Oceans Behavioral Hospital of Greater New Orleans

“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: 52121 Based on record review and interviews, the hospital failed to ensure the use of seclusion was implemented according to hospital policy in 1 (#1) of 3 reviewed patient records. The deficient practice is evidenced by failure to ensure the medical record included: 1. A documented physician order for a seclusion event the morning of 07/06/2026; 2. A documented one-hour face-to-face evaluation for the above-mentioned event; and 3. Documented visual checks every 15 minutes for the above-mentioned event. Findings: Review of the hospital’s policy titled, “Seclusion and Restraints- Louisiana (LA) ...” with an effective date of 07/01/2020, revealed, in part: Policy: The facility’s therapeutic program is designed to ensure and respect the patient’s right to be free from seclusion and/or restraints in any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. Leadership continuously fosters ways to prevent, reduce, and/or eliminate/limit restraint and seclusion through: ... compliance with policy, procedure, law, and regulations. Definitions: Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Procedure: 1. Initiation: ... the Registered Nurse (RN) will document physician contact and physician order. 4. Face-to-Face Evaluation: ... document date/time, the patient’s immediate situation, the patient’s reaction to the intervention, the patient’s medical and behavioral condition, the need to continue or terminate the restraint or seclusion, behaviors, ... 7. Monitoring: ... at a minimum, respiratory status, circulation, and skin integrity will be documented as indicated on seclusion/restraint flow sheet every 15 minutes ... Review of Patient #1’s Medical Record revealed he was admitted to the hospital on 06/29/2026 with a diagnosis of schizoaffective disorder, bipolar type. Review of Patient #1’s Nursing Shift Assessment, signed 07/06/2026 at 11:33 a.m., revealed, in part: Nursing Note: ... Placed in seclusion until patient can calm down. Patient was immediately calm and brought back to unit. Further review of the medical record failed to reveal any other documentation of this event the morning of 07/06/2026. The record did not contain a physician’s order for the seclusion and there was no one hour face-to -face for the event. Review of Patient #1’s Observation Check Sheets revealed no documented 15-minute visual checks for the date of 07/06/2026. Review of the hospital’s Seclusion Log, dated 07/06/2026, revealed one seclusion intervention and one chair restraint intervention. Both events documented in the log occured in the afternoon. An interview was conducted on 08/05/2026 at 2:24 p.m. with S1DON. S1DON confirmed staff could not locate any observation check sheets with 15-minute observations for Patient #1 from 07/06/2026. An interview was conducted on 08/06/2026 at 11:11 a.m. with S9RN. S9RN stated she wrote the above-mentioned nursing note and signed it on 07/06/2026 at 11:33 a.m. S9RN confirmed staff placed Patient #1 into seclusion twice on 07/06/2026. She stated Patient #1 required seclusion in the morning hours prior to her nursing note and again in the afternoon. S9RN stated Patient #1’s morning seclusion event required staff to close him into the room for approximately an hour. S9RN stated she documented one-hour face-to-face evaluations in the seclusion and restraint packet. An interview was conducted on 08/06/2026 at 12:45 p.m. with S2QD. S2QD confirmed the only seclusion and restraint packet dated 07/06/2026 for Patient #1 was for the 3:00 p.m. event. She further confirmed there was no documented physician order for Patient #1’s morning seclusion on 07/06/2026. An interview was conducted on 08/06/2026 at 1:09 p.m. with S1DON. S1DON stated she was unaware of Patient #1’s morning seclusion on 07/06/2026. S1DON confirmed staff should implement and document seclusion events according to hospital policy.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 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 1 (#2) of 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 #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 07/15/2026 with Major Depression Disorder. The provider ordered elopement precautions on admission and elopement precautions were not addressed on the nursing care plan for Patient #2. Further review of Patient #2’s medical record revealed the provider documented on 07/17/2026, and 07/19/2026 - 07/26/2026 Patient#2 refused ordered psychiatric medications. Review of Patient #2’s treatment plan revealed no nursing diagnosis or interventions regarding medication non-compliance. In an interview on 08/05/2026 at 11:42 AM, S1DON verified the above mentioned information.”

“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: 52121 Based on record review and interviews, the hospital failed to ensure nursing staff adhered to hospital policies and procedures related to patient transfers in 1 (#1) of 3 reviewed patient records. The deficient practice is evidenced by failure to ensure the medical record included: 1. Tests, reports, or discharge paperwork from the receiving hospital upon patient return; and 2. Documentation of the date and time of patient return. Findings: Review of the hospital’s policy titled, “Transfer of a Patient to an Acute Care Facility” with a revision date of 09/01/2025, 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. Procedure: 11. The Registered Nurse (RN) will obtain all tests, reports, etc. from the receiving hospital upon return of the patient and notify the attending physician of patient’s return and updated status to obtain new orders for continuation of care. These records will be attached to the patient’s medical record at Oceans. 12. Documentation in the patient’s medical record includes: The date and time of patient’s return. Review of the hospital’s Incident Log, dated 06/15/2026 to 08/04/2026, revealed, in part: Person: Patient #1 Date and time: 06/30/2026 8:40 a.m. Category: Patient Injury Medical Transfer: Yes Narrative: 8:43 a.m. He punched the seclusion wall. His left hand appears broken. 9:20 a.m. Patient left the unit with EMS to transfer. Review of Patient #1’s Seclusion and Restraint Packets, dated 06/29/2026 to 07/07/2026, revealed, in part: Seclusion, Date In: 06/30/2026, Time In: 5:20 p.m., Date Out: 06/30/2026, Time Out: 5:36 p.m. Debriefing: Reviewed what led to seclusion/restrain and what could have been done differently: Patient was upset because he was prescribed Motrin 800 milligrams for fractured finger. Review of Patient #1’s Medical Record revealed no discharge paperwork, tests, or reports related to the 9:20 a.m. emergency room transfer on 06/30/2026. Further review revealed no documentation of Patient #1’s date and time of return to the hospital. An interview was conducted on 08/05/2026 at 2:24 p.m. with S1DON. S1DON confirmed staff could not locate any discharge paperwork, tests, or reports related to the 9:20 a.m. emergency room transfer. An interview was conducted on 08/06/2026 at 10:31 a.m. with S10RN. S10RN revealed that Patient #1 transferred to the emergency room twice on 06/30/2026. S10RN stated she received Patient #1 when he returned to the hospital from the 9:20 a.m. transfer. S10RN stated she did not receive any tests, reports, or discharge paperwork when the patient returned. S10RN further stated she learned of the patient’s fracture from the telephone report by the emergency room nurse. An interview was conducted on 08/06/2026 at 1:09 p.m. with S1DON. S1DON confirmed staff should document transfer events according to hospital policy.”

