Physicians Behavioral Hospital

“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 and interview, the facility failed to ensure the patients right to care in a safe setting as evidenced by: 1) Failure to ensure unsecured rooms in the patient care area were locked and not accessible to patients; and 2) Failure to ensure the packaged thermal air conditioner (PTAC) in Rooms “a” - “z” was secured by a ligature free enclosure that would prevent a patient from accessing the interior components of the PTAC which could potentially cause injury or self-harm. Findings: 1) Failure to ensure unsecured rooms in the patient care area were locked and not accessible to patients Observations during a walk - through of the facility on 12/09/2025 from 3:15 p.m. to 4:30 p.m. revealed Room “yy” unlocked and containing the following items: --Janitorial cart which was unlocked with some of its contents being multiple plastic trash liners; -- a wooden mop handle; -- a metal mop handle; --2, 5-gallon buckets of iSHine Floor Finisher; and --1, 5-gallon bucket of Shineline Emulsifier. All of the above-mentioned items could potentially be used by a patient for self-harm/injury or injury to other patients. This placed current Patients #R2 - #R14 at risk for harm and/or injury. In an interview on 12/11/2025 and present during the walk-through, S2AAdm and S3HM confirmed the above-mentioned findings and confirmed Room “yy” should be locked and secured. 2) Failure to ensure the packaged thermal air conditioner (PTAC) in Rooms “a” - “xx” were secured by a ligature free enclosure that would prevent a patient from accessing the interior components of the PTAC which could potentially cause injury or self-harm Observations during a walk - through of the facility on 12/09/2025 from 3:15 p.m. to 4:30 p.m. revealed Patients #R9, #R11, #R15 and #R16 rooms having a PTAC that was not secured by a ligature free enclosure. Without a secured ligature free enclosure, a patient would have the potential to remove the plastic front panel of the PTAC and access the mechanical components and parts of the PTAC. This had the potential for all current patients and future patients to create an environment in which self-injurious/harmful behaviors could exist and/or harm to other patients. In an interview on 12/09/2025 and present during the walk-through, S2AADM and S3HM confirmed the above-mentioned findings and further confirmed patient rooms “a” - “vv” and seclusion rooms “ww” - “xx” had a PTAC and further confirmed each of these PTACs were not enclosed by a ligature free enclosure.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48051 Based on record review and interview, the governing body, medical staff and administrative officials failed to ensure all departments of the hospital were measuring, tracking, and analyzing the effectiveness and safety of services and quality of care. Findings: A review of the facility’s document titled, “QUALITY/PERFORMANCE IMPROVEMENT PLAN 2025,” revealed in part: “Purpose On an annual basis the Quality/Performance Improvement Plan is reviewed and update to reflect priorities in providing quality care in a safe environment to all patients. The purpose of the Physicians Behavioral Hospital’s (PBH) Quality/Performance Improvement Plan is to provide framework for a collaboratively planned, systematic and organization-wide approach to improving patient care and organization performance. It is designed to provide an integrated and comprehensive program that will monitor, assess, and improve the quality of patient care delivered at this facility.” The purpose of this plan indicated an organization -wide approach, however this Quality/Performance Improvement Plan failed to reveal quality improvement indicators for 2025 that were related to the services or functions provided by the Outpatient Services department of the facility. A review of the Medical Executive Committee Meeting Minutes from 02/18/2025, 06/24/2025, and 09/17/2025 failed to reveal discussion of Quality Assurance Performance Improvement (QAPI) data related to the Outpatient Services of the facility. Further, the QAPI data that was presented to committee failed to reveal date related to the Outpatient Services of the facility. A review of the Committee of the Whole Meeting Minutes from 02/17/2025, 06/24/2025, and 09/16/2025 failed to reveal discussion of QAPI data related to the Outpatient Services of the facility. Further, the QAPI data that was presented to committee failed to reveal date related to the Outpatient Services of the facility. In an interview on 12/10/2025 at 2:28 p.m. S4UR confirmed the above-mentioned data and confirmed the data that is being collected for Outpatient Services was not presented to these committee members.