’s daily vital sign record revealed a B/P of 183/77 on 02/02/2025 at 4:01 AM. The prior B/P reading on 02/01/2024 at 10:18 PM was 155/78. The latter of the 2 readings does fall within Patient #2’s baseline, however the 183/77 would be outside of the patient’s baseline and considered abnormal. A review of the medication administration record revealed clonidine HCL 0.1mg was administered by mouth on 02/04/2025 at 4:04 AM with a follow up of, “effective 108/56” at 6:04 AM. The medical record did not reveal any documentation of the physician or NPP being contacted regarding this abnormal B/P. In an interview on 02/10/2025 at 3:00 PM, S3DQ confirmed the above mentioned findings.”

“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: 50453 Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair. Findings: Observations during a tour on 02/05/2025 8:45 AM - 10:02 AM revealed the following: - Room a - room p revealed 2 sets of shelves containing large amounts of grey, fuzzy substance resembling dust. - Room q revealed a mattress with 2 large tears in the mattress. In an interview during the hospital tour, S2DON and S4LPNQ confirmed the above mentioned 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: 50453 Based on observation and interview, the hospital failed to ensure the infection prevention program included surveillance of the facility to identify and mitigate identified sources with potential for transmission of infection. This deficient practice was evidenced by failing to ensure the hospital maintained a sanitary environment to prevent infection. Findings: A review of hospital policy # IC-05.04, titled “Separation of Clean and Dirty Supplies,” last revised 01/01/2025, revealed in part: “Procedure: The clean and dirty utility areas are separated into two different rooms. The rooms must be clean and tidy at all times. Sterile and clean items can be stored in the same room, but each category should be located in separate areas, i.e., individual shelves, individual cabinets, individual bins. Any supplies which have been used on or by a patient are considered dirty/soiled. Disposable patient care items are assigned to and used for only one patient are discarded or sent with the patient upon transfer or discharge. Single use items are discarded after each use.” Observations of room r during a tour on 02/05/2025 8:45 AM - 10:02 AM revealed the following used supplies: - Medline Remedy Cleanse No-Rinse Foam Cleaner, quantity 2 - Medline Skin Integrity Cleanser, quantity 2 - Sparkle Fresh Toothpaste, quantity 2 - Moisturize Body Lotion, quantity 2 - Anti-perspirant, quantity 1 - Shaving Cream can, quantity 3 In an interview on 02/05/2025 at 9:11 AM, S2DON and S4LPNQ confirmed the above mentioned findings. S2DON and S4LPNQ also confirmed that opened/used supplies should not be stored in room r and should have been discarded.”

“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: 14442 Based on record reviews and interview, the hospital failed to ensure a registered nurse evaluated the nursing care of each patient. This deficient practice was evidenced by failing to ensure the RN documented assessment findings of a patient (#1) that had a reported change in respiration pattern for 1 (#1) of 3 (#1 - #3) sampled patients. Findings: Review of the hospital policy titled “Early Response to Deteriorating Patient Condition,” last revised 04/01/2024 revealed, in part: “Policy: This facility identifies unexpected acute illnesses which pose life-threatening situations for our patients. This policy defines the procedure for identifying and addressing the following deteriorating conditions that require early response: Abnormal changes/fluctuations in a patient’s status. A Registered Nurse (RN) is immediately available as needed to provide bedside care to each patient. The RN shall be qualified through a combination of education, licensure, and training to conduct an assessment that enables recognition of a need for emergency care and/or assistance. Review of Patient #1’s medical record revealed admit date 12/29/2024. The patient had past medical history of, in part, cerebrovascular accident, hypertension, and asthma. Review of Patient #1’s “Multidisciplinary Progress Note” by S2RN dated 01/11/2025 at 8:39 AM revealed, in part: “At approximately 3:30 AM MHT’s stated that the patient’s breathing pattern was different, and I assess the patient, and vitals was stable. 5:04 AM Patient’s last set of vitals read: 130/84, HR: 103. At approximately 6:50 AM the MHT stated that the patient wasn’t breathing. At 6:54 AM 911 was called and CPR started.” Further review of Patient #1’s medical record revealed no evidence S2RN documented Patient #1’s assessment findings and no evidence of Patient #1’s respiratory status and assessment. In an interview on 01/28/2025 at 1:53 PM, S1Quality Director indicated that the time documented in the “Multidisciplinary Progress Note” of 3:30 AM by S2RN was incorrect. S1Quality Director indicated that S2RN was notified by MHT of change in breathing pattern and assessed Patient #1 at approximately 4:54 AM. S1Quality Director confirmed S2RN did not document Patient #1’s assessment findings and respiratory assessment findings.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 14442 Based on record review, video review, and interview, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital. This deficient practice was evidenced by failing to ensure hospital Code Blue Response policy and procedure was implemented by nursing staff for 1 (#1) of 1 unresponsive patient from a total sample of 3 (#1 - #3) patients. Findings: Review of the hospital policy titled “Code Blue Response,” last revised 08/01/2021 revealed, in part: “Policy: It is the policy of this facility to administer cardiopulmonary resuscitation (CPR) when a person’s breathing and/or pulse cease. CPR shall continue until person resumes cardiopulmonary functions or the emergency medical services arrive. Procedure: 1. The first provider or employee to arrive at the patient’s side will assess patient for symptoms of cardiopulmonary failure, such as unconsciousness, absent respiration, absent heartbeat (check carotid pulse), dilated or constricted pupils, or change in skin color. 2. Stay with the victim, never leaving them unattended. Instruct a staff member to announce Code Blue, and to telephone 911 for emergency medical services, and obtain the emergency cart which has necessary supplies such as an Automated External Defibrillator (AED). 3. Initiate CPR to include the use of an AED. 4. Continue CPR until patient resumes cardiopulmonary functioning or emergency medical services arrives and takes over the code blue response.” Review of Patient #1’s medical record revealed admit date 12/29/2024. The patient had past medical history of, in part, cerebrovascular accident, hypertension, and asthma. Review of Patient #1’s “Multidisciplinary Progress Note” dated 01/11/2025 revealed, in part: “At approximately 6:50 AM the MHT stated that the patient wasn’t breathing. At 6:54 AM 911 was called and CPR started and initiated AED attached to the patient.” Review of Patient #1’s “Code Blue/CPR Flow Sheet” dated 01/11/2025 revealed, in part: “Reason for code: Patient was found unresponsive with no pulse and no observed breathing. Time CPR initiated 6:55 AM. Assessment: Pulseless, unresponsive. Summary: At approximately 6:50 AM the MHT stated that the patient wasn’t breathing. At 6:54 AM patient assessed by RNs after tech notified RN that they had concern over the patient’s condition. Both RNs came to assess the patient. CPR initiated immediately and 911 called. CPR started and initiated AED attached to the patient, which informed staff to continue CPR. CPR continued until EMS arrived and they began resuscitation efforts. 7:15 AM EMS arrived on the scene after 911 was called and transported the patient to ER at 7:25 AM after resuscitation efforts as well as CPR were performed on the patient. 8:23 AM spoke with ER on phone and was given update that the patient passed in the ER.” A review of the hospital video footage for 01/11/2025 and Patient #1 was done with S1Quality Director on 01/28/2025 at 2:06 PM. At approximately 5:15 AM, S2RN, S3MHT, and S4MHT exited a room with Patient #1 in a Geri-chair and wheeled Patient #1 into the hospital day room. At approximately 6:53:21 to 6:53:50 AM, S5MHT, S4MHT, S2RN, and S3MHT seen observing and touching Patient #1. At approximately 6:54:50 AM, S6RN exited nurses’ station with vital sign machine and S6RN attached it to Patient #1. At approximately 6:55:24 and 6:55:42 AM, S6RN pressed button on vital sign machine. At approximately 6:56:36 AM, S7RN performed sternal rubs on Patient #1. At approximately 6:56:51 AM, S6RN exited nurses’ station with backboard and AED. At approximately 6:57 AM, S7RN began CPR on Patient #1 while in Geri-chair. CPR continued on Patient #1 while in Geri-chair. At approximately 6:59:48 AM, AED applied to Patient #1’s chest. At approximately 7:01:39 AM, EMS entered the day room. At approximately 7:02:06 AM, Patient #1 moved to the ground and EMS assumed control of code. At approximately 7:22:58 AM, patient transferred off unit by EMS. Review of video footage failed to reveal staff obtained the emergency cart which had necessary CPR supplies. Review of video footage failed to reveal staff obtained oxygen, bag valve mask, suction device, and airway management tools. In an interview on 01/29/2025 at 10:44 AM, S1Quality Director and S8Regional DON confirmed that hospital Code Blue Response policy not implemented by staff. S8Regional DON confirmed staff did not obtain the emergency cart which had all necessary supplies and did not obtain and apply AED timely.”

“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 provide care in a safe setting. The deficient practice is evidenced by failure to initiate seizure precautions for 1 (#3) of 1 reviewed patients with suspected seizures from a total of 3 reviewed patient records. Findings: Review of the medical record for Patient #3 revealed the patient was taken to an acute care hospital on 12/22/2024 after exhibiting seizure-like activity. The patient was discharged back to the psychiatric hospital on 12/23/2024. Review of the “After Visit Summary” provided at discharge revealed instructions for neurology follow up and seizure precautions. Review of the “Physician’s Orders” and ‘Behavioral Health Observation Sheets” revealed Patient #3 was not started on seizure precautions until 01/05/2025, after a second visit to the emergency department for seizure-like activity. In interview on 01/09/2025 at 1:05 PM, S3QD verified Patient #3 was not placed on seizure precautions as per the discharge instructions after the first visit to the emergency department.”

“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 incidents of possible abuse and/or neglect were reported to the Louisiana Department of Health within 24 hours of becoming aware of the incident. The deficient practice is evidenced by failure of the facility to report a fight that occurred at the facility. Findings: Review of LA R.S. 40:2009.20 revealed, in part, “facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.” Review of video was performed on 01/06/2025 between 11:00 AM and 2:45 PM. Video from 01/04/2025 revealed Patient #3 was attached by several girls at 4:50 PM. The video revealed the mental health technicians (MHTs) reacted quickly, but Patient #3 was knocked to the floor and kicked and hit repeatedly by the girls for approximately thirty seconds. Review of the incident reports revealed an incident report for the occurence was filled out for the fight on 01/04/2024, but review of the self-reports of possible abuse sent to Louisiana Department of Health revealed the incident was not reported. Interview on 01/08/2025 at 1:20 PM, S3QD verified the psychiatric hospital did not report the abuse of Patient #3 by the other patients to Louisiana Department of Health as required.”

“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: 44495 Based on record review, video review, and interview the governing body failed to provide clear and written guidance for the safe initiation of a new Bluetooth enabled observation system. The deficient practice is evidenced by failure of the governing body to establish policies with clear guidance for proper use of the observation system and failure to establish procedures to monitor for proper use and to effectively implement corrective actions related to quality of care in a timely manner. Findings: Tour of the facility on 01/08/2024 at 10:00 AM revealed the hospital was using a new Bluetooth enabled system to document patient observations. The system allowed the behavioral health technician (BHT) to document the ordered observations electronically when the patient was in Bluetooth range. If the patient was observed by BHT but not within range of the Bluetooth system, the BHT could manually enter the observation in the system, which was called a “forced” entry. In interview on 01/08/2024 at 11:25 AM, S3QD was asked about the distance range on the system and if it was possible to have the patient in Bluetooth range but not visible to the BHT. S3QD stated the manufacturer set the ranges and they were still adjusting them, S3QD explained the range was not established by distance but by frequency. S3QD verified it was possible that occasionally a patient might be detected when not visable on the other side of a wall. On 01/08/2025 between 1:22 PM and 1:51 PM, S3QD navigated the review of video of an incident that occurred on 01/04/2025. The video revealed Patient #3 was in her room between 1:04 PM and 2:21 PM and was not in the view of the assigned MHT for more than an hour and yet the observations were documented at least every 15 minutes as ordered. Further investigation revealed that the system had documented the entries as “forced” or manual entries. On 01/08/2025 at 3:40 P.M., a demonstration of the range of the system was performed with S2DON. The demonstration verified that the Bluetooth range was variable and noted to be longer if a patient was moving out of range and shorter when coming into the range. The demonstration also verified that a patient might be considered in range although not visible while positioned more than 10 feet away in an adjacent room. In interview on 01/08/2025 at 3:07 PM, S3QD verified there were no policies developed to guide the use of the system which had been in use for three weeks and the facility continued to follow Policy CS-23, “Level of Observations,” last revised 03/01/23. S3QD verified reports with data, like the one that showed a MHT had “forced” a significant number of observations consecutively in a short period of time, were sent to S1ADM via email daily. S3QD verified the reports were collected and reviewed at the weekly meeting about the system. S3QD verified the nurses did not have real time access to review the documented care provided by the MHTs during the shift, and no one was assigned to review the data collected and analyze the quality of care provided by the MHTs immediately after the shift, or daily as the reports were recieved.”

“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: 44495 Based on video, record review, and interview the registered nurse failed to supervise the care provided to the patients by the mental health technicians (MHTs). The deficient practice is evidenced by failure of the registered nurse to ensure the direct care staff to performed direct observation every 15 minutes as ordered for 1(#3) of 1 patient for whom video was reviewed from a total sample of 3 (#1-#3) patients. Findings: Review of the policy “Levels of Observations,” last revised 03/01/2023, revealed in part, “Observation Levels: Every 15 minutes- the staff member will visually observe the patient every 15 minutes to moniter their location and activity, with an demphasis on any noticable behaviors of escalation, aggression and unsafe activities.” On 01/08/2024 between 1:22 PM and 1:51 PM, S3QD reviewed the video from the hall outside the room of Patient #3 with the surveyor. The video revealed on 01/04/2025 between 1:04 PM and 2:21 PM, Patient #3 was in the bedroom and no mental health technician performed observation rounds outside the bedroom during that time. Review of the “Behavioral Health- Patient Observation Sheet” revealed Patient #3 had orders for observations to be performed every fifteen minutes from 0:16 AM through 6:44 PM on 01/04/2025. Patient #3 was also on precautions for elopement, self-harm and violent behavior. Further review revealed S6MHT documented observation at 1:06 PM in the hall, and S5MHT documented observations at 1:17 PM, 1:31 PM, 1:37 PM, 1:48 PM, and 2:00 PM in the bedroom. After reviewing the video and observation sheets on 01/08/2024 at 3:07 PM, S3QD verified Patient #3 was not directly observed by the mental health technicians as documented in the patient record. S3QD also verified the electronic documentation did show S5MHT had “forced” the electronic observation because the patient was not in range and there was another patient with two forced observations by S5MHT during that time for whom video was not reviewed. S3QD verified the nursing staff did not have real time access to review the observations made by the mental health technicians during the shift. When asked how the nursing staff monitored the MHTs to ensure they were performing the observations as ordered, S3QD stated, “The nurses do their own rounds every 2 hours.” S3QD verified the facility had no policy for the use of the newly initiated electronic monitoring and no policy that addressed the review of data provided by the system.”