“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 signed master treatment plan or treatment plan updates by the members of the interdisciplinary team (IDT) on 2(#2, #3) of 2 patients’ treatment plans reviewed for the sample. Findings: A review of the hospital policy number CS-02 last revised 05/01/2025 titled, “Treatment Planning; Integrated/Multidisciplinary,” 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. The documentation also serves as a resource for reviewing the efficacy of care provided. PROCEDURE: 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). Review of Patient #2’s medical record revealed Patient #2 was admitted on 07/15/2026 for Major Depressive Disorder on a PEC/CEC. Further review of Patient #2’s Multidisciplinary Integrated Master Treatment Plan initiated on 07/15/2025 with Treatment Plan Update dated 07/20/2026 did not reveal a signature by the MD. In an interview on 08/05/2026 at 11:40 AM, S1DON confirmed Patient #2’s Multidisciplinary Integrated Master Treatment Plan Update was not signed by the MD and the IDT did not meet again before Patient #2’s discharge on 07/27/2026. Review of Patient #3’s medical revealed Patient #3 as admitted on 07/10/2026 for Schizoaffective Bipolar Type, Unspecified Dementia on a PEC/CEC. Further review of Patient #3’s Multidisciplinary Integrated Master Treatment Plan initiated on 07/10/2026 with Treatment Plan Updates dated 07/13/2026 and 07/20/2026 did not reveal a signature by the MD. In an interview on 08/05/2026 at 2:05 PM, S1DON confirmed Patient #3’s Multidisciplinary Integrated Master Treatment Plan Updates were not signed by the MD and the IDT did not meet again before Patient #3’s discharge on 07/27/2026.”

“Personnel - Discharge Planning CFR(s): [The hospital must employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to:] Engage in discharge planning; This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure each patient/patient representative participated in the discharge planning process. This deficient practice is evidenced by failure of the physician or nurse to review the patient’s discharge treatment plan and medication regimen with the patient’s residential facility at discharge of 1 (#2) of 2 (#2, #3) patients medical records reviewed. Findings: Review of the hospital policy #PC-18 titled “Discharge Planning: Transition Record” last revised on 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. Policy: Discharge planning commences upon admission to any program. Tentative discharge plans are established, reviewed, and modified throughout treatment. Procedure: 4. Social Services/Case Management personnel shall: -Notifies patient and family of the date discharge will occur; -When feasible, prior to discharge or transfer to a lower level of care, conducts a discharge conference with patient (family/significant others, as appropriate to: ~Finalize living arrangement and post-treatment care plans to meet ongoing needs for care and services; ~Review patient progress in treatment; ~Discuss patient and family’s expectations of patient’s behavior and participation in recommended therapies post-discharge. 5. The Nurse shall: -Review patient’s medication regimen and educate on medications; -Upon discharge, provide the patient recommendations for anticipated continuing care, treatment, and services and discharge medication interventions. 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: -Reason for inpatient admission; -Principal diagnosis at discharge; -Current medication list; - Studies pending at discharge; -Patient self-management instructions; -Contact information for obtaining results of studies pending at discharge, if indicated; -Plan for follow-up care including primary physician, other health care professional, or site designated for follow up, any/all follow-up appointments and aftercare services; -Patient signatures of acceptance/understanding of recommendations and Transition Record being provided.” Review of Patient #2’s medical record revealed he was admitted to the hospital on 07/15/2026 at 5:00 PM from an outside residential facility on a PEC and subsequently a CEC for increased agitation, hostile, verbally aggressive, scratching and spitting at nursing home staff because he was unwilling to take his medications. Review of Patient #2’s provider progress notes during hospitalization revealed in part the following: 07/17/2026 at 3:35 PM documented by S5NP: Patient #2 refusing ordered medications 07/20/2026 at 2:30 PM documented by S8MD: Patient #2 reports he doesn’t feel safe at nursing home and states he feels like they are trying to kill him. 07/21/2026 at 12:57 PM documented by S5NP: Patient #2 continues to refuse medications 07/22/2026 at 11:28 PM documented by S6NP: Patient #2 continues to refuse medications 07/23/2026 at 10:45 AM documented by S6NP: Patient #2 continues to refuse medications and doesn’t want to go back to the nursing home 07/24/2026 at 12:53 PM documented by S5NP: Patient #2 continues refuse medications so titration of medications stopped 07/25/2026 at 12:40 PM documented by S5NP: Patient #2 remains withdrawn and irritable with medication non-compliance Review of Patient #2’s social worker notes during hospitalization revealed in part the following: 07/20/2026 at 11:24 AM documented by S3LPC: Patient reports reluctance to returning to nursing home due to disliking placement 07/22/2026 at 1:22 PM documented by S3LPC: Therapist emailed clinical to patient living facility and provided discharge protection 07/27/2026 at 4:39 PM documented by S3LPC: Patient discharged from facility via transportation van to previous residential facility. Patient irritable and resistant to discharge back to nursing home, but finally accepted discharge and signed required documents. Review of Patient #2’s nursing notes during hospitalization did not reveal any communication with Patient #2’s residential living facility/nursing home. In an interview on 08/05/2026 at 11:20 AM S1DON verified that both the nurse and social worker coordinate patients’ discharges and communicates with outside residential facilities so they can prepare to receive patients. In an interview on 08/05/2026 at 11:50 AM S3LPC verified she emailed Patient #2’s nursing home on 07/22/2026 and no further documentation of communication with nursing home from 07/22/2026 to 07/27/2026. In an interview on 08/05/2026 at 11:55 AM S4NS revealed Patient #2 complained about returning to the nursing home, but didn’t state reasons. S4NS further stated that there is no documentation in Patient #2’s medical record that she called report to Patient #2’s nursing home before or after discharge. S4NS did report that she spoke to Patient #2’s nursing some time on the 07/27/2026 after his discharge because she knew Patient #2 had eloped from the nursing home.”