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility failed to ensure the discharge summary included all requirements of the facility policy and all requirements set forth in the behavioral health service (BHS) provider state regulations for an Intensive Outpatient Program (IOP) at La R.S. 48:5649E in 2 (#1, #2) of 3 sampled patients medical records. Findings: A review of facility policy, “Discharge Summary,” policy number HIM006, with an approval in 2008 (month and day not available) and last revised in 2025 (month and day not available), revealed in part: “PROCEDURE The Discharge Summary shall include the following: A. Identifying information 1. Name of Physician 2. Date 3. Patient’s name, age, and sex 4. Date of admission 5. Date of discharge B. Initial assessment and Diagnosis 1. Reason for admission (to include mental and legal status) 2. Pertinent history and physical findings 3. Admitting diagnosis and Discharge Diagnosis C. Findings 1. Pertinent negative and positive laboratory 2. Pertinent negative and positive x-ray findings D. Hospital Course 1. Course and progress of patient by each problem number 2. Special procedures and treatment of patients by each problem 3. Identify any known complications such as fractures, seizures, infections, adverse medication effects, suicide attempts, cardiac arrest 4. Consultation findings and recommendations E. Condition on discharge 1. Patient’s ability to function at the time of discharge 2. Patient’s behavior at the time of discharge (include useful approaches; and problems and issues yet to be worked on after discharge) 3. Prognosis F. Post Hospital Care Plans 1. Include prescribed medications and dosage (include knowledge and attitude toward medication) 2. Aftercare plans (include recommended modality of therapy and frequency, as well as name of who will provide aftercare, when, and where) 3. Dietary and/or restrictions G. Final Diagnosis H. Signature of Physician” A review of behavioral health service (BHS) provider state regulations at La R.S. 48:5649E revealed in part: “Discharge Summary. The BHS provider shall ensure that each client record contains a written discharge summary that includes: 1. the client’s presenting needs and issues identified at the time of admission; 2. the services provided to the client; 3. the provider’s assessment of the client’s progress towards goals; 4. the discharge disposition; and 5. the continuity of care recommended following discharge, supporting documentation and referral or transfer information.” A review of medical records revealed the following: A review of Patient #1’s discharge summary failed to reveal the patient’s presenting needs and issues identified at the time of admission, a discharge and final diagnosis, the services provided to patient over their admissions, the course and progress of the patient towards their goals, and the patient’s condition at time of discharge, including the patient’s ability to function at the time of discharge and problems and issues yet to be worked on after discharge. A review of Patient #2’s discharge summary failed to reveal a discharge and final diagnosis, the services provided to patient over their admissions, the course and progress of the patient towards their goals, and the patient’s condition at time of discharge, including the patient’s ability to function at the time of discharge and problems and issues yet to be worked on after discharge. In an interview on 12/10/2025 at 2:00 p.m. S3DOTS confirmed the above-mentioned findings. In an interview on12/10/2025 at 2:30 p.m. S1AADM confirmed the above-mentioned Discharge Summary policy would refer to inpatient and outpatient discharges.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48051 Based on observation and interview, the facility failed to ensure clean linen was stored in a clean and sanitary to avoid sources and transmission of infection. Findings: Observations during a walk - through of the facility on 12/09/2025 from 3:15 p.m. to 4:30 p.m. revealed clean linen stacked in Rooms “zz” and “aaa.” Room “zz” had a shelving unit with multiple face towels and bath towels being stored uncovered. The towels in Room “zz” were being exposed to multiple staff members walking through this room and to following items: 1 clothes washer, 1 clothes dryer, 3 brown bags of patient belongings (confirmed by S2HM as needing to be laundered), a vending machine, a mop bucket and mop, a dust mop, and 3-5-gallon containers of Kentwood Water (sealed). Room “aaa” had shelving with multiple stacks of clean linen (face towels, bath towels, bed linens, and blankets) being stored. The clean linen in these 2 rooms was not covered and protected from exposure to the environmental elements of each room. In an interview on 12/09/2025 and present during the walk-through, S2AADM and S3HM confirmed the above-mentioned findings and S3HM further confirmed the clean towels should not be stored in Room “zz” and all clean linen should be covered.”

“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: 20310 Based on record review and interview, the provider failed to ensure the patient has the right to be free from all forms of abuse by failing to provide information regarding abuse and neglect (to include reporting requirements, prevention, intervention and detection) during the orientation training for 2 of 6 employees whose personnel files were reviewed (S2MHT, S3MHT). Findings: Review of the personnel files revealed S2MHT was hired 08/17/2024 and S3MHT was hired 12/17/2024. Review of the training logs for S2MHT and S3MHT revealed no documented evidence of training related to abuse and neglect. On 01/08/2025 at 12:50PM, an interview with S1ADM confirmed that the above employees had not received training regarding abuse and neglect during their orientation and had not received training as of this date.