“Therapeutic Activities - Program CFR(s): The program must be appropriate to the needs and interests of patients and be directed toward restoring and maintaining optimal levels of physical and psychosocial functioning. This Standard is not met as evidenced by: 44495 Based on observation, record review, and interview the psychiatric hospital failed to ensure all activities were therapeutic and age appropriate. The deficient practice is evidenced by the viewing of a movie with a Motion Picture Association of America (MPAA) rating of Restricted (R) by the adolescent patients. Findings: Review of the “Inpatient Adolescent Program Handbook,” dated 09/01/2023, revealed in part, “Television sets are provided in patient lounges. Television can be a hindrance to the recovery process; however, there are designated times for watching the news and viewing television during free time. Television viewing is not to interfere with any scheduled activity or take place of completing assigned work. The choice of programs to be watched shall be governed by the democratic process as long as they are appropriate to the therapeutic process.” Review of the patient census for 01/08/2024 revealed the admitted patients ranged in age from 10 to 17 years old. A tour of the facility was conducted on 01/08/2025 between 10:00 AM and 10:25 AM. While in Room A, direct observation revealed a movie playing on the television that was extremely violent and contained profanity. The movie was identified as a rated R movie. The rating was assigned for violence throughout, pervasive language, and some nudity. In interview at the time of discovery, S4QA verified the movie was not appropriate. When asked how the movie was selected, S5MHT stated “One of the boy’s requested it.” In interview on 01/08/2025 at 10:55 AM, S3QD verified the movie was not appropriate.”

“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 supervision as ordered by the physician for 1 (#2) of 4 (#1-#4) psychiatric patients observed with potential ligature risk (See findings under A-0144); 2) failure to notify psychiatric physician following an incident of self-injurious behavior in Patient #1 potentially leading to a 2nd self-injurious behavior incident (See findings under A-0144); 3) failure to ensure psychiatric patients did not have access to items and contraband considered potential risks for self-harm or harm to others (See findings under A-0144); 4) failure to ensure each patient was accurately identified per psychiatric hospital policy in 2 (#R5 and #R23) of 2 (#R5 and #R23) patients observed (See findings under A-0144); 5) failure to ensure observation check sheets with precautions were implemented per policy in 12 (#R11-#R22) of 29 (#2, #R1-#R28) Patient Observation Sheets reviewed (See findings under A-0145). 6) failure to have the patient/patient representative/nurse sign the statement of Patient Acknowledgment of rights in 1 (#4) of 4 (#1-#4) patients sampled (See findings under A-0116); 7) failure to ensure the patient /patient representative was included in the development and implementation of the patient’s plan of care for 1 (#4) of 4 (#1- #4) patients sampled (See findings under A-0130); and 8) failure to ensure each patient or patient representative was provided information about his/her health status, diagnosis, and prognosis in order to make “informed” decisions regarding his/her care. This deficient practice is evidenced by the lack of a signed informed consent form for 1 (#4) of 4 (#1-#4) patients sampled (See findings under A-0131).”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital failed to ensure that the medical record contained documented evidence of patient notification of their rights. This is evidenced by failing to have the patient/patient representative/nurse sign the statement of Patient Acknowledgment of rights in 1 (#4) of 4 (#1-#4) patients sampled. Findings: Review of the psychiatric hospital’s policy #: RTS-01, titled. “Patient Rights Louisiana”, Revised: 09/01/2023, revealed in part: Policy: ...Every patient shall receive a written copy of their rights ...and shall sign an acknowledgement that they are aware of their rights. The written copy shall include all applicable state and federal rights protections afforded to the patient. Procedure: ...4. If the patient is cognitively and/or physical unable to sign and comprehend this information about their rights, the patient’s guardian or a family member will be so informed and will sign for them as legally appropriate. Continued review of the psychiatric hospital’s policy #: RTS-01, titled. “Patient Rights Louisiana”, Revised: 09/01/2023, failed to reveal the patient had the right to receive care in a safe setting. Review of Patient #4’s medical record revealed an admission date of 10/31/2024 under a Formal Voluntary Admission that was later changed by spouse to Non-Contested Admission. Continued review failed to reveal evidence Patient #4 or her spouse were given the opportunity to acknowledge that they were aware of all patient rights. In an interview on 11/07/2024 at 10:40 a.m., S4QD verified the psychiatric hospital policy did not include the patient right for care in a safe setting. In an interview on 11/07/2024 at 4:05 p.m., S4QD confirmed the medical record failed to reveal evidence Patient #4 or her spouse were given the opportunity to acknowledge that they were aware of all patient rights.”

“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 1 (#4) of 4 (#1- #4) patients sampled. Findings: Review of the psychiatric hospital’s policy #: RTS-01, titled. “Patient Rights Louisiana”, Revised: 09/01/2023, revealed in part: ...Exhibit A: Rights of Persons Suffering from Mental Illness and Substance Abuse Summarized in Layman Terms. You are guaranteed certain rights by the Constitution. Through state and federal law, you are guaranteed additional rights as follows ....Treatment ...You have a right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. If you are unable to make decisions about the care, treatment, and services, the rights of involvement of family/surrogate decisions maker instated on the patient’s behalf will be respected in accordance law and regulations. Review of Patient #4’s medical record revealed an admission date of 10/31/2024 with diagnosis of Major Depressive Disorder and Anxiety. Review of Patient #4’s medical document titled “Treatment Plan” dated 10/31/2024 failed to reveal evidence Patient #4 or her spouse participated in her plan of care. In an interview on 11/07/2024 at 4:08 p.m., S4QD confirmed the medical record failed to reveal evidence Patient #4 or her spouse participated in her plan of care.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47397 Based on record review and interview the hospital failed to ensure each patient or patient representative was provided information about his/her health status, diagnosis, and prognosis in order to make “informed” decisions regarding his/her care. This deficient practice is evidenced by the lack of a signed informed consent form for 1 (#4) of 4 (#1-#4) patients sampled. Findings: Review of psychiatric hospital’s policy titled “Informed Consent, Care Decisions, and Conflicts Resolution”, revised 12/01/2024, revealed in part: ...Policy: The facility recognizes the benefit and the need to involve patients and significant others, when appropriate in care treatment and services decisions, conflict resolution and to ensure that appropriate informed consent is obtained as outlined by the State, Federal and other regulatory bodies. Procedure: Informed Consent 1. The Governing Body/Administration dictates that informed consent is mandatory on those procedures, care, treatment, and services normally requiring informed consent and mandates that all staff responsible for the delivery of care, treatment and services educate patients/patient’s family/representative to allow for informed decision making as to participate in the care, treatment, and services being delivered. 3. The facility will, during the admission process, obtain signature on informed consent forms. If the patient is unable to sign due to physical impairments, verbal consent can be obtained and documented with two witnesses. In the case of involuntary commitment, the facility will follow the policies of the organization related to involuntary admission. 4. Specific informed consent is required in the following circumstances: Facility treatment programming/admission. Review of Patient #4’s medical record revealed an admission date of 10/31/2024 under a Formal Voluntary Admission that was later changed by spouse to Non-Contested Admission. Continued review failed to reveal evidence Patient #4 or her spouse signed an informed consent form acknowledging that they were provided information about Patient #4’s health status, diagnosis, and prognosis in order to make “informed” decisions regarding her care. In an interview on 11/07/2024 at 4:05 p.m., S4QD confirmed the medical record failed to reveal evidence Patient #4 or her spouse signed an informed consent form.”

“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 of the hospital to provide continuous line of sight supervision as ordered by the physician for 1 (#2) of 4 (#1-#4) psychiatric patients observed with potential ligature risk; 2) failure to notify psychiatric physician following an incident of self-injurious behavior in Patient #1 potentially leading to a 2nd self-injurious behavior incident; 3) failure to ensure psychiatric patients did not have access to items and contraband considered potential risks for self-harm or harm to others; 4) failure to ensure each patient was accurately identified per psychiatric hospital policy in 2 (#R5 and #R23) of 2 (#R5 and #R23) patients observed; 5) failure to conduct a contraband search of each patient per psychiatric hospital policy in 4 (#1-#4) of 4 (#1-#4) patients reviewed; and Findings: 1) Failure of the hospital to provide continuous line of sight supervision as ordered by the physician for 1 (#2) of 4 (#1-#4) psychiatric patients observed with potential ligature risk. Review of psychiatric hospital’s policy #: CS-23 titled “Level of Observations” revealed in part ...Observation Levels: ...Line of Sight (Constant Observation)-the staff member will ensure the patient is visually within sight at all times ... Review of Patient #2’s medical record revealed an admission date of 11/04/2024 at 8:35 p.m. with a diagnosis of Psychosis, visual hallucinations, paranoia, impulsivity, violence, COPD on oxygen therapy, UTI, hypertension, diabetes, and atrial fibrillation. Review of Patient #2’s physician orders dated 11/05/2024 at 9:00 a.m. revealed observation level, continuous line of sight due to oxygen tubing required with oxygen therapy. Review of Patient #2’s observation sheet dated 11/05/2024 from 7:00 a.m. until 6:45 a.m. on 11/06/2024 revealed observation level indicated every 15 minutes observation. On 11/06/2024 from 10:22 a.m.-11:45 a.m. a review of video footage was navigated by S4QD for the location ‘A’, on 11/05/2024 from 7:00 p.m. through 11/06/2024 at 8:51 a.m. The review failed to reveal Patient #2 was continuously in line of sight of nursing staff from 7:00 p.m. until 8:50 a.m. At 8:51 a.m. on 11/06/2024, the video revealed an MHT pulling up a chair to Patient #2’s doorway for continuous line of sight observation. In an interview on 11/06/2024 at 12:17 p.m., S4QD confirmed the above findings as observed on video. S4QD verified the observation sheet dated 11/05/2024 failed to indicate that Patient #2 was on continuous line of site observations as ordered by the physician. In an interview on 11/06/2024 at 3:05 p.m., S4QD verified that Patient #2 had physician orders for continuous, line of sight observations due to the tubing required for oxygen therapy and patient diagnoses of Psychosis, visual hallucinations, paranoia, impulsivity, and violence. 2) Failure to notify physician following an incident of self-injurious behavior in Patient #1 potentially leading to a 2nd self-injurious behavior incident. Review of psychiatric hospital’s policy #: AS-19 titled, “Suicide/Homicide Risk Assessment”, revised 11/01/2013, revealed in part: Procedure: Inpatient: ...3 ....Report and document any suicidal/homicidal/violence ideation/plan to the ...physician immediately ... Review of psychiatric hospital’s policy #: NSG-02 titled, “Documentation”, revised on 01/01/2023 revealed in part: ...Routine: 1. RN and/or LPN documents ...any notifications or issues reported to the physician or non-physician practitioner ... Review of Patient #1’s medical record revealed a date of birth of 10/16/2009 with an admission to the Kentwood location on 09/04/2024 with a diagnoses of Major Depressive Disorder and Homicidal Ideations. Review of Patient #1’s Psychiatric evaluation dated 09/04/2024 revealed patient with history of self-injurious behavior and suicidal ideation. Review of physician orders dated 09/26/2024 at 8:00 p.m. revealed Suicide/Self Harm Precautions Continuous. Review of self-report dated 10/21/2024 at 5:47 p.m. revealed Patient #1 went into bathroom and broke off a piece of plastic and then went into the hallway and began scratching his neck, causing superficial cuts. Then proceeded to the boys’ dayroom, where his injury was noted by social worker and nurse. Further review failed to reveal Patient #1’s psychiatrist, S12PMD or delegate was notified of the self-injurious behavior. Review of nursing note dated 10/21/2024 at 5:30 p.m. failed to reveal S12PMD or psychiatric delegate was notified of the self-injurious behavior. Review of Self-Report dated 10/29/2024 at 4:09 p.m. revealed Patient #1 was let into the bathroom, where he broke off a piece of plastic, then went into a hallway and made scratches to left wrist. Further review revealed S12PMD was notified of this incident. Review of physician orders dated 10/29/2024 at 8:00 p.m. revealed Line of Sight- continuous observation. In an interview on 11/07/2024 at 11:36 a.m., S4QD confirmed S12PMD or psychiatric delegate should have been notified of the self-injurious behavior on 10/21/2024, especially in light of the patient history of self-injurious and suicidal behaviors stated in the psychiatric evaluation on admission. 3) Failure to ensure psychiatric patients did not have access to items and contraband considered potential risks for self-harm or harm to others. Review of psychiatric hospital’s policy #: EOC-28 titled, “Safety Inspection of all Areas”, revised on 08/01/2024 revealed in part: Purpose: To monitor the physical environment to ensure patient safety and compliance with regulatory standards. Policy: areas of the facility shall be inspected to ensure that safety standards are being met, that when deficiencies are found corrective action is taken. Procedure ...2. The nursing department completes a safety walk through patient care areas every shift to assess the environment for potential unsafe conditions...Day shift safety and security rounds to be done at the beginning of every shift ... Review of psychiatric hospital’s policy #: NSG-222 titled, “Body and Belongings Search”, revised on 07/01/2024 revealed in part: Procedure ...7. Contraband items include the following ...Substances containing alcohol (such as mouthwashes ...) ...Any substance or object flet to be potentially injurious to the patient or that may be used as a weapon. Observations during tour of location ‘A’ on 11/06/2024 from 8:25 a.m.-9:30 a.m. guided by S9QA revealed the following in part: 8:26 a.m. area ‘a’: observed a box of Styrofoam cups in a large plastic bag next to garbage can lined with plastic bag next to the 2 scales where patients are weighed on intake. 8:27 a.m. area ‘b’: observed 2 garbage cans lined with empty plastic bags next to storage container with urine cups and paper bags. 8:47 a.m. area ‘c’: observed a large garbage can lined with large plastic bag and 2 bottles of shaving cream. 8:50 a.m. patient room ‘d’: observed water-like substance noted to bedroom floor leading from bed into bathroom. Continued observation revealed 2 wet bath towels laying in water covering the bathroom floor. 8:58 a.m. patient room ‘e’: observed wet bathroom floor with unattended shower chair made of pvc-type pipe. A toothbrush on floor with bottle of body wash. 9:03 a.m. patient room ‘f’: observed bathroom with toothbrush on sink with toothpaste cap. 9:11 a.m. room ‘g’: observed plastic cup holder with large vice-like mounting screw that twists out of the cup holder. 9:13 a.m. room ‘h’: observed with paper bag containing 4 bottles of shampoo, deodorant, bottle of mouthwash, and a bottle of shaving cream. In an interview on 11/06/2024 at 9:13 a.m., The Patient #R19 stated, “they gave it to me.” 9:22 a.m. room ‘i’: observed shampoo and deodorant on sink. Unattended shower chair made of pvc-type pipe. Shampoo in crevice of handrail. In an interview on 11/06/2024 at 9:25 a.m., S9QA confirmed the above findings as contraband and items considered potential risks for self-harm or harm to others. S9QA stated the items should be removed immediately. Observations during tour of location ‘B’ on 11/07/2024 from 9:23 a.m.-9:55 a.m. guided by S1DON and S9QA revealed the following: 9:31 a.m. room ‘j’: observed panel on the ceiling with 3-Phillip’s head-type screws. In an interview on 11/07/2024 at 9:31 a.m., S1DON and S9QA confirmed the 3-Phillip’s head-type screws were a safety risk and need to be removed immediately. 9:46 a.m. room ‘k’: observed toothbrush contained in a plastic cylinder noted to bedside shelf. In an interview on 11/07/2024 at 9:46 a.m., S1DON and S9QA confirmed the toothbrush and the plastic cylinder were considered contraband and should be removed immediately. 4) Failure to ensure each patient was accurately identified per psychiatric hospital policy in 2 (#R5 and R23) of 2 (#R5 and R23) patients observed. Review of psychiatric hospital’s policy #: EOC-103 titled, “Hospital Armbands”, Effective 04/01/2020 revealed in part: Purpose: A clearly defined and consistently implemented practice for identifying patients and communicating patient risk factors, precautions, or special needs by standardizing the use of color-coded bands to support optimal safe care ...Policy ...All patients will be accurately identified prior to receiving any care, treatment or services consistently in all inpatient settings. To establish guidelines to ensure patient safety ...utilizing preprinted color-coded alert wristbands ...Procedure for Identification ...5. All inpatients will have an ID band placed before treatment is initiated ...Patient Care Provider at Point of Care will ...2. Prior to care, treatment, or procedure, the patient is to be identified ...Procedure For Arm Band Placement/Removal/Refusal: 1. When patient’s identity cannot be verified because the imprinted band is ...missing, no services will be performed until the patient ID band is properly replaced. 2. ...missing bands shall be replaced immediately with a new band ...3. A multidisciplinary note will be completed when a patient ID band is found to be missing ...4. If a patient refuses to wear the ID band they must have the ID band in their possession and present it to the department for testing/treatment/procedure ... Review of psychiatric hospital’s policy #: NSG-25 titled, “Principles of Medication Administration”, revised on 02/01/2024 revealed in part: Purpose: To establish guidelines to promote the safety of patients ...Procedure ...5. When utilizing an e-Mar through the Electronic Medical record (EMR) the nurse will identify the patient via scanning the barcode located on the patient’s identification armband ... Observations during tour of location ‘A’ on 11/06/2024 from 8:25 a.m.-9:30 a.m. guided by S9QA revealed the following in part: 9:07 a.m. room ‘l’: observed armband laying on bedside table with Patient #R5’s name. In an interview on 11/06/2024 at 9:07 a.m., Patient #R5 stated the arm band fell off of his arm “a couple of days ago”. 9:18 a.m. room ‘m’: observed armband laying on bedside table with Patient #R23’s name. In an interview on 11/06/2024 at 9:26 a.m., S9QA confirmed the above findings and stated the armbands should be immediately replaced with new armbands for both patients. On 11/06/2024 from 10:22 a.m.-11:45 a.m. a review of video footage navigated by S4QD for location ‘A’ on 11/05/2024 from 7:00 p.m. through 11/06/2024 at 8:51 a.m. 10:06 p.m. revealed the following: 10:06 p.m.: Patient #R5 at nurses’ station window speaking with nurse. Observation failed to reveal an armband on Patient #R5’s right or left wrist. In an interview on 11/06/2024 at 10:40 a.m., S4DQ confirmed the above observation. 5) Failure to conduct a contraband search of each patient per psychiatric hospital policy in 4 (#1-#4) of 4 (#1-#4) patients reviewed. Review of psychiatric hospital’s policy #: NSG-02 titled, “Documentation”, revised on 01/01/2023 revealed in part: Admission: 1. The nurse records a notation of the admission information in the medical record which can include the following information ...Patient searched/Belongings Searched ... Review of psychiatric hospital’s policy #: NSG-22 titled, “Body & Belongings Search”, revised on 07/01/2024 revealed in part: ...Inpatient ...1. Nursing staff are responsible for conducting the admission body and belongings search ...8. The licensed nurse will document in the patient’s medical record that a body search was conducted, rationale for body search, persons present at the time of the search disposition of contraband found and patients response to the search. A review of Patients’ #1-#4 medical records failed to reveal evidence a contraband search was conducted or documented per hospital policy. In an interview on 11/06/2024 at 3:26 p.m., S4QD verified that Patients’ #1-#4 medical records failed to reveal evidence a contraband search was conducted or documented per hospital policy.”