“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’s representative participated in developing and implementing the patient’s plan of care for 1 (#1) of 3 medical records reviewed. Findings: Review of the hospital policy number RTS-01, titled “Patient Rights Louisiana,” last revised 09/01/2023, revealed in part: “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 as 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 with law and regulations. You have the right to be informed about the outcomes/unanticipated occurrences of are in order to participate in current and future healthcare decisions.” 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 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.” Review of Patient #1’s medical record revealed the patient was admitted on 03/30/2026 with an admission diagnosis of Major Neurocognitive Disorder with Behavioral Disturbance. Patient #1 had a history of Alzheimer’s Dementia. Further review revealed the patient was confused and gravely disabled. Additional review revealed documentation that the patient’s consents were signed verbally by her daughter as her power of attorney. Review of the Interdisciplinary Treatment Plan Update, dated 04/06/2026, revealed in part: New medication changes: Yes (Abilify) Continued Stay Criteria: Unable to effectively manage mental illness; Disease process severely inhibits social integration/function. Documentation of Family/Significant Other Involvement: Blank Patient Signature: Verbal, Verbal Acknowledgment (date/time: 04/06/2026 at 10:15 AM) There was no documented evidence that the patient’s responsible party participated in the treatment planning or why the patient was unable to sign. In an interview on 04/28/2026 at 2:53 PM, S3DON confirmed the above-mentioned findings. S3DON confirmed there was no documented evidence of why the patient representative did not participated in the treatment team plan of care.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50453 Based on observations and interviews, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for psychiatric patients. Finding: Observations during a tour on 04/28/2026 from 10:34 AM - 11:10 AM revealed the following: -Room ‘a’: sink cover not secured with 3 exposed screws with the potential to cause harm; -Room ‘b’: baseboard loose with a hole and exposed sheet rock with the potential to hide contraband; and -Room ‘c’: chipped wood on shelf exposing a screw with the potential to cause harm. In an interview during the tour, S2DOQ confirmed the above-mentioned 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: 50453 Based on record review and interview, the hospital failed to ensure nursing staff adhered to the policies and procedure of the hospital. This deficient practice is evidenced by failure of registered nurse to document rounds per policy on 1 (#2) of 3 patient medical records reviewed. 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. Observations should be both safe and therapeutic. Respect should be shown for the patient’s need for autonomy while ensuring safety. 3. The Registered Nurse 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 Patient #2’s medical record revealed Patient #2 was admitted on 04/10/2026 at 1:17 PM with a diagnosis of Major Neurocognitive disorder severe with behavioral disturbances. Patient #2 had a history of dementia and was on fall risk precautions. Review of Patient #2’s orders revealed Patient #2 was changed from every 15 minute observations to Line of Sight observations on 04/17/2026 at 11:15 PM. Review of Patient #2’s Observation Check Sheet/Graphic Flowsheet revealed in part the following: 04/17/2026 Q15 observation level flowsheet- revealed Q15 minute observations ended at 11:45 PM. Further review revealed S6RN initialed the observations for 1:00 AM, 3:00 AM, and 5:00 AM. Further review revealed that a new observation sheet was initiated at 12:00 AM for Line of Sight observations. In an interview on 04/29/2026 at 10:29 AM, S3DON confirmed that nurse did not follow policy and should not initial observations until they are performed at the time of the observation. S3DON also confirmed that the Q15 minute observation flowsheet ended when the Line of Sight flowsheet was initiated.”

“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 record review and interview the hospital failed to ensure care in a safe setting. The deficient practice is evidenced by failure of a staff member acknowledge and assist a patient after a fall. Findings: Review of hospital policy number AS-12 last revised 11/16/2022 titled “Fall Assessment/ Re-Assessment and Precautions” revealed in part: 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”. Review of Patient #2’s medical record revealed Patient #2 was admitted on 04/02/2025 with Major Neurocognitive Disorder with behavioral disturbances and psychosis. On 04/16/2025 Patient #2 was assaulted by MHT resulting in fall to the ground. Review of the Self-Report involving Patient #2 revealed the following: Date of Incident: 04/16/2025, time: 5:12 PM, Type of occurrence: Alleged Physical Abuse Describe the facts of the occurrence: Patient #2 fell to the floor, breaking her fall with her left hand. Later Patient #2 stated the staff pushed her. Initial Actions: Upon assessment of Patient #2, S8RNCN noted deformity to Patient #2’s left middle finger. The provider was notified and orders were received to transfer Patient #2 to the local ED. S6MHT was suspended pending investigation. Investigation Results: The allegation of abuse is unable to be substantiated due to lack of evidence. On 04/23/2025 at 1:05 PM video footage was reviewed for the incident involving Patient #2 that occurred on 04/16/2025 navigated by S1DON. Review of the video footage revealed the following: 17:11:32 PM- Patient #2 seen in hallway talking to a patient sitting in wheelchair. S6MHT sitting in hallway. 17:11:38 PM- Patient #2 seen in hallway pushing patient in wheelchair 17:11:49 PM- Patient #2 pushing patient in wheelchair and looks back at S6MHT 17:12:04 PM- S6MHT gets up from sitting in hallway and walks toward Patient #2 pushing patient in wheelchair 17:12:06 PM- S6MHT grabs wheelchair and stops Patient #2 from pushing patient in wheelchair 17:12:29 PM- S6MHT seen walking Patients #2 backward away from the patient in the wheelchair 17:12:32 PM- S6MHT holding Patient #2’s arms while standing in doorway when S6MHT pulls away from Patient #2 with her right arm and pushes Patient #2 with her left arm causing Patient #2 to fall to ground. 17:12:45 PM- S7MHT steps over Patient #2 to empty patients’ meal tray in the trashcan in the hallway without offering care to Patient #2 assistance 17:13:05 PM- S7MHT talking with Patient #2 sitting on the floor and S6MHT walks to nurses’ station talking with S8RNCN 17:13:22 PM- S8RNCN seen talking with Patient #2 who is still sitting on the ground 17:14:02 PM- S8RNCN assist Patient #2 to a standing position 17:14:27 PM- S8RNCN, S9MHT, and Patient #2 seen walking down hallway toward Patient #2’s room In an interview on 04/23/2025 at 1:15 PM, S1DON verified S7MHT did not assess or assist Patient #2 after her fall.”