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 17450 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: Failure of the hospital to provide supervision as ordered by the physician for 1 current patient on 1:1 observation level (Patient #1), 1 current patient on LOS observation level (Patient #2) and 18 current random patients on routine observation levels (Patients #R1-R18). This resulted in an Immediate Jeopardy Situation. S1Administrator was notified on 9/18/2024 at 4:00 p.m. The hospital provided the following plan of removal for the Immediate Jeopardy situation: Eliminate Line of Sight observation status from policy. Medical director approval on 9/19/2024 and Board approval completion dated by 9/20/2024. Retrain/Inservice per NSG 034 Levels of Observation policy for 1:1 9/18/2024. Establish 1:1 Accounting Log and inservice starting 09/18/2024. This will ensure the 1:1 are assigned timely an ensure q12hr assessment/reassessment and no excessive 1:1 utilization. Establish Nurse and MHT Assignment Sheet to be utilized every shift every day, 9/18/2024. This will establish direct patient accountability between nurse and MHT. We anticipate all staff will be inserviced by 9/27/2024. However, as the direct caregivers work assigned shifts, they will be inserviced and caught up to speed relative to this training or they will not work. Root Cause Analysis: the direct oversight by nursing leadership has neglected the routine rounding and evaluation of the q15 observations sheets performed by the MHT. The nurses became reliant upon the MHT performing these duties but failed to routinely audit the MHT knowledge in real-time of each patient exact whereabouts at all times. Immediate Corrective Actions: created 1:1 Accounting Log, created Nurse/MHT Assignment sheets, Inservice for q15 retraining, 1:1 accounting log, Nurse/MHT Assignment sheets Short Term Corrective Measures: 1:1 accounting sheets will identify the patient that is currently on 1:1 and have the charge nurse sign the acknowledgement sheet, get the initials of the nurse assigned to said patient on 1:1 and time the nurse assessment for continued observation status if warranted. This will create a more proactive approach, at least 3 times a day, to acknowledge that the patient in fact still warrants such strenuous observation status. Nurse/MHT assignment sheets will memorialize and create top of mind awareness of which nurse is assigned to what MHT, therefore the nurse will have more proactive accountability to the q15 observation indexing. We will revise the NSG 034 Nursing Levels of Observation policy to remove line of sight as a status. Patients will either be routine observation or 1:1 per doctor’s order. Monitoring and Ongoing Compliance: In order for the jeopardizing circumstance not to reoccur, routine audits will be performed. Nurse assigned the specific patient will routinely audit through the shift the q15. The process will be vertically audited beyond that. The Nurse/MHT assignment sheets will be audited by the DON. The 1:1 accounting logs will be audited by the Compliance Manager. On 09/19/2024 at 12:45 p.m., the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiency remains at a Condition level (See findings in A0144);”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 17450 Based on observation, record review, and interview, the hospital failed to ensure patients receive care in a safe setting as evidenced by: 1) Failure of the hospital to provide supervision as ordered by the physician for 1 current patient on 1:1 observation level (Patient #1), 1 current patient on LOS observation level (Patient #2) and 18 current random patients on routine observation levels (Patients #R1-R18); 2) Failure of the hospital to provide supervision as ordered by the physician for 1 discharged patient who was sexually violated, while on ordered 1:1 observation level (Patient #3) and 3) Failure to ensure 1 patient did not have access to items considered contraband (Patient #4) Findings: 1. On 09/18/2024 at 1:35 p.m., observation on the “Grey Hall” revealed S2BHT was standing outside Patient #1’s door. Interview with S2BHT at that time revealed the patient was on 1:1 observation level. The surveyor asked S2BHT what 1:1 observation level meant and the tech stated that the patient was to be watched at all times. The surveyor asked if the tech could see the patient in his room if the tech was standing outside the room in the hallway and the S2BHT stated no. At that time, the surveyor entered Patient #1’s room and observed him awake sitting on the bed. The bed was unable to be visualized from the doorway of the room. Further interview with S2BHT at that time revealed there were 9 other patients on the hall, but S2BHT was the only tech on the hall at the time due to the other tech being off the hall. S2BHT stated there was also another patient on the hall on LOS observations (Patient #2). S2BHT stated the patient was in his room. The surveyor asked if that patient could be seen from the hallway, and S2BHT stated no. At that time, the surveyor entered Patient #2’s room and the patient was walking around the room. There was no supervision of the patient by any staff at that time. On 09/18/2024 at 1:45 p.m., observation reveals S2BHT walking down the hall passing out snacks to the patients on the hall. Patient #1 (1:1) was observed in his room and unable to be visualized from the hallway. On 09/18/2024 at 1:50 p.m., observation of the Close Observation logs for Patient #2 (LOS level) and