“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 record review, and interview the hospital failed to provide an environment free from neglect. This deficient practice is evidenced by failure to ensure observation check sheets with precautions were implemented per policy in 12 (#R11-#R22) of 29 (#2, #R1-#R28) Patient Observation Sheets reviewed. Findings: Review of psychiatric hospital’s policy #: RTS-10 titled, “Abuse and/or Neglect of Patients by Staff Members, Students, Interns”, revised on 01/11/2016 revealed in part: ...Policy ...Neglect is the failure to provide the proper or necessary medical care ...for a consumer’s well-being ...Examples of actions/inactions which could be considered mistreatment/abuse include: ...Failing to or refusing to attend to the necessary care and treatment ...Implementing actions contrary to the prescribed treatment of the program. Review of psychiatric hospital’s policy #: CS-23 titled “Level of Observations” revised 03/01/2023, revealed in part ...Procedure ...3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. Additional information regarding activities are included on the form when relevant ...The observing staff initials the 15-minute increments on the form to indicate the patient was observed. This form ...will also be utilized for 1:1 monitoring when a stricter level of monitoring is ordered and will be notated as such on top of form .... On 11/06/2024 at 8:41 a.m., observation sheets were provided by S12RN as the observation sheets to be utilized by the day shift staff on 11/06/2024 starting at 7:00 a.m. A review of the observation sheets revealed 12 (#R11-#R22) of 29 (#2, #R1-#R28) observation sheets that were blank except for the date, 11/06/2024, the initials of S12RN indicating the nurse had validated MHT rounds, and S12RN’s signature at the bottom of the page. Additionally, the 12 observation sheets were on the nurses’ unit desk and not with the MHTs for use. The 12 sheets failed to reveal observation levels for each patient. Further review failed to reveal MHT initials on the 12 observation sheets indicating rounds were conducted from 7:00 a.m. until 8:41 a.m. In an interview on 11/06/2024 at 8:45 a.m., S9QA verified the above findings. In an interview on 11/06/2024 at 9:50 a.m., S4QD verified the above findings.”

“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 assigned the nursing care of each patient to other nursing personnel in accordance with Hospital policy and the patient’s needs. This deficiency is evidenced by failing to ensure a Registered Nurse completed patient care assignments at the beginning of shift for 29 (#2, #R1-#R28) of 29 (#2, #R1-#R28) patients on the census Findings: Review of psychiatric hospital’s policy #: NSG-05 titled “Nursing Assignments”, revised 06/01/2023, revealed, in part: ...Policy: It is the charge nurse’s responsibility to complete the nursing assignment sheet at the onset of every shift. On 11/06/2024 at 8:39 a.m. a review of psychiatric hospital document titled “7A-7P Assignment Sheet”, dated 11/06/2024 failed to reveal assignments made for 29 (#2, #R1-#R28) of 29 (#2, #R1-#R28) patients on the census for 11/06/2024. In an interview on 11/06/2024 at 8:39 a.m., S12RN and S9QA verified the assignment sheet was not completed. In an interview on 11/06/2024 at 10:05 a.m., S2DQ verified the nursing shift began at 7:00 a.m. and the assignment sheet should have been completed.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 48050 48537 Based on interviews and record review, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. The deficient practice was evidenced by the failure of the admitting practitioner’s failure to order medical care based on the medical diagnoses at the time of admission to the facility in 1 (#2) of 3 (#1-#3) patient records reviewed for the sample. Findings: Review of the hospital policy number QAPI-00 titled, “Quality Assessment and Performance Improvement (QAPI) Plan” last revised on 06/01/2024 revealed the following: Policy: Aligned with the organization’s core convictions rooted in the belief that everyone deserves dignity and respect, the hospital is dedicated to delivering safe, compassionate, high-quality care.The plan focuses on the evaluation of the current performance of the hospital and the identification of opportunities for improvement. This involves systemic monitoring, measurement, analysis, and robust action planning using a defined performance improvement methodology to ensure that the hospital delivers high-quality care and meets regulatory requirement. The committee’s primary objective is to identify and address any breakdowns that may compromise patient care and safety, striving to continuously improve and promote positive patient outcomes. 2. Medical Staff The medical staff provides effective mechanisms to monitor, assess, and improve the quality and appropriateness of patient care and the clinical performance and competency of all individuals with delineated clinical privileges. Performance improvement opportunities are addressed, with improvement strategies and actions implemented, to ensure improved performance is achieved and sustained. Review of Patient #2’s medical record revealed she was admitting to the facility on 08/29/2024 at 5:45 p.m. from an outside referring facility emergency room after receiving one dose of oral Macrobid antibiotic treatment for a urinary tract infection with a diagnosis of major depressive disorder. Review of Patient #2’s medical record revealed the following: On 08/29/2024 at 6:36 p.m. - Patient arrived via ambulance from nearby emergency room at 5:45 p.m. AAO x3. Patient is forgetful, but is able to verbalize partial reason for admission (UTI). Denies AVH, SI and HI. Patient easily reoriented to current situation. Signed by S9RN Review of Patient #2’s history and physical completed on 08/30/2024 at 5:13 p.m. by S10NP revealed Patient #2 was admitted to the psychiatric hospital facility after becoming overheated in the outside referring facility emergency room and developed visual hallucination reporting she believed someone wanted to kill her and palpitations. S10NP documented Patient #2’s chief complaint in her own words to be “Can I have some Tylenol?” Continued review of the medical record revealed S10NP documented “negative” for each body system in the Review of Systems which indicated in his evaluation of her symptoms she was not reporting any symptoms including psychiatric symptoms like hallucinations. S10NP documented Patient #2’s physical assessment to be normal and within the normal expected limits of a patient her age. S10NP documented “UTA” for Patient #2’s neurological exam and cranial nerve exam. Review of S10NP’s documented Assessment & Plan stated to follow up on admission labs. Further review of the history and physical revealed no documentation as to why S10NP did not address the urinary tract infection Patient #2 was tested for and diagnosed with at the outside referring facility emergency room or reference to acknowledging Patient #2 had a UTI.. Review of Patient #2’s admission orders revealed the following orders placed on admission: 08/29/2024 Admit to Care of S8MD, PEC, Admitting Diagnosis: MDD 08/29/2024 Legal Status - LA Continuous Request Type: Now, Legal Status: Physician Emergency Certificate 08/30/2024 Methenamine Hippurate (Hiprex) 1G Take 1 tablet by mouth daily for prevention of bacterial urinary tract infection 08/30/2024 Urinalysis with Reflex to C/S Discontinued 08/31/2024 Review of S11NP’s note dated 08/31/2024 at 7:39 p.m. it was documented Patient #2 continued to have episodes of confusion, paranoia and agitation particularly during the evening hours. She had also told S11NP she believed she was in there in the hospital because she had a urinary tract infection. Review of S10NP’s note dated 08/31/2024 at 10:24 p.m. it was documented Patient #2 was seen in gerichair with no new issues or complaints with poor insight. Plan to follow up on admission labs and no new recommendations for the day. Review of Patient #2’s lab orders revealed an order for a urinalysis with culture & sensitivity if indicated was originally ordered on 08/30/2024 by S10NP and discontinued on 08/31/2024. The urinalysis with culture and sensitivity if indicated was then reordered again on 09/01/2024 by S13NP and resulted on 09/03/2024. On 10/22/2024 at 3:45 p.m., an interview was conducted with S12NS. She stated the reason for the delay in collecting the admission labs for Patient #2 was likely because she was admitted to the hospital on a weekend and the lab does not come to collect labs on the weekend and then that following Monday was the Labor Day. She stated since the provider did not order the labs as STAT orders and were just ordered as routine admit labs, they would just be collected by the lab on the next routine draw. On 10/23/2024 at 1:36 p.m., a telephone interview was conducted with S10NP. He stated he was one of the medical NPs providing care for the patients at the facility. He stated he vaguely remembered Patient #2, but if the H&P was signed by him then he was the one who completed it. He stated his process for admitting a new patient who has been referred to the facility by an outside facility directly would be to review the referral paperwork that is sent from the referring facility for the patient including labs, tests and procedures completed prior to arrival. He stated based on what had already been done for the patient at the prior facility including recommendations, he would conduct his evaluation and assessment of the patient as to not duplicate or delay any treatment or medications if possible. He stated if a patient was transferred to the facility after having had a urinalysis completed in the emergency department to test for urinary tract infection and it came back with a positive result for a UTI, he would not reorder the urinalysis upon admission to the facility, he would just start the patient on antibiotics to begin/continue treatment for the UTI. He stated it could be possible for an older adult female in her early 80s, similar to the age of Patient #2, suffering from an untreated UTI for multiple days could exhibit symptoms easily mistaken for symptoms psychiatric in nature like altered mental status, increased agitation, and hallucinations. He stated he was unaware if this was true for Patient #2 because he could not remember her situation as he did not have her chart in front of him. He stated he was familiar with the hospital’s lab collection procedure for which providers put in routine lab orders whether at admission or during the stay and the labs are collected the next morning by the outside lab provider Monday-Friday. He stated the lab provider does not come to the facility on weekends and/or holidays. The surveyor informed him Patient #2 had been diagnosed with a UTI at the ER of the outside referring facility on the day of admission to the facility and received a one-time dose of oral antibiotics prior to arriving at the facility, but her treatment for the UTI had not been continued upon her arrival to the facility and another urinalysis was ordered upon admission but was not collected until 09/03/2024 which had delayed Patient #2’s treatment of the UTI. He stated “okay.””