“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 recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to accurately self-report an incident which involved a patient and an employee. 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 patient safety incident and any interventions take to reduce the risk of future incidents and promote safety.” Review of Patient #2’s medical record revealed Patient #2 was admitted on 04/02/2025 with Major Neurocognitive Disorder with behavioral disturbances and psychosis. On 04/16/2025 Patient #2 was assaulted by MHT resulting in fall to the ground. Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report finalized on 04/17/2025 revealed the following documentation: Incident type documented as: Alleged Patient Abuse; Staff to Patient Assault Date/Time Incident: 04/16/2025 at 5:12 PM Patient Information documented on report included: Patient #2 documented as both being the victim Incident Details: First Employee aware of the allegation and how they became aware of the allegation: S6MHT was redirecting Patient #2 from pushing another patient’s wheelchair when Patient #2 fell to the ground. Describe the alleged incident: Patient #2 fell to the floor, breaking her fall with her left hand. Patient #2 later stated to staff that she was pushed. List-all x-rays/test conducted and results: X-ray taken at local ED revealed fracture of phalanx of left middle finger and fracture of fifth metacarpal bone of left hand Did the aggressor have a history of this behavior: N/A Video Surveillance information documented on report included: Video surveillance at incident site: yes What was revealed on video? Answer: At 5:12 PM, S6MHT seen sitting on chair in the hallway. Patient #2 is standing nearby, talking to a peer who is sitting in a wheelchair. Several seconds later, Patient #2 begins to push the peer’s wheelchair. S6MHT stands up to intervene, initially by grasping the wheelchair. Patient #2 can be seen grabbing onto S6MHT’s hand. S6MHT pushes Patient #2’s hand back away from her, causing Patient #2 to fall backward. We are unable to see Patient #2 land on the floor due to the angle of the camera. Comments documented on report included: Upon review of the camera footage, it was noted that S6MHT did not use an approved grasp-release technique for which she was trained, which resulted in Patient #2 losing her balance during the encounter. Patient #2 was promptly assessed by the charge nurse and transferred to the ED for further evaluation and treatment. Upon return from the ED, Patient #2 reported to S2ADON, that she had been pushed but believed it was an accident. S6MHT was also interviewed during the investigation process and maintained that the fall was accidental. She was ultimately terminated from employment on 04/17/2025 for violation of policy. S8RNCN did not witness the incident. No other staff members were present in the hallway when the event occurred. Investigation Results: The allegation of abuse is unable to be substantiated due to lack of evidence. On 04/23/2025 at 1:05 PM video footage was reviewed for the incident involving Patient #2 that occurred on 04/16/2025 navigated by S1DON. Review of the video footage revealed the following: 17:11:32 PM- Patient #2 seen in hallway talking to a patient sitting in wheelchair. S6MHT sitting in hallway. 17:11:38 PM- Patient #2 seen in hallway pushing patient in wheelchair 17:11:49 PM- Patient #2 pushing patient in wheelchair and looks back at S6MHT 17:12:04 PM- S6MHT gets up from sitting in hallway and walks toward Patient #2 pushing patient in wheelchair 17:12:06 PM- S6MHT grabs wheelchair and stops Patient #2 from pushing patient in wheelchair 17:12:29 PM- S6MHT seen walking Patients #2 backward away from the patient in the wheelchair 17:12:32 PM- S6MHT holding Patient #2’s arms while standing in doorway when S6MHT pulls away from Patient #2 with her right arm and pushes Patient #2 with her left arm causing Patient #2 to fall to ground. 17:12:45 PM- S7MHT steps over Patient #2 to empty patients’ meal tray in the trashcan in the hallway without offering care to Patient #2 assistance 17:13:05 PM- S7MHT talking with Patient #2 sitting on the floor and S6MHT walks to nurses’ station talking with S8RNCN In an interview on 04/23/2025 at 1:15 PM, S1DON verified S6MHT pulls away from Patient #2 with her right arm and pushes Patient #2 with her left arm causing Patient #2 to fall to the ground. Furthermore, S1DON verifies S6MHT has been terminated and is the only intervention done related to the above incident.”

“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 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 follow a MD order to perform a tasks for 2 (#2, #3) of 3(#1-#3) patients reviewed; 2)Failure of the Registered Nurse to document patient observations every 2 hours per hospital policy for 2 (#2, #3) of 3 (#1-#3) Patient Observation Check Sheets reviewed; 3)Failure of the Registered Nurse to assign Observation Levels for 3 of 3 (#1-#3) Patients’ Observation Check Sheets reviewed; 4)Failure of the Registered Nurse to supervise staff to ensure timely observation rounds performed for 1 (#3) of 3 (#1-#3) Patients’ Observation Check Sheets reviewed; and 5)Failure of the Registered Nurse to supervise staff to ensure preventative/comfort measures were performed every 2 hours for 1 (#1) of 3 (#1-#3) Patients’ Observation Check Sheets reviewed. Findings: 1)Failure of the Registered Nurse (RN) to follow a MD order to perform a task. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 04/02/2025 with Psychosis with Dementia. Review of Patient #2’s MD orders revealed the following orders: -On 04/03/2025 MD ordered Clonidine 0.1mg 1 tablet by mouth every 4 hours PRN for systolic BP > 160; Diastolic BP >90 with the indication for administration listed as hypertension. -On 04/02/2025 MD ordered Motrin 200mg 1 tablet by mouth every 6 hours PRN give with 400mg- 600mg with the indication for administration listed as pain. Further review of Patient #2’s MAR revealed RN administered the following medications: -On 04/14/2025 at 7:00 AM, the nurse administered Clonidine 0.1mg 1 tablet by mouth for BP 118/73. -On 04/14/2025 at 9:43 AM, the nurse administered Motrin 400mg by mouth for Pain 0/10 -On 04/18/2025 at 10:00 AM, the nurse administered Clonidine 0.1mg 1 tablet by mouth for BP 142/86. In an interview on 04/23/2025 at 1:34 PM, S1DON verified the nurse performed the above mentioned tasks without following the MD orders. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 02/05/2025 with Major Neurocognitive Disorder with Psychosis and Behavioral Disturbances. Review of Patient #3’s MD orders revealed an order dated 02/06/2025 for Zyprexa 10mg by mouth one time only indication Hallucinations. Further review of Patient #3’s MAR did not reveal that the nurse administered the Zyprexa 10mg one time only as ordered by the provider. In an interview on 04/24/2025 at 11:08 AM, S1DON verified the nurse did not follow the above mentioned MD order. 2) Failure of the Registered Nurse to document patient observations every 2 hours per policy. Patient #2 Review of the Patient #2’s Observation Check Sheet failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN: -04/02/2025 between 11:00 PM to 6:45 AM on 04/03/2025 RN observations were not performed -04/09/2025 between 7:00 PM to 11:00 PM RN observations were not performed -04/11/2025 between 7:00 PM to 6:45 AM on 04/12/2025 RN observations were not performed -04/15/2025 between 7:00 PM to 1:00 AM on 04/16/2025 RN observations were not performed -04/21/2025 between 7:00 PM to 11:00 PM RN observations were not performed In interview on 04/23/2025 at 1:58 PM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy. Patient #3 Review of Patient #3’s Observation Check Sheets failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN: -On 02/06/2025 at 9:00 PM and 5:00 AM on 02/07/2025 RN observations were not performed -On 02/10/2025 between 7:00 PM to 6:45 AM on 02/11/2025 RN observations not performed -On 02/14/2025 at 5:00 PM RN observations not performed -On 02/16/2025 between 7:00 PM to 6:45 AM on 02/17/2025 RN observations not performed In interview on 04/24/2025 at 11:30 AM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy. 3)Failure of the Registered Nurse to assign Observation Levels for 3 (#1-#3) of 3 (#1-#3) Patients’ Observation Check Sheets reviewed. Patient #1 A review of the Patient Observation