Patients #R1-R8 (every 15 minute observation level) revealed the last documentation on the logs was at 1:15 p.m. (35 minutes since the patients had been observed by staff). At that time, S2BHT revealed that the other tech on the hall was responsible for documenting on the Close Observation logs for all patients except Patient #1 (1:1 patient). S2BHT confirmed the logs should be signed off by staff every 15 minutes, indicating that the patient was observed. S2BHT confirmed that the logs were not current and that the last documented observation of the other patients was at 1:15 p.m. (35 minutes earlier). On 09/18/2024 at 1:55 p.m., observation of the “Blue Hall” with S1Administrator revealed all patients were off the hall, either outside or seeing the physician. Observation of a clipboard on a table in the hall revealed all 10 patients Close Observation logs were on the clipboard. Review of the logs for Patients #R11-R20 revealed the last documented observation was at 1:15 p.m. (40 minutes earlier). At that time, S1Administrator confirmed the Close Observation logs should be current and up to date. S1Administrator further confirmed that there was no documented evidence that the patients were being observed per physician orders. On 09/18/2024 at 2:45 p.m., observations on the “Grey Hall” revealed that S2BHT was standing outside of Patient #1’s (1:1 observation level) room talking to another tech. The surveyor asked why the tech was not observing the patient in his room and S2BHT stated that he likes to give the patient “a little space and comfort”. The surveyor asked why the patient was on 1:1 observation level and S2BHT stated it was because the patient was aggressive. On 09/18/2024 at 3:25 p.m., observations on the “Grey Hall” revealed a new shift of techs was on the hall. Observation revealed S3BHT was standing outside of Patient #1’s room assisting with obtaining vital signs on another patient. The surveyor asked if Patient #1 was still on 1:1 observation level and S3BHT stated yes. The surveyor asked what that meant and S3BHT stated it meant to watch the patient at all times. The surveyor asked S3BHT if he could see the patient while he was standing in the hall and he stated no. Further observations at that time revealed Patient #2 (LOS level) was ambulating in the day room with no staff supervision. Review of the medical record for Patient #1 revealed an admit date of 09/13/2024 with chief complaint of being homicidal and suicidal. Review of the physician progress note on 09/14/2024 revealed the patient is aggressive and unable to direct on the unit. The patient is spitting on staff, broke the window out in his room, and charged at staff. On 09/14/2024 at 5:50 a.m., the physician wrote an order to place patient in active suicide and 1:1 for aggression and threats. Review of the medical record for Patient #2 revealed an admit date of 09/17/2024 with a diagnosis of paranoid schizophrenia. On 09/18/2024 at 2:30 p.m., interview with S4RN confirmed that the patient was on LOS observation level. On 09/18/2024 at 3:50 p.m., S1Administrator confirmed that patients on 1:1 monitoring levels should be observed at all times and within arm’s length of staff. S1Administrator also confirmed that patients on LOS observations should be in constant visual at all times. He further confirmed that all Close Observation logs should be current and signed off by staff every 15 minutes, indicating observation was performed. S1Administrator agreed that the lack of ordered observations placed the above patients at risk for serious injury, serious harm, serious impairment or death. 2. Review of the medical record for Patient #3 revealed an admit date of 09/02/2024. Diagnoses included bipolar disorder and recent manic episode with psychosis. Review of physician progress note dated 09/07/2024 revealed the patient was having increased agitation and aggression with hypersexual behaviors. The patient was ordered 1:1 observation level at this time. Review of physician progress note dated 09/12/2024 revealed patient remains 1:1 due to assault on staff member. Review of physician progress note dated 09/15/2024 revealed staff report defiant on unit. Remains 1:1 and attacked a tech earlier this week. Patient sat on another patient’s lap and allowed him to touch her inappropriately. Review of the LDH Hospital Abuse/Neglect Initial Report form dated 09/15/2024 at 8:45 a.m. revealed in part that the patient grabbed another patient’s hand and forced it down the front of her pants approaching her pubic area. The report further stated this is not alleged; this in fact happened as evidenced by both victim and aggressor’s acknowledgement of such. The initial actions taken stated that the patient’s courtyard privileges were immediately revoked. The report stated Patient #3 was on 1:1 observation level, starting on 09/07/2024, and remained on 1:1 until her discharge on 09/16/2024. The report further stated that the tech stated the patient needed to get some air and took the patient to the outside common area where the incident took place. On 09/18/2024 at 3:50 p.m., interview with S1Administrator confirmed that there was no investigation performed to determine how this sexual incident with Patient #1 occurred, since the patient was on 1:1 observation level. S1Administrator further confirmed there was no new interventions put in place, no increased monitoring of 1:1 patients and no further training conducted to the staff to ensure incidents like this one would not occur again. S1Administrator confirmed that that the lack of ordered 1:1 observations by the staff allowed Patient #1 to be sexually violated by another patient. 