“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: 48050 Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. The deficient practice is evidenced by failure of the hospital to initiate changes and monitor for compliance after allegation of abuse/neglect was made against members of the Behavioral Health staff. Findings: Review of the hospital’s policy titled “Patient Grievance Process” last revised date 09/01/2024 revealed in part: GRIEVANCE: A formal or informed written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient’s rights. Role of the Patient Advocate: 2. Complete a thorough investigation of all grievances representing the expressed desires of the individuals served and advocating for the resolution of their grievances. Review of the hospital’s policy titled “Assessment and Reporting of Abuse, Neglect” last revised date 10/01/2024 revealed in part: PROCEDURE: C. A description of actions taken by the facility subsequent to the event to include: iv. Educational/training programs provided to staff members prior and subsequent to the event, to include, content and attendees. Review of the hospital policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan” last revised on 06/01/2024 revealed the following: Policy: Aligned with the organization’s core convictions rooted in the belief that everyone deserves dignity and respect, the hospital is dedicated to delivering safe, compassionate, high-quality care.The plan focuses on the evaluation of the current performance of the hospital and the identification of opportunities for improvement. This involves systemic monitoring, measurement, analysis, and robust action planning using a defined performance improvement methodology to ensure that the hospital delivers high-quality care and meets regulatory requirement. The committee’s primary objective is to identify and address any breakdowns that may compromise patient care and safety, striving to continuously improve and promote positive patient outcomes. 2. Medical Staff The medical staff provides effective mechanisms to monitor, assess, and improve the quality and appropriateness of patient care and the clinical performance and competency of all individuals with delineated clinical privileges. Performance improvement opportunities are addressed, with improvement strategies and actions implemented, to ensure improved performance is achieved and sustained. In an interview on 10/23/2024 at 10:00 a.m. S1QD verified that the only interventions done related to the self-report involving Patient #2 was education for the registered nurses only regarding skin assessments. In an interview on 10/23/2024 at 2:34 p.m. S3DON reveals she can’t remember if she did an educational in-service with the nurses regarding skin assessments. Furthermore she was unable to produce educational material or an in-service sign in sheet for attendees of the education. In an interview on 10/23/2024 at 3:30 p.m. S2HA verified that there was no follow up with S3DON regarding required education for the nurses as a result of the investigation related to allegations of abuse.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48537 Based on interviews and record review, the hospital failed to ensure the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. This deficient practice was evidenced by the failure to update the care plan of 1 (#2) of 3 (#1-#3) patients reviewed for completed and updated care plans. Findings: Review of the hospital policy number CS-02 titled, “Treatment Planning; Integrated/Multidisciplinary” last revised on 07/01/2024 revealed the following: Procedure: 2. The admitting nurse is responsible for the following: -Formulating the initial treatment plan based on physician’s orders/initial orders/initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment, related measurement-based tools and family/significant other information within 24 hours (1 treatment day IOP) of admit or sooner if patient’s needs warrants immediate action. -Initiating individualized treatment problem/nursing diagnosis list as identified in the assessment -Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations and physician’s orders. Review of the hospital policy number NSG-42 titled, Activities of Daily Living (ADL) last revised on 03/01/2023 revealed the following: Purpose: To establish procedures for assisting patients with activities of daily living to promote positive self-concept and overall well-being and functional independence. Policy: Patients are encouraged ...The functional ability of each patient is determined on admission during the nursing admission assessment. Depending upon the functioning abilities of each patient, the nursing staff will supervise, assist, teach, and/or provide activities of daily living including personal hygiene. Procedure: 6. The RN will incorporate the patient’s level of performing activities of daily living in patient’s treatment planning with the goal to have the patient perform these self-care task independently, as deemed appropriate. Review of the medical record for Patient #2 revealed she was admitted to the hospital on 08/29/2024 at 5:45 p.m. S9RN documented Patient #2 was incontinent upon arrival, was cleaned, a new depends was applied and she was transferred to unit bed and redness was noted to her sacrum with otherwise skin intact. Review of the Hospital’s Observation Check Sheet/Graphic Flowsheet dated 08/29/2024 - 09/05/2025, Patient #2 received incontinent checks by the assigned mental health techs and nurses assigned to her care every two hours while she was in the facility. Review of Patient #2’s Nursing Plan of Care started on 08/29/2024 revealed no documentation of a care plan problem related to incontinence care or risk for impaired skin integrity. On 10/23/2024 at 3:55 p.m., an interview was conducted with S1QD. She stated the expectation for all nurses is to make sure the nursing care plans are individualized and current to the needs of each patient. She stated if a patient were to be incontinent and have a documented redden sacrum on admission that would mean they were at higher risk for potential skin breakdown and should be care planned accordingly. S1QD reviewed Patient #2’s nursing care plan and confirmed no documentation related to incontinence care or impaired skin integrity was on the nursing care plan and should have been. S2HA reviewed Patient #2’s nursing care plan and confirmed no documentation related to incontinence care or impaired skin integrity was on the nursing care plan and should have been.”

“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: 48050 Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment were maintained in such a manner that the safety and well-being of patients were assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair. Findings: On 10/23/2024 at 2:10 p.m. during a tour of the facility, the counter top in Room a was missing a piece of laminate exposing wood. In an interview on 10/23/2024 at 2:10 p.m. S1QD verified laminate was missing from the counter top in Room a exposing wood.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 48537 Based on record review and an interview, the hospital failed to ensure all patient treatments were within compliance of particular aspects of the patients’ individual treatment program as evidenced by failure to have a signed master treatment plan by MD for 1 (#2) of 3 (#1-#3) patients’ treatment plans reviewed for the sample. Findings: Review of the hospital policy number CS-02 titled, “Treatment Planning; Integrated/Multidisciplinary” last revised on 07/01/2024 revealed the following: Purpose: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. Policy: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient’s involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs and identified by the patient, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. Procedure: 1. The admitting physician is responsible for providing the following: -Prescribing treatment modalities for the initial plan of care in the psychiatric evaluation. -Providing direction to the multi-disciplinary team in the formulation of treatment planning goals, objectives and clinical interventions. -Certifying admission/stays and levels of care. -Documenting progress towards meeting the treatment objectives and direction for patient plan. 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). Review of Patient #3’s medical record revealed he was admitted to the facility on 10/18/2024 at 3:30 a.m. from an outside referring facility emergency room for dementia with behavioral disturbance. Review of Patient #3’s Interdisciplinary Treatment Plan Master Sheet dated 10/18/2024 was not signed by the physician. Review of Patient #3’s Interdisciplinary Treatment Plan Update - Inpatient dated 10/22/2024 was also not signed by the physician. On 10/23/2024 at 9:45 a.m., an interview was conducted with S7QA during patient record review. While reviewing the treatment plan, she confirmed the S8MD had not signed the Interdisciplinary Treatment Plan Master Sheet date 10/18/2024 or the Interdisciplinary Treatment Plan Update - Inpatient dated 10/22/2024. On 10/23/2024 at 10:15 a.m., an interview was conducted with S1QD. She stated interdisciplinary treatment plan master sheet is signed by the patient, admitting registered nurse, therapist/social worker, recreational therapist, and admitting psychiatric MD. She stated the weekly updated treatment plans are signed by the same individuals with the exception of the registered nurse may change depending on which nurse is caring for the patient on the day of the IDT meeting. She stated the master treatment plan is completed upon admission and is signed by the patient and admission nurse within 24 hours of the patient’s admission. The therapist/social worker, recreational therapist and psych MD have 72 hours from the time of the patient’s admission to the hospital to sign the master treatment plan. S1QD confirmed S8MD had not signed the Interdisciplinary Treatment Plan Master Sheet dated 10/18/2024 or the Interdisciplinary Treatment Plan Update - Inpatient dated 10/22/2024.”

“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: 48050 Based on record review and interview, the 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 of the MD to ensure the patient /patient representative was included in the development and implementation of the patient’s plan of care for 1 (#2) of 3 (#1-#3 ) patient medical records reviewed for care plan development and implementation. Findings: Review of the hospital’s policy titled, “Patient Rights Louisiana”, revised date 09/01/2023, revealed in part: PURPOSE: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient’s rights if deemed necessary. PROCEDURE: 4. If the patient is cognitively and/or physically unable to sign and comprehend this information about their rights, the patient’s guardian or a family member will be so informed and will sign for them legally appropriate; or if the patient is disoriented or in a state that impairs cognition at the time of entry, he/she is informed of his/her rights at an appropriate time during care, treatment, and services. Treatment: You have the right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. If you are unable to make decisions about the care, treatment, and services, the rights of involvement of family/surrogate decisions maker instated on the patient’s behalf will be respected in accordance law and regulations. Review of Patient #2’s medical record reveals documentation that Patient #2 remains confused, lethargic with poor insight and judgement with significant impairments and concentration throughout hospitalization. Furthermore social service staff documents working with Patient #2’s grandson to facilitate safe discharge. Patient #2 was living independent prior to hospitalization, but is no longer capable of doing so because Patient #2 requires supervision and assistance. Social service staff documents three times that Patient #2’s grandson request the MD caring for Patient #2 to communicate Patient #2’s treatment plan, but no documentation that MD contacted Patient #2’s grandson. On 10/08/2024 at 2:30 p.m. S1QD verified the above mentioned documentation in Patient #2’s medical record. On 10/08/2024 at 2:30 a.m. S5CD verified the above mentioned documentation in Patient #2’s medical record. On 10/09/2024 at 10:00 a.m. an interview with S8MD verified that he did not communicate with Patient #2’s grandson.”

“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 observation and interview, the hospital failed to provide care in a safe setting. The deficient practice is evidenced by 1) failure of nursing staff to provide line of sight observation for a patient requiring oxygen therapy; and 2) failure of nursing staff to ensure the unit was free of restricted items. Findings: 1) Failure of nursing staff to provide line of sight observation for a patient requiring oxygen therapy. Review of Policy AS-01, “Assessment Process Inpatient,” revised 06/01/2024 revealed in part, “ Procedure: Intake Professional: . . . 3. The findings are communicated with the Director of Nursing (DON), Registered Nurse (RN), and /or Physician/Non-Physician Practitioner (NPP) to review the physician needs of the patient, i.e. medical equipment, safety issues, medications, etc. and to determine the most appropriate treatment for the patient.” Review of Policy NSG-21, “Oxygen Therapy,” reviewed 06/01/2023 revealed in part, “7. Monitor the patient’s safe use of oxygen and provide safety instructions. (i.e., keep away from flammables, electric sparks, etc.) 8. The physician will consider and order the appropriate level of observation (i.e. line of sight, 1:1, etc.) when patients on oxygen or other continuous respiratory devices such as CPAP, are not under direct supervision in the general milieu.” Review of the nurse to nurse admission report for Patient #4 revealed admission on 08/14/2024 with a diagnosis of major depressive disorder, dementia, chronic obstructive pulmonary disease, and congestive heart failure. The nurse also reported the patient was “total assist x 2” and the patient required oxygen at 2 liters/ minute via nasal cannula. Review of the nursing admission assessment revealed the patient was not at increased risk for elopement, falls or suicide. Review of the orders revealed the patient was to be observed every 15 minutes. Tour of the facility on 08/15/2024 at 12:27 p.m. revealed Patient #4 lying in her bed receiving oxygen from a portable concentrator. There was no one inside the room and no one with a visible line of sight. In interview on 08/15/2024 at 12:27 p.m., S2QD verified the patient should have been on line of sight observation when receiving oxygen therapy in her room. 2) Failure of nursing staff to ensure the unit was free of restricted items. Review of Policy NSG-22, “Body and Belongings Search,” revised 07/01/2024 revealed in part: “Contraband items include the following: . . . Any substance or object felt to be potentially injurious to the patient or that may be used as a weapon,” and “All contraband items as described in this policy are to be inventoried, documented, and secured/locked with luggage and returned upon discharge.” Tour of the facility on 08/15/2024 at 12:25 p.m. revealed a paper bag with a patient’s belongings on the floor unattended in Room “a.” Further inspection revealed a large box of colored pens sitting at the top of the bag. A patient returned to the room and explained her belongings had been returned to her because she had been discharged and was waiting to leave. The patient then exited the room again leaving the items unattended. In interview on 08/15/2024 at 12:25 p.m., S2QD verified the items should not have been returned to the patient while she was still on the unit.”

“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 hospital failed to ensure the patient’s right to have a complete, individualized treatment plan and 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 a complete and individualized patient plan of care for 1 (#3) of 3 (#1- #3) sampled patient records reviewed. Findings: Review of the hospital’s policy titled, “Patient Rights”, revised 09/01/2023, revealed in part: Policy, in part: The organization supports the patient’s right to care, treatment and services within its mission and applicability to law and regulation, and supports and protects the fundamental human, civil, constitutional and statutory rights of each patient. Treatment, in part: ...You have the right to an individualized treatment plan ...You have the right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. If you are unable to make decisions about the care, treatment, and services, the rights of involvement of family/surrogate decisions maker instated on the patient’s behalf will be respected in accordance low and regulations. Review of Patient #3’s medical record revealed an admission date of 07/21/2024 at 5:50 p.m. and discharge date of 07/27/2024. Diagnoses included autism with poor impulse control, Suicidal Ideation, Major Depressive Disorder, Mood Disorder, and Medication Non-Compliance. Review of Patient #3’s Interdisciplinary Treatment Plan, dated 07/21/2024 at 6:07 p.m. failed to reveal Problem: Autism. Further review failed to reveal short term/long-term goals, outcomes and interventions pertaining to Autism. Continued review failed to reveal discharge plans, patient strengths and assets, labilities and special needs, diagnosis, and observation levels. Further review failed to reveal a physician signature indicating the physician participated in the development of this treatment plan. Additional review failed to reveal the patient’s or patient representative’s signature indicating Patient #3’s participation in this treatment plan. Review of Patient #3’s Interdisciplinary Treatment Plan-Update, dated 07/25/2024 at 10:25 a.m. failed to reveal Problem: Autism. Further review failed to reveal short term/long-term goals, outcomes and interventions pertaining to Autism. In an interview on 07/30/2024 at 3:47 p.m., S3QD confirmed Patient #3’s Treatment Plans dated 07/21/2024 and 07/25/2024 failed to reveal the problem Autism and the short term/long-term goals, outcomes and interventions pertaining to Autism. In an interview on 07/30/2024 at 4:03 p.m., S3QD confirmed Patient #3’s Treatment Plan dated 07/21/2024 failed to reveal the patient’s or patient representative’s signature indicating participation in this treatment plan. S3QD verified the treatment plan was incomplete as above.”