Check Sheet for Patient #1 dated 02/27/2025, 03/05/2025 and 03/14/2025 failed to reveal an assigned observation level checked per physician order by the Registered Nurse. In interview on 04/23/2025 at 3:35 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheet per hospital policy. Patient #2 A review of the Patient Observation Check Sheets for Patient #2 dated 04/03/2025, 04/05/2025, and 04/09/2025 failed to reveal an assigned observation level checked per physician order by the Registered Nurse. In interview on 04/23/2025 at 1:44 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy. Patient #3 A review of the Patient Observation Check Sheets for Patient #3 dated 02/15/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. In interview on 04/24/2025 at 11:34 AM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy. 4)Failure of the Registered Nurse to supervise staff to ensure timely Mental Health Technician (MHT) observation rounds performed every 15 minutes for 1 (#3) of 3 (#1-#3) Patients’ Observation Check Sheets reviewed. Review of Patient #3’s Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on 02/18/2025 between 1:45 AM to 6:45 AM In interview on 04/24/2025 at 11:35 AM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy. 5)Failure of the Registered Nurse to supervise staff to ensure preventative/comfort measures were performed every 2 hours for 1 (#1) of 3 (#1-#3) Patients’ Observation Check Sheets reviewed. Review of Patient #1’s medical record revealed Patient #1 was admitted on 02/27/2025 with Major Depressive Disorder with psychotic features and to rule out Dementia vs Delirium. Review of Patient #1’s Nursing Admission Assessment dated 02/27/2025 at 11:14 AM revealed Patient #1’s genitourinary neuromuscular dysfunction with paralysis to left side with recent falls and wheelchair bound. Further review of Patient #1’s Observation Check Sheets revealed the MHT did not offer the patient water, perform incontinence care, or reposition every 2 hours on the following dates/times: -On 02/27/2025 between 9:00 PM to 02/28/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours. -On 02/28/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/01/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/01/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/02/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/02/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/03/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/03/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/04/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/04/2025 at 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/05/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/05/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/06/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/06/2025 between 9:00 PM to 03/07/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours. -On 03/07/2025 between 9:00 PM to 03/08/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours. -On 03/08/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/09/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/09/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/10/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/10/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/11/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/11/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/12/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/12/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/13/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours. -On 03/13/2025 between 11:00 PM to 03/14/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours. In an interview on 04/23/2025 at 3:27 PM, S1DON verified above findings mentioned.”

“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 hospital failed to ensure that 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 is evidenced by the failure to update the care plans of 2 (#1, #4) of 5 (#1-#5) patient reviewed for completed and updated care plans. Findings: A review of the hospital’s policy, “Treatment Planning: Integrated/Multidisciplinary,” Policy Number: CS-02, revised date of 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 the patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. 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 hours of admit or sooner if patient’s needs warrants immediate action. 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwillingness shall be documented in the patient’s medical record. A review of the hospital’s policy number NSG-39 last revised 10/01/2023 titled, “Skin/Wound Care”, revealed in part: PURPOSE: To identify patients at risk for skin break down and pressure injury formation and skin abnormalities and provide interventions for the prevention, assessment, and treatment of such. PROCEDURE: Braden Scale Risk Assessment: 2. If the Braden score is less than 18, the start of care skin care guideline will be initiated. 3. An impaired skin integrity treatment plan will be initiated or updated according to the patient’s assessed results. Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 02/27/2025 with Major Depressive Disorder with psychotic features and rule out Dementia vs Delirium. Patient #1 is wheelchair bound with a past medical history of CVA with residual left hemiplegia. Review of Patient #1’s plan of care did not address potential for impaired skin integrity even though Patient #1’s Braden Scale II done on 02/27/2025 scored a 17 and on 03/14/2025 scored a 15 which both scores indicates mild risk to develop pressure injuries. In an interview on 0/424/2025 at 10:04 AM, S1DON verified the above mentioned findings. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 04/02/2025 with the following diagnosis Psychosis with dementia. Patient #2 sustained a fall on 04/16/2025 and was evaluated in the ED and diagnosed with a closed displaced fracture of left middle finger and 5th finger. Patient #2 had splint with ace wrap to left hand and Tylenol ordered PRN pain. Review Patient #2’s plan care revealed no updates made regarding fall and diagnosis of closed displaced fracture of left middle finger and 5th finger. In an interview on 04/23/2025 at 2:21 PM, S1DON verified the above mentioned findings. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 02/05/2025 with Major Neurocognitive Disorder with Psychosis and Behavioral Disturbances. Review of Patient #3’s MD orders revealed the following orders: 02/20/2025 Consult for Forced Medications due to ongoing medication noncompliance with decompensation 02/23/2025 Cheeking Precautions 02/24/2025 Provide additional snacks TID 02/24/2025 Assist with meals 02/26/2025 Weight patient twice a week on Wednesday and Friday Review of Patient #3’s plan of care did not reveal updates of the above mentioned provider orders. In an interview on 04/24/2025 at 11:35 AM, S1DON verified the above mentioned things.”

“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 signed master treatment plan by the members of the interdisciplinary team (IDT) on 1(#1) of 3(#1-#3) patients’ treatment plans reviewed for the sample. Findings: A review of the hospital policy number PC-018 last reviewed 11/11/2021 titled, “Multidisciplinary Treatment Plans,” revealed in part: PURPOSE: To establish guidelines for the development of multidisciplinary treatment plans that provide direction for the patient’s course of treatment, utilize input from all disciplines, establish ongoing individualized treatment, and promote progress during treatment. PROCEDURE: 3. The multi-disciplinary treatment team is comprised of the physician, nurse, licensed therapist, and recreational therapist. Outside agencies/caregivers may also be included as appropriate. The plan shall be approved and signed by the physician to ensure continuity of care, coordination, and integration of services provided. 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). Review of Patient #1’s medical record revealed Patient #1 was admitted on 02/27/2025 for Major Depressive Disorder on a PEC/CEC. Further review of Patient 1’s Multidisciplinary Integrated Master Treatment Plan initiated on 02/27/2025 or Treatment Plan Update dated 03/10/2025 did not reveal a signature by a nurse. In an interview on 04/24/2025 at 10:04 AM, S1DON confirmed Patient #1’s Multidisciplinary Integrated Master Treatment Plan and Treatment Plan Update were not signed by a nurse.”