3. Review of the medical record for Patient #4 revealed an admit date of 09/12/2024 at 11:37 a.m. The patient was transferred from another facility due to paranoid and aggressive behaviors. Review of the admission nurses notes dated 09/12/2024 at 11:37 a.m. revealed that the patient would be on routine (every 15 minute) observations. Review of an incident report dated 09/12/2024 at 7:10 p.m. revealed that another patient reported that Patient #3 was standing in his window asking the other patient to raise up her shirt. A male tech went into Patient #3’s room to pull him from the window and the patient fought back swinging at the tech. The report further states that the patient hit the tech with an object and punctured the tech’s forearm with the object. Review of nurses notes dated 09/12/2024 at 7:15 p.m. revealed that the patient was observed by a tech to be masturbating in front of his bedroom window attempting to induce the patient on another hall (windows face each other) to pull up her shirt. The tech went into Patient #4’s room and the patient tried to stab the tech with an unknown object. There was an altercation between the patient and the tech. The patient now complains of left shoulder pain and was sent to the ER for evaluation. The tech has two puncture wounds on his inside right forearm. There was no documented evidence in the record that the patient nor his room was searched to locate the object that was used to injure the tech. On 09/19/2024 at 12:30 p.m., interview with S5DON revealed that she was unsure what type of object that Patient #4 used to stab the tech. She stated that they assumed it was a plastic fork because there were four puncture wounds on the tech’s arm. When asked if there had been any investigation to determine what object was used to injure the tech, S5DON stated no. On 09/19/2024 at 12:45 p.m., interview with S4RN revealed that she was working the evening that the incident occurred with Patient #4. When asked what Patient #4 used to stab the tech, S4RN stated that the patient was holding a small golf pencil when she walked into the room and that she assumed that was what was used. When asked if the patient or the room was searched for any other contraband after this incident, S4RN stated no. On 09/19/2024 at 1:55 p.m., interview with S1Administrator confirmed that a thorough investigation was not performed after this incident with Patient #4 to determine what the patient had used or how he had obtained it. When asked if the hospital had reviewed the process for searching patients upon admit for contraband after this incident, S1Administrator stated no. When asked if any new interventions or processes had been put in place after this incident with Patient #4, S1Administrator stated no.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program’s performance improvement program implemented preventive actions. This deficient practice is evidenced by the lack of an implemented preventive action plan following incidents involving patient observation levels and contraband. Findings: 1. Review of the medical record for Patient #3 revealed an admit date of 09/02/2024. Diagnoses included bipolar disorder and recent manic episode with psychosis. Review of physician progress note dated 09/07/2024 revealed the patient was having increased agitation and aggression with hypersexual behaviors. The patient was ordered 1:1 observation level at this time. Review of physician progress note dated 09/12/2024 revealed patient remains 1:1 due to assault on staff member. Review of physician progress note dated 09/15/2024 revealed staff report defiant on unit. Remains 1:1 and attacked a tech earlier this week. Patient sat on another patient’s lap and allowed him to touch her inappropriately. Review of the LDH Hospital Abuse/Neglect Initial Report form dated 09/15/2024 at 8:45 a.m. revealed in part that the patient grabbed another patient’s hand and forced it down the front of her pants approaching her pubic area. The report further stated this is not alleged; this in fact happened as evidenced by both victim and aggressor’s acknowledgement of such. The initial actions taken stated that the patient’s courtyard privileges were immediately revoked. The report stated Patient #3 was on 1:1 observation level, starting on 09/07/2024, and remained on 1:1 until her discharge on 09/16/2024. The report further stated that the tech stated the patient needed to get some air and took the patient to the outside common area where the incident took place. On 09/18/2024 at 3:50 p.m., interview with S1Administrator confirmed that there was no investigation performed to determine how this sexual incident with Patient #1 occurred, since the patient was on 1:1 observation level. S1Administrator further confirmed there was no new interventions put in place, no increased monitoring of 1:1 patients and no further training conducted to the staff to ensure incidents like this one would not occur again. S1Administrator confirmed that that the lack of ordered 1:1 observations by the staff allowed Patient #1 to be sexually violated by another patient. Observations during the survey on 09/18/2024 revealed Patient #1 was not observed at 1:1 observation level and Patient #2 was not observed at LOS observation level, as ordered by the physician. 