“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: 50453 Based on record review and interview the hospital failed to protect patients from neglect as evidenced by failing to investigate and report allegations of neglect in 1 (#1) of 3 (#1-#3) sampled patients. Findings: Review of the hospital’s policy titled, “Abuse and/or Neglect of Patients by Staff Members, Students, Interns,” effective date 01/11/2016, revealed in part: Policy: Patients have the right to be free from neglect, exploitation, and verbal, mental, physical and sexual abuse. Definition of “Abuse” is the infliction of physical or mental injury ... to the extent that his health or mental or emotional well-being is endangered. Definition of “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. No employee or student will mistreat and/or neglect a patient. Examples of actions/inactions which could be considered mistreatment/abuse include: ...Failing to or refusing to attend to necessary care and treatment; implementing actions contrary to the prescribed treatment of the program; failing to intervene to protect a patient from abuse and/or mistreatment. Any staff suspected of any infractions will be investigated under this policy. Review of the hospital’s policy titled, “Transportation of Patients/Prospective Patients,” revised 11/01/2023, revealed in part: Purpose: To outline guidance for the provision of safe and effective transportation to prospective or currently admitted patients. Policy: All Transportations provided by the facility for prospective patient or a currently admitted patient will be provided according to the assessed security needs of the individual. Transportation could include ... Outpatients requiring transport to program. Outpatient Transports: 2. Arrangements to Attend Program: ...forwards directions to transportation coordinator. 3. Transportation Coordinator: Assigns driver to transport patient to and from outpatient program. 4. Drivers: Transports patients to and from program unless otherwise specified by Program Administrator. Review of Patient #1’s medical record revealed a diagnosis of Intellectual Disability, Bipolar Disorder, and Impulse Control. Patient #1 was admitted to the Intensive Outpatient Program (IOP) on 06/17/2024 after inpatient treatment. Patient #1 lives at Location A and is transported to IOP via Transport C which is contracted with the IOP facility. During an interview on 07/30/2024 at 9:50 a.m. S5IOPLPN stated she communicates to the driver of Transport C regarding which patients to transport. S5IOPLPN enters information into System D which communicates specifics about the patients regarding transport needs. Patient information is entered before 3 p.m. so the drivers are aware of any precautions/notes for the next morning. During an interview on 07/30/2024 at 12:05 p.m. S5IOPLPN stated that Patient #1 has specific instructions that have been conveyed to Transport B drivers in regards to drop off locations. S5IOPLPN stated that Patient #1 is not to be dropped off at Location A until after 3 p.m. and is to be dropped off at Location B prior to 3:00 p.m. This was arranged because staff are not available to receive patients before 3 p.m. at Location A. S5IOPLPN explained that once a message is entered by her for a patient, the drivers are able to see it on their end. During an interview on 07/30/2024 at 12:10 p.m. S5IOPLPN was able to navigate System D used to communicate with the drivers regarding patients who are picked up and brought to IOP. A review of system log for Patient #1 for 06/17/2024, 06/24/2024, and 07/24/2024 revealed the following: Patient being dropped off before 2:30 p.m. patient needs to be dropped off at location B. If after 3:00 p.m. patient is to be dropped off at location A. Further review revealed that looking at the calendar view, the note was visible for the Patient #1. During an interview on 07/30/2024 at 12:15 p.m. S5IOPLPN stated the notes usually transfer over on an excel sheet for patients, but the note for Patient #1 did not transfer over during review of system with S5IOPLPN. S5IOPLPN confirmed that the drivers have access to this view and should have seen the note. During an interview on 07/30/2024 at 12:20 p.m. S5IOPLPN confirmed she had been notified of 2 incidents (06/19/2024 and 06/24/2024) involving Patient #1. Both incidents have notes documented in Patient #1’s medical record. Review of Patient #1’s medical record revealed a progress note entered by S5IOPLPN from 06/19/2024 at 8:39 a.m. stating “Patient was involved in an incident on the bus, she fell on another patient, was informed by S11SD.” During an interview on 07/30/2024 at 12:25 p.m. S5IOPLPN confirmed that the patient was transported via ambulance for further evaluation post fall on 06/19/2024. Review of Patient #1’s medical record revealed a progress note entered by S5IOPLPN from 06/24/2024 at 2:19 p.m. stating: Was informed by S4DIOP that one of the patients on the bus called her and stated the bus driver dropped Patient #1 off at Location A alone and no one was there. S5IOPLPN immediately called the S11SD at 2:19 p.m. and told him S12D just dropped off a MR patient home alone and no one was there. S11SD told me he was going to call the driver immediately and have them return to pick the patient back up until proper drop off time. Further review of Patient #1’s medical record revealed the following progress notes entered by S5IOPLPN from 06/25/2024: at 11:28 a.m. - Received a call from Director of Location B, he was calling to make sure the psychiatric hospital was aware of the patient being left at the group home alone. I let Director of Location B know the moment I was made aware I notified the S11SD. 11:38 a.m. - Received call from Supervisor of Location B, she again informed me of what happened when the driver left the patient home alone, she stated the patient was dropped off 2:06 p.m. on 06/24/2024 with temps at 93 degrees outside, and when the driver returned it was 25-30 minutes later the staff had arrived home by that time. She requested the contact information for the transportation supervisor. She also stated she will be filling a complaint of neglect with state against Transport C. I notified the interim administrator. During an interview on 07/30/2024 at 2:35 p.m. with S5IOPLPN, she does not keep a log of complaints that come through to her. She documents a note in the patient chart regarding the issue. S5IOPLPN also notifies the clinical director of complaints (including those involving Transport C). Review of the incident log failed to reveal a documented incident involving Patient #1. Review of the self-report log failed to reveal a documented incident involving Patient #1. Review of the complaint/grievance log failed to reveal a documented incident involving Patient #1. During an interview on 07/30/2024 at 2:37 p.m. S3QD confirmed that there was no incident on the log for incidents involving Patient #1 for 06/19/2024 or 06/24/2024. During an interview on 07/31/2024 at 10:07 a.m. S9RVP confirmed that the incidents involving Patient #1 should have had an incident report completed.”

“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 identify, measure, analyze, and track adverse patient events. This deficient practice is evidenced by failure of the hospital staff to identify 2 incidents involving harm to Patient #1. Findings: Review of the hospital policy titled, “Quality Assessment and Performance Improvement Plan,” Revised 02/01/2019, revealed in part: ...the organization is dedicated to providing safe, compassionate and quality care ...The Governing Board ensures the QAPI plan reflects the complexity of the hospital’s services, including ...contract services, and focuses on indicators related to improved health outcomes ...and corrective actions as indicated. Procedure, in part: 1 ....Provide for a facility-wide program that ensures the facility designs processes well and systematically measures, assesses, analyzes, and improves its performance to achieve optimal patient health outcomes in a collaborative and interdisciplinary approach. These processes include mechanisms to assess the needs and expectations of patients ... Ensure that Improvement process is organization-wide, monitors, assesses and evaluates the quality and appropriateness of patient care and clinical performance to identify changes that will lead to improved performance and reduce the risk of sentinel events. Corrective actions are taken and evaluated when problems or improvement opportunities are identified ... Provide appropriate reporting of information to the Governing Board to furnish it with the information it needs in fulfilling its responsibility for the quality of patient care and safety. 2. Important key aspects and processes of care to health and safety of patients are identified. Included are those that ... place patients at risk or serious consequences if care is not provided correctly or not provided when indicated ... b. Performance of patient care and quality control activities in the following services are monitored assessed and evaluated, in part: Contracted Services. Review of the hospital policy titled, “Incident Reporting,” effective date 02/01/2024, revealed in part: Purpose: To document any potential or adverse incidents within the facility or on the facility grounds/property/vehicle, with the facts available at the time, recorded by persons involved either in the incident or in the discovery of the incident. Policy: Facility staff will report all patient incidents using the facility’s electronic incident reporting system (EIRS) or a paper incident report. Definitions: Patient Incident - anything that is out of the expected norm for the patient ... Incident Reporting Investigation: 1. Upon completion of entry into the EIRS, the system will send an email to the identified hospital leadership for notification and investigation. 2. Each department Director is responsible for reviewing incidents that occur in their area, investigating and completing follow-up. 7. The Quality Director and Hospital Administrator are mandatory reviewers of all incidents. 9. The Quality Director shall track and trend all incident types. 10. All aggregated data should be brought forward to the appropriate committee for performance improvement activities. Review of the hospital policy titled, “Patient Grievance Process,” revised 07/01/2024, revealed in part: Policy: The Governing Body is responsible for effective operation of the complaint/grievance resolution process. Each facility has identified an individual to serve as the facility Patient Advocate who is responsible for the investigation, follow-up and response to grievances submitted by a patient or caregiver. Definitions: Complaint: An expression of dissatisfaction, however made, about the standard of service, actions or lack of action by staff or regarding the facility and is resolved by staff present at the time the complaint is made, requiring no further resolution. Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient’s rights. Grievance Procedures: 1. The Patient Advocate logs the grievance allegation onto the “Complaint/Grievance Log” and opens an investigation to determine the validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. If the grievance is regarding an allegation of abuse or neglect, the patient advocate escalates the concern to the hospital leadership immediately and appropriate state mandatory guidelines for reporting will be followed ... Role of the Patient Advocate: 1. Maintains a complete “Complaint/Grievance Log” along with files and results of all grievances ... 2. Complete a thorough investigation of all grievances ... 3. Responsible for reporting all grievance investigation findings and resolutions to QAPI committee and ensuring the Governing Board receives an updated and accurate Complaint/Grievance log. Role of the Administrator: 1. Ensure appropriate policies and procedures are followed for grievances alleging abuse and neglect of patients. 3. Updates the Governing Board on the Complaint/Grievance log. Review of Patient #1’s medical record revealed a diagnosis of Intellectual Disability, Bipolar Disorder, and Impulse Control. Patient #1 was admitted to the Intensive Outpatient Program (IOP) on 06/17/2024 after inpatient treatment. During an interview on 07/30/2024 at 12:20 p.m. S5IOPLPN confirmed she had been notified of 2 incidents (06/19/2024 and 06/24/2024) involving Patient #1. Both incidents have notes documented in Patient #1’s medical record. Review of Patient #1’s medical record revealed a progress note entered by S5IOPLPN from 06/19/2024 at 8:39 a.m. stating “Patient was involved in an incident on the bus, she fell on another patient, was informed by S11SD.” During an interview on 07/30/2024 at 12:25 p.m. S5IOPLPN confirmed that the patient was transported via ambulance for further evaluation post fall on 06/19/2024. Review of Patient #1’s medical record revealed a progress note entered by S5IOPLPN from 06/24/2024 at 2:19 p.m. stating: Was informed by S4DIOP that one of the patients on the bus called her and stated the bus driver dropped Patient #1 off at Location A alone and no one was there. S5IOPLPN immediately called the S11SD at 2:19 p.m. and told him S12D just dropped off a MR patient home alone and no one was there. S11SD told me he was going to call the driver immediately and have them return to pick the patient back up until proper drop off time. Further review of Patient #1’s medical record revealed the following progress notes entered by S5IOPLPN from 06/25/2024 at 11:28 a.m. - Received a call from Director of Location B, he was calling to make sure the psychiatric hospital was aware of the patient being left at the group home alone. I let Director of Location B know the moment I was made aware I notified the S11SD. 06/25/2024 at 11:38 a.m. - Received call from Supervisor of Location B, she again informed me of what happened when the driver left the patient home alone, she stated the patient was dropped off 2:06 p.m. on 06/24/2024 with temps at 93 degrees outside, and when the driver returned it was 25-30 minutes later the staff had arrived home by that time. She requested the contact information for the transportation supervisor. She also stated she will be filling a complaint of neglect with state against Transport C. I notified the interim administrator. During an interview on 07/30/2024 at 2:35 p.m. S5IOPLPN confirmed that she does not keep a log of complaints that come through to her. She documents a note in the patient chart regarding the issue. S5IOPLPN also notifies the clinical director of complaints (including those involving Transport C). Review of the current quality indicators being monitored in the QAPI program failed to reveal documented evidence of quality indicators for contracted transportation services. During an interview on 07/30/2024 at 1:23 p.m., S3QD confirmed contracted transportation services are not included and monitored in the QAPI program and should be part of the QAPI program moving forward. Review of the incident log failed to reveal any documented incidents involving Patient #1. Review of the self-report log failed to reveal any documented incidents involving Patient #1. Review of the complaint/grievance log failed to reveal any documented incidents involving Patient #1. During an interview on 07/30/2024 at 2:37 p.m. S3QD confirmed that there was no documented incident on the logs involving Patient #1 for 06/19/2024 or 06/24/2024. During an interview on 07/31/2024 at 9:29 a.m. S8CD confirmed that both incidents involving Patient #1 occurred prior to her hire date. S8CD confirmed they have not been logging incidents/complaints for IOP. S8CD confirmed there are no open complaints on the complaint log at this time. During a 07/31/2024 at 10:07 a.m. S9RVP confirmed that the incidents involving Patient #1 should have had an incident report completed.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... 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) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital’s governing body failed to ensure the Quality Assessment and Performance Improvement (QAPI) program reflected the complexity of the hospital’s services as evidenced by failing to include all contracted services in the QAPI program. Findings: Review of the hospital policy titled “Quality Assessment and Performance Improvement Plan” Revised 02/01/2019, revealed in part: ...the organization is dedicated to providing safe, compassionate and quality care ...The Governing Board ensures the QAPI plan reflects the complexity of the hospital’s services, including ...contract services, and focuses on indicators related to improved health outcomes ...and corrective actions as indicated. Procedure, in part: 1 ....Incorporate quality planning throughout the facility that includes, but is not limited to, high risk, high volume, high cost, and potentially increased patient safety risk priorities ...Provide appropriate reporting of information to the Governing Board to furnish it with the information it needs in fulfilling its responsibility for the quality of patient care and safety. b. Performance of patient care and quality control activities in the following services are monitored assessed and evaluated, in part: Contracted Services. Review of the current quality indicators being monitored in the QAPI program failed to reveal documented evidence of quality indicators for contracted transportation services. In an interview on 07/30/2024 at 1:23 p.m., S3QD agreed contract services providing services affecting the health and safety of patients should be part of the QAPI continuous monitoring activities. S3QD verified contracted transportation services are not included and monitored in the QAPI program and should be part of the QAPI program moving forward.”