“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 members of the multidisciplinary team complied with hospital policy for the development of individualized treatment plans. The deficient practice is evidenced by failure to have a master treatment plan signed by all members of the interdisciplinary team and the patient in 2 (#F1 & #F2) of 3 (#F1-#F3) reviewed master treatment plans. Findings: Review of the hospital 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 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: 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 #F1: Review of Patient #F1’s medical record revealed she was admitted to the facility on 01/14/2025 at 4:30 AM from an outside referring facility emergency room for Schizophrenia. Review of Patient #F1’s Interdisciplinary Treatment Plan Master Sheet dated 01/14/2025 revealed it was not signed by the both Patient #F1 and the staff therapist and/or staff social worker. Further review revealed no documentation the patient was unable/unwilling to participate or refused to sign the treatment plan. On 02/18/2025 at 2:18 PM, an interview was conducted with SF1DOQ. She reviewed the IDT Master Sheet dated 01/14/2025 in Patient #F1’s medical record. She confirmed it was not signed by Patient #F1 and should have either been signed by the patient or documented “patient refused” or “patient unwilling/unable to participate” within 24 hours of admission to the facility. SF1DOQ also confirmed the IDT Master Sheet dated 01/14/2025 in Patient #F1’s medical record was not signed by the therapist and/or social worker and should have been signed within 72 hours of the patient’s admission to the facility. Patient #F2: Review of Patient #F2’s medical record revealed she was admitted to the facility on 02/01/2025 at 4:05 AM from an outside referring facility emergency room for Major Depressive Disorder. Review of Patient #F2’s Interdisciplinary Treatment Plan Master Sheet dated 02/01/2025 revealed it was not signed by the staff therapist. On 02/18/2025 at 2:20 PM, an interview was conducted with SF1DOQ. She reviewed the IDT Master Sheet dated 01/14/2025 in Patient #F2’s medical record. SF1DOQ also confirmed the IDT Master Sheet dated 01/14/2025 in Patient #F2’s medical record was not signed by the therapist and/or social worker and should have been signed within 72 hours of the patient’s admission to the facility.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by: 1) Failure to ensure a patient complaint of alleged staff to patient physical abuse was recognized as a grievance (See Findings Tag A0118); 2) Failure to ensure a patient was provided with written notice of its decision following its resolution of its grievance investigation process (See Findings Tag A0123); 3) Failure to ensure a patient received care in a safe setting by properly monitoring a high fall risk patient which resulted in a fall with head injury (See Findings Tag A0144); 4) Failure to thoroughly investigate and report allegations of abuse within 24 hours to the Department of Health and Hospitals or law enforcement (See Findings Tag A0145); and 5) Failure to thoroughly investigate and report allegations of elopement within 24 hours to the Department of Health and Hospitals or law enforcement (See Finding Tag A0145).”

“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: 48537 Based on record review and interviews, the hospital failed to ensure a patient complaint of alleged staff to patient physical abuse was recognized as a grievance. This deficient practice was evidenced by failing to correctly identify a patient grievance for 1 (#3) of 3 (#1 - #3) total sample patients reviewed for complaints/grievances. Findings: Review of the hospital’s policy number RTS-04 titled “Patient Grievance Process” last revised on 09/01/2024 indicated the following 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 -Timely referral to the appropriate external agency as deemed necessary Policy: 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. Definitions 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 Submission 2. Depending on the nature of the complaint, the staff will offer resolution at the time the complaint is made, and if resolved, report the encounter to the Patient Advocate. The complaint with resolution will be logged on the “Complaint/Grievance Log” with no additional action. 3. If no resolution is made by staff present at the time of the complaint, the Patient Advocate is notified, and the grievance process is initiated. If the patient and/or family file a grievance allegation as defined above, the grievance process is initiated immediately. 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. 2. The Patient Advocate completes the investigation using the “Grievance Report” within 7 calendar days of the date of the notification or receipt of the grievance allegation. Role of the Patient Advocate: 1. Maintains a complete “Complaint/Grievance Log” along with files and results of all grievances including a signed copy of the letter sent to the grievant and dated documentation of the method of delivery. 2. Complete a thorough investigation of all grievances representing the expressed desires of the individuals served ad advocating for the resolution of their grievances. 3. Responsible for reporting all grievance investigation findings and resolutions to QAPI committee hierarchy. Roles of the Administrator: 1. Ensure appropriate policies and procedures are followed for grievances alleging abuse and neglect of patients.” Review of the hospital’s Complaint and Grievance Log for September - November 2024 revealed no documented complaints or grievances for Patient #3. On 12/02/2024 at 3:15 p.m., a telephone interview was conducted with S9NP. He stated the bruising to Patient #3’s left eye/temporal region and face were new to him when he saw her on the afternoon of 11/05/2024 and she did not have that bruising when he made rounds on her on 11/04/2024. He confirmed Patient #3 verbally reported to him on 11/05/2024 staff had “beat her up” on the prior shift. On 12/02/2024 at 4:04 p.m., an interview was conducted with S11RN. She stated Patient #3 had reported to her prior to 11/05/2024 that night shift staff had assaulted her. S11RN stated she had completed a hand written report and gave it to S10FADON. S11RN stated she could not recall the exact date of when Patient #3 reported the assault to her, but stated it was around the time of when the 11/05/2024 incident with the generalized bruising had occurred but was prior to that event. S11RN stated she had “started to become suspicious” of the increased bruising on Patient #3. S11RN stated she had never personally seen any other staff members be physical or assault Patient #3. S11RN stated when Patient #3 reported the assault to her, she asked Patient #3 if she could tell her who the person or persons were who assaulted her and she stated Patient #3 could not provide her with a name of a staff member, but she did describe them which was what she included in her report. S11RN stated she put in her report word for word what Patient #3 said regardless of what she stated if it was appropriate or not. S11RN stated once she completed the report, she gave it to her superior, which at the time was S10FADON. S11RN stated she did not know if it was reported to and investigated by the Patient Advocate. On 12/03/2024 at 10:15 AM, an interview was conducted with S1DON. She reviewed the facility provided hospital “Complaint and Grievance Log” for September - November 2024. She confirmed per hospital policy a reported allegation of abuse to a staff member would be considered a complaint and/or grievance and should be reported to the Patient Advocate for review and investigation. She confirmed there were no documented complaints and/or grievances associated with Patient #3 listed on the log.”