2. Review of the medical record for Patient #4 revealed an admit date of 09/12/2024 at 11:37 a.m. The patient was transferred from another facility due to paranoid and aggressive behaviors. Review of the admission nurses notes dated 09/12/2024 at 11:37 a.m. revealed that the patient would be on routine (every 15 minute) observations. Review of an incident report dated 09/12/2024 at 7:10 p.m. revealed that another patient reported that Patient #3 was standing in his window asking the other patient to raise up her shirt. A male tech went into Patient #3’s room to pull him from the window and the patient fought back swinging at the tech. The report further states that the patient hit the tech with an object and punctured the tech’s forearm with the object. Review of nurses notes dated 09/12/2024 at 7:15 p.m. revealed that the patient was observed by a tech to be masturbating in front of his bedroom window attempting to induce the patient on another hall (windows face each other) to pull up her shirt. The tech went into Patient #4’s room and the patient tried to stab the tech with an unknown object. There was an altercation between the patient and the tech. The patient now complains of left shoulder pain and was sent to the ER for evaluation. The tech has two puncture wounds on his inside right forearm. There was no documented evidence in the record that the patient nor his room was searched to locate the object that was used to injure the tech. On 09/19/2024 at 12:30 p.m., interview with S5DON revealed that she was unsure what type of object that Patient #4 used to stab the tech. She stated that they assumed it was a plastic fork because there were four puncture wounds on the tech’s arm. When asked if there had been any investigation to determine what object was used to injure the tech, S5DON stated no. On 09/19/2024 at 12:45 p.m., interview with S4RN revealed that she was working the evening that the incident occurred with Patient #4. When asked what Patient #4 used to stab the tech, S4RN stated that the patient was holding a small golf pencil when she walked into the room and that she assumed that was what was used. When asked if the patient or the room was searched for any other contraband after this incident, S4RN stated no. On 09/19/2024 at 1:55 p.m., interview with S1Administrator confirmed that a thorough investigation was not performed after this incident with Patient #4 to determine what the patient had used or how he had obtained it. When asked if the hospital had reviewed the process for searching patients upon admit for contraband after this incident, S1Administrator stated no. When asked if any new interventions or processes had been put in place after this incident with Patient #4, S1Administrator stated no.”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 36293 Based on record review and interviews, the hospital failed to ensure personnel met applicable standards required by State regulations for hospital personnel. This deficient practice is evidenced by failure to ensure direct care staff had the required CPI and CPR training as required by their job description. Findings: Review of the hospital’s Job Descriptions revealed in part: Registered Nurse - Job Requirements/Skills CPR (cardiopulmonary resuscitation) certification, CPI (Nonviolent Crisis Physical Intervention Training). Mental Health Technician - Job Requirements/Skills CPR (cardiopulmonary resuscitation) certification, CPI (Nonviolent Crisis Physical Intervention Training). Review of the direct care personnel’s certifications revealed: 2 of 14 RN’s failed to have the required CPI training certification (S3RN, S4RN); and 9 of 25 MHT’s failed to have the required CPR training certification (S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S12MHT, S13MHT). Interview on 07/23/2024 at 4:20 p.m., S2HR Director confirmed the RN’s and MHT’s did not have the required CPI and CPR certifications and training as required by their job descriptions.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) 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 improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 36293 Based on record review and interviews, the hospital failed to ensure the Quality Assurance/Performance Improvement (QAPI) program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure direct care staff had the required certification and training as required in their job descriptions. Findings: Review of the hospital’s policy titled, “Plan for Staff Orientation, In-service training and Evaluation revealed in part: Policy - It is the policy of this facility to assess the learning needs of each employee upon hire, during orientation, and on an ongoing basis throughout employment. Review of the direct care personnel’s certifications revealed: 2 of 14 RN’s failed to have the required CPI training certification and 9 of 25 MHT’s failed to have the required CPR training certification. Interview on 07/23/2024 at 2:27 p.m., S1Administrator confirmed all direct staff are to have CPR and CPI training and acknowledged this should have been captured as part of their quality assurance program.”