“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 facility failed to meet the requirements for the Condition of Participation (CoP) for Patients’ Rights. The deficient practice is evidenced by: 1. Failure to have inpatient room doors that allow easy access to patients related to proper use of locks and/or if the keyhole had been tampered with by a patient. Staff having to use a key to access the patient room could allow the patient the ability to tamper with the lock and/or insert an object into the key hole, which could prevent or delay the staff obtaining access to the patient (see findings under Tag A0144); 2. Failure to ensure 15 minute observations of adolescent psychiatric patients were performed as ordered (see findings under Tag A0144); 3. Failure to provide privacy during personal bathing (shower) by having no shower curtains for the shower stalls (see findings under Tag A0143); 4. Failure to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the view from the outside into 10 of 10 patient rooms observed (see findings under Tag 0143). An Immediate Jeopardy (IJ) was identified on 06/05/2024 at 3:45 p.m. and reported to S1QD and S2RADM. The Immediate Jeopardy (IJ) situation was the result of the hospital’s failure to ensure patient safety. A second Immediate Jeopardy (IJ) situation was the result of the hospital’s failure to easily access patients due to improper lock usage. The hospital’s failure to maintain adequate supervision of patients created the potential for serious harm/injury. On 06/06/2024 S1QD and S2RADM presented the plan for lifting the immediacy of the IJ. The plan included re-education in regards to monitoring compliance with observation, rounding and reviewing camera footage and re-education regarding proper use of locks in patient care areas. On 06/06/2024 at 11:00 a.m. the Immediate Jeopardy was removed and remains at a Condition level.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 50453 Based on observation and interview, the hospital failed to ensure each patient has the right to personal privacy. This deficient practice had the potential to impact any of the 12 adolescent patients that were on the unit during the time of the survey and is evidenced by: 1. Failure to provide privacy during personal bathing (shower) by having no shower curtains for the shower stalls; 2. Failure to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the view from the outside into 10 of 10 patient rooms observed. Findings: A review of hospital policy, “Patient Rights Louisiana,” last revised 09/01/2023, revealed in part: Purpose: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient’s rights if deemed necessary. Treatment: You have the right to treatment that recognizing and respects your personal dignity, confidentiality, privacy and security. Rights of Minors: A. Each minor patient has a right to care provided in a dignified and humane manner, and to such privacy as is possible consistent with the minor’s treatment plan. 1. Failure to provide privacy during personal bathing (shower) by having no shower curtains for the shower stalls. Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed 4 shower stalls in the bathroom with no shower curtains to allow for privacy while performing hygiene. The patients are able to be visualized by staff unclothed while showering. During patient shower time, staff remain outside of room (cc) unless performing q15 minute observations of patient. In an interview during the tour on 06/03/2024, S1QD indicated that there are no shower curtains due to the patients pulling them down. 2. Failure to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the view from the outside into 10 of 10 patient rooms observed. Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed 10 of 10 rooms lacked any covering over the windows in the bedrooms to provide privacy from passersby on the outside of the building. In an interview during the tour on 06/03/2024, S1QD and S4ADON confirmed that people on the outside of the building would be able to see into the rooms, and personal privacy was not provided.”

“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 and interview, the hospital failed to ensure patients requiring inpatient psychiatric care received care in a safe setting. This deficient practice was evidenced by: 1. Failure to have inpatient room doors that allow easy access to patients related to proper use of locks and/or if the keyhole had been tampered with by a pateint; 2. Failure to ensure 15 minute observations of adolescent psychiatric patients were performed as ordered; 3. Failure to follow MD order by failing to maintain LOS; 4. Failure to provide the order level of observation for a patient in seclusion. Findings: Review of facility policy, “Level of Observations,” last revised 03/01/2023, revealed in part: Three levels of observation are utilized: every 15-minutes (Q15 minutes) observation; Line of Sight (Constant Observation); and one-to-one observation ... Every 15-minutes - the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. Line of Sight (Constant Observation) - the staff member will ensure the patient is visually within sight at all times. One-to-one observation - the staff will ensure the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. Procedure 3 ... The observing staff initials the 15-minute increments on the form to indicate the patient was observed. Line of Sight Observations: The designated staff (MHT) is assigned to perform line of sight observation and can observe multiple patients, but must remain in the area with the patients such that if a patient needs immediate intervention, the staff member can intervene and call for assistance. Line of sight observation level includes constant observation in the bathroom and toilet areas, unless the door is able to be left ajar and the observer is able to access the room immediately. One-to-one Observation: is defined as: Keeping the patient under direct observation within one arm’s reach of the patient at all times. This includes use of bathroom and bathing. 1. Failure to have inpatient room doors that allow easy access to patients related to proper use of locks and/or if the keyhole had been tampered with by a pateint. An observation during a tour revealed that each inpatient room door locks from the outside upon closing. In order to open a closed door, the patient must either open it from the inside or a staff member must use a key to open the door from the outside within the main hall. Staff having to use a key to access the patient room could allow the patient the ability to tamper with the lock and/or insert an object into the key hole, which could prevent or delay the staff obtaining acess to the patient. On 06/05/2024 from 12:45 p.m. - 1:50 p.m., during a review of video footage dated 06/05/2024 from 7:00 a.m. - 11:00 a.m., revealed main hallway. S12MHT was assigned to perform q15 minute observations on patient #16. Review of footage revealed the following: -10:13 a.m. S12MHT rounds on patient #16 in his room. -10:27 a.m. S12MHT goes to round on patient #16 in room (m). Video footage shows S12MHT knock on patient door. S12MHT then gets her key and unlocks patient door from main hallway to access patient. Unable to view how long patient door had been closed. During an interview on 06/05/2024 at 1:15 p.m. S1QD confirmed findings above. 2. Failure to ensure 15 minute observations of adolescent psychiatric patients were performed as ordered. In an interview on 06/05/2024 at 1:40 p.m., S1QD confirmed the following 3 patients on the night shift of 06/04/2024 were assigned to rooms (i-p): -Patient #17 in room (j) -Patient #16 in room (m) -Patient #18 in room (p) On 06/05/2024 from 12:45 p.m. - 1:50 p.m., a review of video footage dated 06/04/2024 from 10:00 p.m. - 5:00 a.m., revealed main hallway. S11MHT observing rooms 105, 107, and 108 is viewed slumped forward with her head on the table and not moving to make observations of patients she was assigned to. No direct observations made for room (i-p) during the following periods: 1:30 a.m. - 2:59 a.m. 3:30 a.m. - 4:58 a.m. In an interview on 06/05/2024 during review of video footage S1QD confirmed findings above. In an interview on 06/05/2024 at 2:00 p.m. S1QD confirmed S11MHT signed observation sheets but did not actually round per video footage during the times above. In an interview on 06/05/2024 at 9:40 a.m., S1QD confirmed the following patient on the day shift of 06/05/2024 was assigned to room (m): - Patient #16 in room (m) On 06/05/2024 from 12:45 p.m. - 1:50 p.m., a review of video footage dated 06/05/2024 from 7:00 a.m. - 11:00 a.m., revealed main hallway. S12MHT was assigned to perform q15 minute observations on patient #16. No direct observations made on patient #16 during the following periods: 7:03 a.m. - 7:45 a.m. 8:52 a.m. - 9:44 a.m. In an interview on 06/05/2024 during review of video footage S1QD confirmed findings above. In an interview on 06/05/2024 at 2:00 p.m. S1QD confirmed S12MHT signed observation sheets but did not actually round per video footage during the times above. 3. Failure to follow MD order by failing to maintain LOS. Review of a self-report incident that occurred on 05/16/2024 at 6:19 a.m. revealed that patient #1 was on LOS observation when he was involved in an altercation with another patient. S13MHT was assigned to maintain LOS on Patient #1, reported that he did not witness incident. In an interview on 06/06/2024 at 10:00 a.m. S3DON confirmed that S13MHT did not maintain LOS as per MD order on patient.”

“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: 48050 Based on record review and interview, the hospital failed to ensure patients were free from abuse and 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 was evidenced by the hospital’s failure to thoroughly investigate all reported cases of possible abuse or neglect in 1of 11 reviewed incidents that was reported to Louisiana Department of Health. Findings: 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. Review of hospital policy revised 11/01/2023 titled “Assessment and Reporting of Abuse, Neglect” revealed in part: PROCEDURE: Procedure to Respond to Alleged or Suspected Abuse, Neglect, Exploitation by Facility staff or by another patient. 2. If the allegations involves another patient or a staff member of the facility, the Administrator/Administrator-on-Call are responsible to ensure a thorough investigation is performed and will respond immediately to address any clinical assessments and ensure the provision of any clinical interventions necessitated by the circumstances and perform an investigation to determine if the allegations are substantiated. Review of hospital policy revised 09/01/2023 titled “Patient Rights Louisiana” revealed in part: Abuse, Neglect, Exploitation, Harassment: You have the right to be free from mental, physical, and verbal abuse; neglect; exploitation; and/or harassment. Review of hospital policy revised on 03/01/2023 titled, “Level of Observations” revealed in part: Observation Levels: Line of Sight (Constant Observation)- the staff member will ensure the patient is visually within sight at all times. Review of Self-Reports for April and May 2024 revealed, in part, “11 incidents involving patient altercations.” One incident investigated involving an altercation between Patients #1, #8, #18. The Self-Report reviewed indicated that the facility investigated incident and found allegations unsubstantiated. Further review revealed Patient #1 was on a line of sight observation which S13MHT was assigned during time of incident. S13MHT reported not witnessing the event therefore not following MD order. In an interview on 06/06/2024 at 10:17 a.m. S4ADON indicated performing the investigation regarding the altercation involving Patients #1, #8, and #18, but failed to substantiated incident not recognizing S13MHT was not following MD orders for line of sight observation on Patient #1. S4ADON verified that hospital policies/procedures for level of observations were not followed.”

“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: 48050 Based on record review and interview the hospital failed to analyze and track all adverse patient events. The deficient practice is evidenced by failure of hospital staff to initiate an incident reports after a patient exhibited self-harm behavior. Findings: Review of hospital policy effective date 02/01/2024 titled, “Incident Reporting” revealed in part: PURPOSE: to document any potential or adverse incidents within the facility or on the facility grounds/property/vehicle, with the facts available at the time, recorded by persons involved, either in the incident or in the discovery of the incident. DEFINITIONS: Patient incident- anything that is out of the expected norm for the patient. Incident Severity: Mild harm: minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and/or increased length of stay. No harm: Event reached the patient, but no harm was evident. On 06/04/2024 medical record review revealed that Patient #4 had punched a wall on 04/25/2024 and 04/29/2024. Furthermore neither incidents were reported per hospital policy/procedures. On 06/04/2024 review of Incident Reporting Log did not reveal entries for Patient #4 punching a wall on 04/25/2024 or 04/29/2024. In an interview on 06/04/2024 at 11:20 a.m. S1QD verified no incident report was entered for Patient #4 punching a wall on 04/25/2024 and/or 04/29/2024.”

“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: 48050 Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. This deficiency is evidenced by failure of the Registered Nurse to perform neurovascular checks for Patient #8 per NPP order. Findings: Review of hospital policy revised 01/01/2023, titled “Documentation” reveal in part: PURPOSE: To maintain a comprehensive and chronologically continuous account of treatment delivered to a patient by nursing staff. ROUTINE: 3. Documents the implementation and execution of physician and NPP orders. Review of Patient #8’s medical record revealed a NPP ordered neurovascular checks every 4 hours ordered 05/16/2024 7:28 p.m. to start at 9:00 p.m. and ordered to continue neurovascular checks every 4 hours on 05/17/2024 at 8:06 p.m. Review of nursing documentation revealed neurovascular checks done on 05/16/2024 at 9:00 p.m., and on 05/17/2024 at 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 3:20 p.m., and on 05/18/2024 at 1:00 a.m., 5:00 a.m., 1:00 p.m. The nurse missed the neurovascular assessments on 05/18/2024 at 9:00 a.m. and 7:30 p.m. In an interview on 06/05/2024 at 10:28 a.m. S1QD verified that there were no nursing neurovascular assessments for Patient #8 on 05/18/2024 at 9:00 a.m. and 7:30 p.m.”

“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: 50453 Based on record review and interviews the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient’s needs for 6 (#8, #17, #19-#22) of 14 (#8-#9, #16-#27) patients on the unit. Findings: Review of facility policy titled, “Seclusion and Restraints - LA/MS/OK,” last revised on 05/01/2024, revealed in part: Definition: Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for management of violent or self-destructive behavior. 3. Utilization of Seclusion: *Assign a trained/competent staff member to provide one-to-one observation of the patient for continuous monitoring while in seclusion. Review of facility policy, “Level of Observations,” last revised 03/01/2023, revealed in part: Three levels of observation are utilized: every 15-minutes (Q15 minutes) observation; Line of Sight (Constant Observation); and one-to-one observation ... Every 15-minutes - the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. Line of Sight (Constant Observation) - the staff member will ensure the patient is visually within sight at all times. One-to-one observation - the staff will ensure the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. Procedure 3 ... The observing staff initials the 15-minute increments on the form to indicate the patient was observed. Line of Sight Observations: The designated staff (MHT) is assigned to perform line of sight observation and can observe multiple patients, but must remain in the area with the patients such that if a patient needs immediate intervention, the staff member can intervene and call for assistance. Line of sight observation level includes constant observation in the bathroom and toilet areas, unless the door is able to be left ajar and the observer is able to access the room immediately. One-to-one Observation: is defined as: Keeping the patient under direct observation within one arm’s reach of the patient at all times. This includes use of bathroom and bathing. On 06/05/2024, Medical Record Review of patient #17 revealed that patient #17 was put in seclusion with 1:1 observation on 05/25/2024 from 12:18 p.m. - 12:50 p.m. Further review of observation documentation during seclusion revealed S14MHT documented q15 minute checks on the observation flowsheet for patient #17 who was on a 1:1 level of observation, while also documenting q15 minute checks on 5 other patients (#8, #19-#22). On 06/05/2024 at 12:10 p.m., S1QD confirmed the findings above.”