“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: 48537 Based on record review and an interview, the hospital failed to ensure a patient was provided with written notice of its decision following its resolution of its grievance investigation process for 1 (#3) of 3 (#1 - #3) patients reviewed for grievances. Findings: Review of the hospital’s policy number RTS-04 titled “Patient Grievance Process” last revised on 09/01/2024 indicated the following in part: “Purpose: To provide an internal process that establishes guidelines for: -Provision of a response Policy: 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. Definitions 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 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. 2. The Patient Advocate completes the investigation using the “Grievance Report” within 7 calendar days of the date of the notification or receipt of the grievance allegation. 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 investigating 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.” Review of the hospital’s Complaint and Grievance Log for September - November 2024 revealed no documented complaints or grievances for Patient #3. Review of Patient #3’s Nursing Notes dated 11/05/2024 revealed the following note: 11/05/2024 at 1:38 PM - Patient #3’s daughter-in-law notified that patient had bruising of unknown source. Family informed they will be provided with developing findings. Signed by: S11RN On 12/02/2024 at 4:04 PM, an interview was conducted with S11RN. She stated she had not provided Patient #3’s family with any additional follow-up regarding the investigation into the bruising of unknown source Patient #3 sustained on or around 11/05/2024. She stated she was unaware if any other facility staff provided the family with an update either. S11RN stated she only reported the allegation of suspected staff abuse to Patient #3 to S10FADON who was her direct superior at the time. She stated she did not report it to the Patient Advocate and was unsure if S10FADON reported it to the Patient Advocate or the DON for further investigation. On 12/03/2024 at 10:15 AM, an interview was conducted with S1DON. She reviewed the facility provided hospital “Complaint and Grievance Log” for September - November 2024. She confirmed per hospital policy a reported allegation of abuse to a staff member would be considered a complaint and/or grievance and should be reported to the Patient Advocate for review and investigation. She confirmed since no documented complaints and/or grievances associated with Patient #3 were listed on the log, no notice of grievance decision report letters would have been sent and/or provided to 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: 48537 Based on record review and interviews, the hospital failed to ensure patients received care in a safe setting by failing to properly monitor high fall risk patient patients which resulted in a fall with head injury for 1 (#3) of 3 (#1-#3) patient reviewed for falls. Findings: Review of the hospital policy number AS-12 titled “Fall Assessment/Re-Assessment and Precautions” last revised on 11/16/2022, indicated the following, in part: “Purpose: To screen patient’s potential for falling and decrease the risk of injury. Policy: Inpatient 1. All patients will be assess and identified for the potential of being at risk for falls at the time of 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 RN will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated. Procedure: Inpatient 5. Interventions shall include: -Additional fall precautions - (must select at least 2 additional interventions from below that are appropriate to the patient’s individual needs) -Line of Sight observation level -1:1 observation level -Reclining chair -Assist with ADLs” Review of the hospital’s policy number CS-23 titled, “Level of Observations” last revised on 03/01/2023, indicated the following, in part: “Purpose: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient’s need for autonomy while ensuring safety. Policy: 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: Line of Sight (Constant Observation) - the staff member will ensure the patient is visually within sight at all times Procedure: Line of Sight Observation -Patient is under constant observation and within line of sight at all times. -Line of Sight observation level may be required for the patient assessed as high or increased risk in the context of their illness and their environment. -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. -In some instances, it may be clinically identified that the assigned observer is to remain in the same room as the patient at all times. This can include assigning one observer to a shared room with two patients, if appropriate. This must be clearly documented on the inpatient observation record. -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.” Review of Patient #3’s Provider Orders from Admission (10/08/2024) to Discharge (11/09/2024) revealed the following in part: On 10/08/2024 at 3:00 PM Fall Precautions were ordered by S7MD. On 11/08/2024 at 8:00 PM Line of Sight Observation were ordered by S7MD. On 11/09/2024 at 9:00 AM Transfer Patient - Send to ER for further eval and treat of fall with head injury was ordered by S9NP. Furthermore, Patient #3 did not return to the facility and was officially discharged from the system on 11/10/2024 at 10:00 AM. Review of Patient #3’s Nursing Notes on 11/08/2024 between 11:00 PM and 11:36 PM by S12RN staff reported to her around 11:00 PM Patient #3 had fallen and hit her head. Upon her assessment of Patient #3, S12RN had found a “gulf ball sized area” to the back of her head with a smear of blood and no other new notable injuries visible on patient’s skin. Patient #3 denied any pain to her at that time and Patient #3’s mental status remained unchanged. S12RN notified S9NP who gave an order to send Patient #3 to the local emergency department of further evaluation and treatment. S12RN documented vital signs and neuro checks and notified S1DON of the incident. The local ambulance transport company was contact to set up transport for Patient #3 to the local emergency room and Patient #3’s family was notified of the incident. Patient #3 was left the facility and was transferred to local emergency room at 11:36 PM. Review of the facility’s Incident Report dated 11/08/2024 for Patient #3 revealed the following in part: Date/Time of Incident: 11/08/2024 at 11:00 PM Occurrence: Incident Category: Fall Location: Patient Room Notifications: Nurse Practitioner - S9NP - 11/08/2024 - 11:02 PM Director of Nursing - S1DON - 11/08/2024 - 11:03 PM Administrator on Call - 11/08/2024 - 11:05 PM Family Contact - 11/08/2024 - 11:10 PM Brief Description of Incident: 11:00 PM - Reported by staff pt with fall and hit her head. Upon assessment, gulf side area to back of head noted with smear of blood noted. No other new injuries observed on pt skin. Patient denies any pain at present. Mental status remains unchanged. S9NP notified, order received to send out to ED for further eval and treatment. Neuro checks initiated per facility protocol. BP 164/57, p 79, t 97.8, r 18, sat 100% on RA. Related Causes & Factors: Confused/disoriented; Policy/procedure not followed; other - patient LOS no one watching at time of call Actions Taken Post-Incident: MD notified; appropriate authorities notified; Family notified; Neuro checks ordered, initiated; Education provided to patient; Education provided to Employee Follow Up/Resolution (DON): Unwitnessed fall with head injury. Pt was transferred to ED and subsequently admitted to HLOC, did not return to facility. Pt was on line of sight observation status at time of injury - staff member was not maintaining appropriate observations, removed from schedule. Corrective action to follow. Patient was on fall precautions at time of event with care plan in place. Neuro checks were initiated per protocol. Orders obtained for transfer. Family notified. Incident Report Electronically Signed by: S12RN at 11/09/2024 at 1:12 AM and S1DON at 11/11/2024 at 7:27 PM Patient Fall Report - Was the fall assisted or unassisted? Unassisted Was the fall observed? No Did the patient sustain an injury as a result of the fall? Yes What type of injury was sustained? Abrasion/scrape; Other (explain) - gulf size area to back of head noted with smear of blood, no other new injuries observed on pt skin, pt denies any pain at present, mental status remains unchanged Prior to the fall, what was the patient doing or trying to do? Unknown Were there any identifiable causes or factors that contributed to the patient’s fall? Confused/disoriented; Intentional act of patient Prior to the fall, was the patient assessed for fall risk? Yes Was the patient determined to be at risk for a fall? Yes What protocols/interventions were in place, or being used, to prevent falls for this patient? Fall alert; Non-slip footwear; other (specify) - LOS At time of the fall, was the patient on medication known to increase the risk for a fall? Yes Was the medication considered to have contributed to the fall? Yes Actions Taken Post-Fall: MD notified; Supervisor notified; Family notified; Care plan initiated/updated; Incident & intervention documented in patient’s record; Neuro checks ordered, initiated; Teaching to patient provided, as appropriate; Transferred to higher level of care; Other (specify) - Sent out to local hospital for further eval and treat Patient Fall Report Electronically Signed: S12RN on 11/09/2024 at 1:16 AM and S1DON 11/11/2024 at 7:57 PM Review of the Observation Check Sheet/Graphic Flowsheet dated 11/08/2024 for Patient #3 revealed her observation level was Line of Sight. S20MHT documented at 10:45 PM Patient #3 was sitting in her room. At 11:00 PM, S20MHT documented Patient #3 had fallen and was offsite. On 12/02/2024 at 3:00 PM an interview was conducted with S1DON. She stated she was made aware of the incident with Patient #3 on the night shift of 11/08/2024 when she fell and hit her head. S1DON confirmed Patient #3 was on LOS observation at the time of the fall, but S20MHT was not properly observing her at the time of the fall. S1DON confirmed there were 2 MHTs on staff working on 11/08/2024 and the staff matrix called for 3 MHTs.”