“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: 50453 Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment were maintained in such a manner that the safety and well-being of patients were assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair. Findings: Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. and on 06/04/2024 from 10:11 a.m. - 10:22 a.m. revealed the following: 1. The mirror bubble in top right corner of the ceiling was broken and the trim was missing from bottom left side of room (u). Restraint chair dirty with rust colored areas noted. 2. Plastic Reference board sign on the wall of (v) was damaged to right bottom corner. 3. Toilet seats were broken in 3 (w, x, and y) out of the 7 (z-cc) bathrooms. 4. Cover not secured covering pipes under the sink was loose and hanging in room (x). 5. There were 4 card board boxes stacked on floor between carts in the room (dd). 6. Missing floor tiles noted in 2 (p, t) out of 20 (a-o, q-s) patient rooms. In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour.”

“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, record review, and interview, the facility failed to ensure facilities, supplies and equipment, were maintained to an acceptable level of safety and/or quality. This deficient practice is evidenced by: 1. Failure to ensure expired supplies were not available for patient use; 2. Failure to ensure the emergency cart is inspected daily. Findings: Review of policy, “Emergency Cart,” last revised 05/01/2021, revealed in part: Procedure: 6. The emergency cart is inspected daily by the designated nursing staff on the designated shift. This inspection includes the following: a. Inspection, stock, and clean cart as needed. b. Identify, remove, and replace expired items. c. Document the completed emergency cart check on the provided checklist. d. Notify the Director of Nursing of any needed supplies that are not readily available for restocking. 1. Failure to ensure expired supplies were not available for patient use. Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed 1 box of Med Gel Adult Resting Tab ECG Electrodes, quantity of 4, with an expiration date of 11/04/2022. In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour. 2. Failure to ensure emergency cart is inspected daily. Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed the Emergency Cart Checklist Log for May revealed missing code cart checks for 05/21/2024, 05/22/2024, and 05/31/2024. In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour. Reviewed copy of Emergency Cart Checklist Log provided. Further review revealed original missing dates discovered during tour were no longer blank. S1QD re-confirmed that dates 05/21/2024, 05/22/2024, and 05/31/2024 were blank during the tour. In an interview, on 06/03/2024 at 2:25 p.m. S3DON confirmed that she altered the Emergency Cart Checklist Log and falsified documentation for 05/21/2024, 05/22/2024, and 05/31/2024 on the original log.”

“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: 50453 Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by: 1. Failing to maintain the temperature log for the patient nourishment refrigerator/freezer; 2. Failing to prevent storage of previously consumed items in the patient nourishment refrigerator; 3. Failing to maintain patient rooms in a sanitary condition. Findings: A review of facility policy, “Care and Monitoring of Refrigerators and Freezers,” last revised on 11/01/2023, revealed in part: Medications, food and nutrition products, and laboratory specimens will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security to maintain product stability. All refrigerator/freezer temperatures shall be maintained within acceptable standards to inhibit microbial growth and reduce the risk of infection. Refrigerator/Freezer Use: FOOD 2. Nutritional supplements and snacks for patients shall be stored in a refrigerator designated for patients only. 3. Food for employees shall be stored in a refrigerator designated for employees only. 4. Food stored in refrigerators should be discarded on a regular weekly schedule and/or when the food is past the printed expiration date. Temperature 1. Options for monitoring temperatures in refrigerators and freezers: Option 1: The temperature of any refrigerator or freezer that contains drugs, patient food, lab specimens, or blood will be checked and recorded in degrees Fahrenheit (*F) on a log ... The log shall contain acceptable temperature ranges for the storage unit, date of reading, temperature observed, and signature of person reading, along with any corrective measures taken. 2. If temperatures register above or below the appropriate range adjust thermostat and re-check temperature in 30 minutes. If temperature continues to be above or below the appropriate range, all stored items shall be removed, the viability of the items stored shall be determined and non-viable items shall be discarded. 3. Environment of Care (EOC) personnel must be notified immediately for an out-of-range temperature finding. 1. Failing to maintain the temperature log for the patient nourishment refrigerator/freezer. Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed a Patient Nourishment Refrigerator Temperature Log for May 2024 and June 2024 had documented dates with a normal range for Patient Nourishment Refrigerator of 32F-40F and Patient Nourishment Freezer of <0F. The following dates the Patient Nourishment Refrigerator was not within normal range (32F-40F) 05/01/2024-05/04/2024, 05/06/2024, 05/09/2024, 05/13/2024, 05/17/2024, 05/21/2024-05/23/2024, and 06/01/2024-06/02/2024. The following dates the Patient Nourishment Freezer was not within normal range (<0F) 05/06/2024-05/07/2024 and 05/23/2024. There was no comment or follow up regarding temperatures out of normal range. In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour. 2. Failing to prevent storage of previously consumed items in the patient nourishment refrigerator. Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed unlabeled personal staff items stored in the refrigerator. Chinese takeout container, takeout container containing Mexican food, red bull, glass starbucks coffee container, and bag with fruit noted in refrigerator. Freezer noted to have a bottle of frozen mountain dew not assigned or labeled to a patient. In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour. 3. Failing to maintain patient rooms in a sanitary condition. Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed the following: a) Room (a) had a clear liquid on panel covering overhead ceiling lights above first bed. In an interview on 06/03/2024, S1QD and S4DON confirmed the above mentioned findings during the facility tour. b) Room (cc) had wet dirty towels in a pile in the corner of the room. In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 48050 Based on record review and interview the hospital failed to document an appropriate discharge plan for each patient including discussion with the patient and the patient’s representative. This deficiency is evidenced by failure to provide an appropriate discharge plan in 3 (#4, #6, #10) of 7 (#5, #6, #7, #10, #11, #12, #4) discharged patients reviewed. Findings: Review of hospital policy PC-18, “Discharge Planning: Transition Record,” revised 02/01/2021 revealed in part,” PURPOSE: To establish for assisting patients to the appropriate level of psychosocial/physical care, treatment and services for post-treatment placement, follow-up, and/or transfer. PROCEDURE: 3. Discharge planning should encompass the following areas: Orders for continuing care to meet physical and psychosocial needs for discharge or transfer. Medical record review revealed Patient #4 was sustained a right hand injury on 04/30/2024 by punching a wall and NPP ordered a hand x-ray to be performed on 05/01/2024. Patient #4 was discharged on 04/30/2024 with no x-ray being performed or follow-up provided on the Transition Record related to right hand injury. In an interview on 06/04/2024 at 1:30 p.m. S1QD verified Patient #4 did not have right hand x-ray ordered completed or follow-up provided regarding right hand injury on his Transition Record. Medical record review of Patient #6 revealed the last medical NPP progress note on 04/30/2024 documented that patient needed further laboratory test and special diet. Patient was discharged on 04/30/2024 with no follow-up provided on the Transition Record related to laboratory testing and/or special diet. In an interview on 06/04/2024 at 1:40 p.m. S1QD verified Patient #6 did not have follow-up for laboratory tests or special diet on transition record. Medical record review revealed Patient #10 was sustained a bilateral hand injuries on 04/30/2024 by punching a wall and NPP ordered a bilateral hand x-rays to be performed on 05/01/2024. Patient #10 was discharged on 04/30/2024 with no x-rays being performed or follow-up provided on the Transition Record related to bilateral hand injuries. In an interview on 06/04/2024 at 1:45 p.m. S1QD verified that Patient #10 did not have bilateral hands x-ray completed or follow-up care provided regarding bilateral hand injuries on the Transition Record.”

“Treatment Plan - Adequate Documentation CFR(s): [The written plan must include] Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to revise a multidisciplinary treatment plan following a change in a patient’s status. This deficient practice was evidenced by: 1. Failure to update the multidisciplinary treatment plan following an incident of seclusion for 1 (#17) out of 18 (#1-#16, #18) patient records; 2. Failure to update treatment plan based on changes in patient condition on 6 (#2, #8, #9, #14, #15, and #17) out of 18 (#1, #3-#7, #10-#13, #16, and #18). Findings: Review of facility policy titled, “Seclusion and Restraints - LA/MS/OK,” last revised on 05/01/2024, revealed in part: Documentation: Treatment Plan: The use of restraint or seclusion must be in accordance with a documented modification to the patient’s treatment plan. The treatment plan must be reviewed and updated at the time of the debriefing or within 24 hours from the seclusion/restraint episode. Treatment Team: 1. The Treatment Team will review the occurrence and use of seclusion/restraints and modify the patient’s plan of care as needed. 2. The Treatment Team must explore whether alternative treatment strategies for the future should be considered when restraint or seclusion is used. Review of facility Policy titled, “Treatment Planning; Integrated/Multidisciplinary,” last revised on 04/01/2021, revealed in part: Purpose: To document and implement treatment objectives/interventions ... throughout the course of patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided ... Revising the plan based on changes in condition and physician’s orders. All physician orders will be incorporated into the Treatment Plan. 1. Failure to update the multidisciplinary treatment plan following an incident of seclusion for 1 (#17) out of 18 (#1-#16, #18) patient records. Review of patient #17 medical record revealed on 05/25/2024 at 12:18 p.m. the patient was put in seclusion following an incident with another patient. The patient was taken out of seclusion at 12:50 p.m. Further review of patient #17 multidisciplinary treatment plan revealed no revision to include the patient’s change in status, interventions implemented, including the use of seclusion, and revision of the treatment goals. In an interview on 06/05/2024 at 12:14 p.m. S1QD confirmed that the treatment plan had not been revised following Patient #17 change in condition resulting in the use of seclusion. 2. Failure to update treatment plan based on changes in patient condition on 6 (#2, #8, #9, #14, #15, and #17) out of 18 (#1, #3-#7, #10-#13, #16, and #18). Review of medical records for 6 6 (#2, #8, #9, #14, #15, and #17) out of 18 (#1, #3-#7, #10-#13, #16, and #18) revealed that the Care Plans were not updated and had no added interventions following the incidents involving patients. In an interview on 06/05/2024 at 12:21 p.m. S1QD confirmed the findings above.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by: 1) failure of the Registered Nurse to supervise, observe and evaluate the care provided by MHTs by rounding every 2 hours, and 2) Failure of the RN to document on the Nursing Shift Assessment a minimum of once per shift (See findings under Tag A0395)”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48050 Based on record review and interview the facility failed to ensure patient complaints were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 2 (#1, #2) of 2 (#1, #2) patients reviewed for complaints/grievances from a total patient sample of 6. Findings: Review of facility policy revised 02/01/2023, titled “Patient Grievance Process” revealed, in part: Policy, in part: A grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, and/or patient’s rights. PROCEDURE: If the patient and/or family file a grievance allegation as defined above, the grievance process is initiated immediately. Review of the Grievance/complaint log revealed no evidence of grievances related to Patient #1 and Patient #2. In an interview on 04/01/2024 at 12:35 p.m. S4CD verified that Patient #1’s sister called the facility upset that patient regarding Patient #1’s medication. S4CD revealed that it had been past 30 days since discharge of Patient #1 so no resolution was given. In an interview on 04/01/2024 at 3:10 p.m. S4CD verified that Patient #2’s family called the facility multiple times upset regarding Patient #2’s discharge plan due to Patient #2’s decline in health and inability to care for herself. In an interview on 04/03/2024 at 12:45 p.m., S1RADM confirmed that the grievance process should have been implemented for Patient #2.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48050 Based on record review and interview the hospital failed to ensure each patient or patient representative consented to treatment and was informed of his or her patient rights. This deficient practice is evidenced by no signed consent for treatment or signed patient rights information form for 1(#3) of 6 (#1-#6) patients sampled. Findings: A review of facility policy revised date 09/01/2023 titled “Patient Rights Louisiana” revealed, in part: PURPOSE: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient’s right if deemed necessary. PROCEDURE: 1. The patient is to be given a copy of the Patient’s Rights as part of the Patient Handbook that is reviewed at the time of admission by a program staff member. The patient acknowledges receipt of their written statement of rights by signing the Statement of Patient Acknowledgement which becomes a part of the medical record. A review of Patient #3’s medical record revealed, in part, that patient was admitted on 03/22/2024. Further review failed to reveal evidence of a signed consent for treatment. Continued review failed to reveal evidence of a signed document indicating Patient #3 was informed of their patient rights. In an interview on 04/02/2024 at 10:15 a.m. S3DON confirmed there was no evidence of a signed consent for treatment. S3DON further confirmed there was no evidence of a signed document that Patient #3 was informed of their patient rights.”

“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: 48050 Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. This deficiency is evidenced by 1) failure of the Registered Nurse to supervise, observe and evaluate the care provided by MHTs by rounding every 2 hours on 4 (#3-#6) of 6 (#1-#6) patients. 2) Failure of the RN to document on the Nursing Shift Assessment a minimum of once per shift in 3 (#1, #2, #6) of 6 (#1-#6) patients’ medical records reviewed. Findings: Review of hospital policy revised 03/01/2023, titled “Level of Observations”, revealed, in part: PROCEDURE: 3. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section (s) of the form. Review of hospital policy revised 01/01/2023, titled “Documentation” revealed in part: Daily: The Registered Nurse (RN) documents or reviews the LPN/LVN documentation on the Nursing Shift Assessment a minimum of once per shift. 1) Review of Patient #3’s medical record revealed on 03/29/2024 at 1:00 a.m. the RN didn’t conduct a safety round every 2 hours as per hospital policy/procedure. In an interview on 04/02/2024 at 11:28 a.m. S3DON verified the RN didn’t conduct an every 2 hours safety round for Patient #3 on 03/29/2024 at 1:00 a.m. Review of Patient #4’s medical record revealed on 03/24/20024 at 5:00 p.m.; 03/25/2024 at 3:00 p.m. and 5:00 p.m.; and 03/29/2024 at 1:00 a.m. the RN didn’t conduct safety rounds every 2 hours as per hospital policy/procedure. In an interview on 04/02/2024 at 2:25 p.m. S3DON verified the RN didn’t conduct an every 2 hours safety rounds for Patient #4 on 03/24/20024 at 5:00 p.m.; 03/25/2024 at 3:00 p.m. and 5:00 p.m.; and 03/29/2024 at 1:00 a.m. Review of Patient #5’s medical record revealed on 03/25/2024 at 3:00 p.m. and 5:00 p.m. the RN didn’t conduct safety rounds every 2 hours as per hospital policy/procedure. In an interview on 04/02/2024 at 4:15 p.m. S3DON verified the RN didn’t conduct an every 2 hours safety rounds for Patient #5 on 03/25/2024 at 3:00 p.m. and 5:00 p.m. Review of Patient #6’s medical record revealed on 03/12/2024 at 9:00 p.m. and 11:00 p.m. the RN didn’t conduct safety rounds every 2 hours as per hospital policy/procedure. In an interview on 04/03/2024 at 10:10 p.m. S3DON verified the RN didn’t conduct an every 2 hours safety rounds for Patient #6 on 03/12/2024 at 9:00 p.m. and 11:00 p.m. 2)Review of Patient #1’s medical record revealed no Nursing Shift Assessment for 01/09/2024 night shift. In an interview on 04/01/2024 at 1:00 p.m. S3DON verified Patient #1 did not have a nursing shift assessment for 01/09/2024 night shift. Review of Patient #2’s medical record revealed no Nursing Shift Assessment for 03/11/2024 day shift. In an interview on 04/01/2024 at 3:30 p.m. S3DON verified Patient #2 did not have a nursing shift assessment for 03/11/2024 night shift. Review of Patient #6’s medical record revealed no Nursing Shift Assessment for 03/14/2024 night shift. In an interview on 04/02/2024 at 9:55 a.m. S3DON verified Patient #6 did not have a nursing shift assessment for 03/14/2024 night shift.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 48050 Based on record review and interview the hospital failed to provide regular re-evaluation of the patient’s condition to identify changes that required modification of the discharge plan. This deficiency is evidenced by failure of the hospital to address Patient #2’s Mini Mental State Exam (MMSE) score of 11 which indicates 10-20 points: moderate dementia on treatment plan and at time of discharge. Findings: Review of hospital policy last revised 04/10/2021, titled “Treatment Planning: Integrated/ Multidisciplinary”, revealed in part: PURPOSE: To document and implement objectives/ interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. Review of hospital policy last revised 01/01/2023 titled, “Documentation” revealed in part: Routine: 1. RN and/or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) documents all extraordinary occurrences and special needs in the multidisciplinary progress notes and documents any notifications or issues reported to the physician or non-physician practitioner (NPP), as applicable. The daily nurse note is only for daily assessment and expected daily occurrences. Review of Patient #2’s medical record revealed a Mini Mental State Exam assessment and score of 11 which indicates moderate dementia. Further review revealed this was not addressed on the care plan and there was no documentation the patient was referred for evaluation and treatment after discharge. In interview on 04/01/2023 at 3:10 p.m., S4CD verified both the hospital staff and the family of Patient #2 had expressed concerns about her decline in mental status and ability to care for herself after discharge. Furthermore S4CD verified there is no documentation in Patient #2’s medical record that the MD was notified of staffs’ concern. In an interview on 04/03/2024 9:20 a.m., S3DON verified staff was concerned for Patient #2’s safety upon discharge. Furthermore S3DON verified Patient #2 was discharged after the CEC was no longer in effect and the patient refused to sign a formal voluntary admission. There was no evidence the patient was referred for evaluation and treatment as an outpatient at the time of discharge In an interview on 04/03/2024 9:20 a.m., S3DON verified staff was concerned for Patient #2’s safety upon discharged.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure all patients treatments were within compliance of particular aspects of the patients’ individualized treatment program as evidenced by failure to have documentation that a treatment team conference was held every 7 days in 1 (#1) of 6 (#1-#6) patients’ medical records and that MD didn’t signed 3 (#2, #4, #6) of the 6 (#1-#6) patients’ medical records reviewed. Findings: Review of hospital policy last revised 04/10/2021, titled “Treatment Planning: Integrated/ Multidisciplinary”, revealed in part: PURPOSE: To document and implement objectives/ interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or willing to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient’s medical record. Coordinating documentation of the treatment plan reviews and revisions to reflect patient progress and any discharge/continuing stay criteria every seven (7) days or at key decision points with multi-disciplinary treatment. Review of Patient #1’s medical record revealed that the treatment plan was initiated 12/29/2023, updated on 01/03/2024 and 01/11/2024. In an interview on 04/03/2024 at 12:15 p.m. S3DON verified Patient #1’s treatment plan was not updated every 7 days per hospital policy/procedure. Review of Patient #2’s medical record revealed no MD signature on the treatment plan. Review of Patient #4’s medical record revealed no MD signature on the treatment plan. Review of Patient #6’s medical record revealed no MD signature on the treatment plan. In an interview on 04/03/2024 at 12:20 S3DON verified Patient #2, #4, #6’s treatment plans were not signed by the MD.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38777 Based on video review, observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. This was evidence by: 1) Failing to ensure staff rounded every 15 minutes on 19 (#1-#19) psychiatric patients of 19 (#1-#19) psychiatric patients with 15 minute observations ordered. (See findings under Tag A0144); 2) Failing to ensure staff identified and reported allegations of abuse for 1 (#1) of 1 (#1) patient reviewed for reporting abuse. (see findings under Tag A0145); 3) Failing to ensure the use of seclusion was performed according to hospital policy. This deficient practice is evidenced by failure to notify the family of 1 (#1) of 1 (#1) patients who was placed in seclusion. (See findings under Tag A0167); 4) Failing to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. (See findings under Tag A0168); 5) Failing to ensure staff provided continuous monitoring for a patient in seclusion. (See findings under Tag A0175); 6) Failing to ensure a one hour face to face evaluation was performed by a physician, other licensed practitioner, or a trained registered nurse for a patient who was placed and released from seclusion. (See findings under Tag A0178).”

“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: 38777 Based on video review and interviews, the hospital failed to ensure staff rounded every 15 minutes on 19 (#1-#19) psychiatric patients of 19 (#1-#19) psychiatric patients with 15 minute observations ordered. Findings: A review of hospital policy titled Level of Observations last revised 03/01/2023 revealed in part: Observation Levels: Every 15 minutes- the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. Physically walks to find each patient on q 15 minute observations. Documents patient’s location and reports identified risk to RN when indicated. Documents the location on the close observation form and documents the activity when indicated, e.g., water offered, and etc. Initials the form every 15 minutes. On 03/21/2024 a review of video footage from 3/20/2024 revealed the following: 8:32 p.m. revealed Patient #1 in hallway. 8:33 p.m. Patient #1walks into Patient #2’s room “a” and closed the door. S6MHT was seen in the hallway, she was assigned Patient #1 and Patient #2. 8:42 p.m. Patient R1 is seen coming out his room “b” and going into Patient #2’s room “a” and immediately back out. 9:08 p.m. No one is seen going back into Patient #2’s room until 9:08 pm Patient #1 exits the room “a”. Patient #1 then walks down the hallway to the bathroom. 9:09:05 p.m. Patient #1 enters the bathroom. Staff are noted in the hallway. Patient #1 does not speak with staff. 9:09:59 p.m. Patient #1 exits the bathroom. 9:10 p.m. Patient #1 goes into Patient #2’s room “a” and exits at 9:12: 39 with his beddings in his arms. 9:12 p.m. Patient #1 is in the hallway talking with staff. 9:13 p.m. Patient #1 speaks with S4RN. 9:14 pm Patient #1 is seen fighting with Patient R2 9:15:54 p.m. Patient #1 placed in the seclusion room by S5LPN and S6MHT. 9:21 p.m. S4RN checks on Patient #1. 9:29 p.m. S7MHT checks on Patient #1. 9:39 p.m. S4RN let Patient #1out of seclusion. In an interview on 03/21/2024 at 4:10 p.m. S1RAdm and S2Adm verified the above information and all 19 admitted patients were on q 15 minute observations. Further review of video footage revealed staff failed to check on Patient #2 from 8:33 p.m. till 9:10 p.m. In an interview on 03/21/2024 at 4::20 p.m. S1RAdm verified staff failed to conduct observation rounds on Patient #2 as noted above. In an interview on 03/22/2024 at 1:20 p.m. S1RAdm verified staff did not round from 8:33 p.m. on 03/20/2024 until S7MHT rounded on the 11 female patients at 9:21 p.m. and no one rounded on the 6 male patients till the fight at 9:14 p.m. S6MHT and S7MHT were in the hallway with backs to the hall and S5LPN was in the nutrition room. During this time frame approximately 6-7 residents were in and out their rooms; therefore staff did not do observations for the other 10 patients. A review of video footage from 03/21/2024 between 2:00 a.m. to 5:10 a.m. S4RN is seen making rounds at 2:55 a.m. and 5:10 a.m.; however, the Mental Health Technicians failed to make rounds on all 19 patients. In an interview on 03/21/2024 at 4:30 p.m. S1RAdm verified the MHTs failed to round every 15 minutes between 2:00 a.m. and 5:10 a.m. on 03/21/2024.”

“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: 38777 Based on interviews, the hospital failed to ensure staff identified and reported allegations of abuse for 1 (#1) of 1 (#1) patient reviewed for reporting abuse. Findings: A review of hospital policy title Assessment and Reporting of Abuse and Neglect last revised 01/01/2023 revealed in part: 1. Should a staff member identify, or be notified of a suspected case of abuse, neglect, and exploitation, he/ she will notify his/ her immediate supervisor and the Administrator- on - Call and the Director of Nursing (DON) immediately. On 03/22/2024 at 12:39 p.m. S6MHT stated she was assigned Patient #1 and Patient #2. S6MHT said that Patient #1 told her that Patient #2 threw him on the bed and sucked his privates. On 03/22/2024 at 12:50 p.m. in an interview S4RN stated she was sitting in the nurse’s station and Patient #1 was talking to S6MHT and Patient #1 said he wanted to go home. S4RN also said that Patient #1 said Patient #2 sucked his penis. In an interview on 03/22/2024 at 10:16 a.m. S2Adm stated S6MHT and S7MHT stated Patient #1 reported the incident to them but they did not believe it because they only saw him go in the room briefly. In an interview on 03/22/2024 at 10:25 a.m. S3DON verified the staff failed to report abuse per policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 38777 Based on record review and interview, the hospital failed to ensure the use of seclusion was performed according to hospital policy. This deficient practice is evidenced by failure to notify the family of 1 (#1) of 1 (#1) patients who was placed in seclusion. Findings: A review of hospital policy titles Seclusion and Restraints LA/MS last revised 06/01/2024 revealed in part: 5. Notify the family as applicable of seclusion/ restraint. Family Notification: 1. The legally authorized representative (LAP) shall be notified as soon as feasible but not greater than 24 hours of each episode of seclusion/ restraint initiated in response to a behavioral emergency. 2. The date and time of notification and the name of the staff member providing the notification must be documented in the patient’s medical record. 3. Documentation will include an unsuccessful attempts, telephone numbers called, and name of the person spoken with. A review of Patient #1’s medical record failed to reveal documentation his family was notified that he was placed in seclusion. In an interview on 03/22/2024 at 10:25 a.m. S3DON verified the staff failed to notify Patient #1’s family of being placed in seclusion. In an interview on 03/22/2024 at 12:50 p.m. S4RN stated she did not recall telling Patient #1’s mother that Patient #1 was in seclusion with the door closed and locked. In an interview on 03/22/2024 at 1:08 p.m. S5LPN stated she and S7MHT placed Patient #1 in the seclusion room with the door closed and locked.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 38777 Based on policy review, record review and interview, the hospital failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice is evidenced by 1 (#1) of 1 (#1) patients sampled being placed in soft restraints with no physician’s order. Findings: A review of hospital policy titled Seclusion and Restraints LA/ MS last reviewed 06/01/2023 revealed in part: Additionally, only the trained Registered Nurse may initiate the emergency application of restraint or seclusion prior to obtaining an order from the physician or NPP. The physician/ NPP will be notified as soon as possible after the initiation of seclusion and/ or restraint. The RN will document physician/ NPP contact and physician order on Physician Order for Seclusion and Restraint Form. For facilities with electronic medical record (EMR), the physician or NPP will directly enter the physician’s order in the ENR. The physician/ NPP order must include the specific behaviors which constituted the behavioral emergency, specify the reason for restraint or seclusion, the type of restraint, and duration of seclusion or restraint. In an interview on 03/22/2024 at 10:25 a.m. S3DON verified the staff failed to document any details about placing Patient #1 in seclusion to include and order for the seclusion. On 03/22/2024 at 12:50 p.m. in an interview S4RN admits the door was closed to the seclusion room and it locks automatically. S4RN denies documenting any of the incident, sexual allegations, fight, or seclusion order.”

“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: 38777 Based on policy review, video surveillance review and interview the hospital failed to ensure staff provided continuous monitoring of 1 (#1) of 1 (#1) patients observed in seclusion per hospital policy. Findings: A review of hospital policy Seclusion and Restraints LA/MS last reviewed 06/01/2023 revealed in part: 3. Utilization of Seclusion: Assign a trained/ competent staff member to provide one- to- one observation of the patient for continuous monitoring while in seclusion. On 03/21/2024 a review of video surveillance from 03/20/2024 revealed in part: 9:14 p.m. Patient #1 is seen fighting with Patient R2. 9:15:54 Patient #1 placed in the seclusion room by S5LPN and S6MHT. 9:21 p.m. S4RN checks on Patient #1. 9:29 p.m. S7MHT checks on Patient #1. 9:39 p.m. S4RN let Patient #1out of seclusion. In an interview on 03/21/2024 at 4:10 p.m. S1RAdm and S2Adm verified the above information. In an interview on 03/21/2024 at 4:12 p.m. S3DON verified staff failed to ensure Patient #1 was continuously monitored while in seclusion.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 38777 Based on policy review, record review and interview the hospital failed to ensure a one hour face to face evaluation was performed by a physician, other licensed practitioner, or a trained registered nurse. This deficiency is evidenced by the failure to document a one hour face to face evaluation in 1 (#1) of 1(#1) reviewed patient placed in seclusion. Finding: A review of hospital policy title Seclusion and Restraints- LA/MS last reviewed 06/01/2023 revealed in part: 4. Face to face evaluation: A one- hour face to face evaluation must be conducted in person by a physician or other NPP, or trained RN in the absence of the physician or NPP. A telephone call or telemedicine methodology is not permitted. A review of Patient #1’s medical record failed to reveal a documented face to face evaluation after being placed in seclusion. Conduct one hour face to face, if trained to do so, even if the patient is no longer in restrain/ seclusion and physician is not present. Document on the Face to Face Evaluation Form: date/ time, patient’s immediate situation, patient’s reaction to the intervention, patient’s medical and behavioral condition, need to continue or terminate the restraint or seclusion, behaviors, alternative interventions to prevent restraint/ seclusion, medical review of patient’s status post- intervention. In an interview on 03/22/2024 at 10:25 a.m. S3DON verified the staff failed to document any details about placing Patient #1 in seclusion to include a face to face evaluation after being placed in seclusion.”