“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 48537 Based on record review and interviews, the hospital failed to ensure patients were free from abuse and neglect and ensure all incidents of 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: 1) failure to thoroughly investigate and report allegations of abuse within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#3) of 3 (#1-#3) patients reviewed for abuse; and 2) failure to thoroughly investigate and report allegations of elopement within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#1) of 3 (#1-#3) patients reviewed for elopement. Findings: Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals indicated the following “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 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 the hospital’s policy number RTS-10 titled “Abuse and/or Neglect of Patients by Staff Members, Students, and Interns” effective 01/11/2016, indicated the following in part: “Purpose: To prevent and rectify misconduct in a just and constructive manner to reduce likelihood of recurrence and to protect patients from abuse. Policy: Patients have the right to be free from neglect, exploitations, and verbal, mental, physical and sexual abuse. This facility supports and conforms to all state and federal guidelines for protection of patients’ rights. Definitions: 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, 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: - Causing pain or suffering; - Direct physical aggressive behavior toward a patient; - Failing to or refusing to attend to the necessary care and treatment; - Implementing actions contrary to the prescribed treatment of the program; - Unauthorized restriction of patients’ rights; - Failing to intervene to protect a patient from abuse and/or mistreatment. Any staff or student suspected of any of the above infractions will be investigated under this policy. If it is determined that the staff member physically, sexually, or verbally abused the patient in question or willfully neglected the patient(s), disciplinary actions will be enacted against him/her, up to and including termination of employment. Employees are educated on this policy. Procedure: Refer to Assessment and Reporting of Abuse, Neglect, Exploitation and/or Extortion of Youth and Adults Policy for report procedures.” Review of the hospital’s policy number AS-18 titled “Assessment and Reporting of Abuse, Neglect, Exploitation” last revised on 10/01/2024 indicated the following, 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 of patients/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 & Medicaid Services) Accreditation: - The Joint Commission Louisiana: - Area police/sheriff’s department - The Louisiana Department of Health - Adult Protective Services of the Louisiana Department of Health - Office of Community Services of the State of Louisiana - The Governor’s Office of Elderly Affairs/Elderly Protective Services - Professional Licensing Boards Procedure: Procedure to Respond to Alleged of Suspected Abuse, Neglect, Exploitation by Facility Staff (employed or contracted) or by another patient: 1. Should a staff member identify, or be notified of, a suspected case or of abuse, neglect, and exploitation, he/she will notify his/her immediate supervisor and the Administrator/Administrator-on-Call and the Director of Nurses (DON) immediately. 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 of any clinical interventions necessitated by the circumstances and perform an investigation to determine if the allegations are substantiated. The Administrator/Administrator-on-Call shall take, or ensure that the following actions are taken, by appropriate staff members: - Contacts attending physician to relay events - Immediately contacts family to inform family of allegations and actions takes and arranges a session. If the patient is an adult, must obtain patient’s consent prior to contacting family - The findings of investigation will be reviewed with patient/family members/authorized representative as required/permitted by law. - If required, obtain consent for further referral, assessment, evaluation, treatment, intervention as pertinent to specific situation as needed will be obtained. - Immediately notify the Regional Director of Clinical Services - Prepare and submit any required Self Report documentation per the following: Louisiana Louisiana Department of Health (LDH) The Facility shall send the Self-Report on the Hospital Abuse and Neglect Self-Reporting Form Louisiana to the email listed above. The Facility may also report to the local law enforcement or the Louisiana Medicaid Fraud Unit, as applicable. Initial reporting must be submitted within 24 hours of a staff member or contract worker becoming aware that an incident of abuse or neglect has been alleged, witnessed or is suspected. Final Investigative Report within five (5) working days of submitting the initial report.” 1) Failure to thoroughly investigate and report allegations of abuse within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#3) of 3 (#1-#3) patients reviewed for abuse. Review of Patient #3’s Provider Orders for October 2024 revealed the following orders: 10/09/2024 9:00 AM Aspirin 81mg 1 tablet by mouth daily Indication: myocardial infarction prevention. Ordered by S9NP on 10/17/2024 at 9:09 AM 10/09/2024 9:00 AM Clopidogrel Bisulfate 75mg 1 tablet by mouth daily Indication: thrombosis prevention after percutaneous coronary intervention. Ordered by S9NP on 10/17/2024 at 9:09 AM Review of Patient #3’s Provider Orders for November 2024 revealed the following orders: 11/05/2024 2:01 PM Transfer Patient - Send patient to ER for further evaluation and treatment of bruising to facial/temporal area and chest area, pt on Plavix and aspirin. Ordered by S9NP on 11/08/2024 at 7:41 AM Review of Patient #3’s Medical Progress Notes dated 11/04/2024 by S9NP revealed the following in part: On 11/04/2024, Patient #3 stated to S9NP, “I want to see my doctor.” Patient in room with MHT at bedside. Patient denies acute medical complaints. Currently calm although labile mood. Physical exam revealed skin documentation of “Other: chronic ecchymosis and skin tears to arms, no active bleeding, bandages noted on forearms.” Electronically signed by S9NP on 11/04/2024 at 4:35 PM Review of Patient #3’s Skin and Wound Care Assessment for 11/05/2024 revealed the following: Date: 11/05/2024 Site: Face Etiology: Bruise Origin: Not present on admission Comment: Left eye bruising Date: 11/05/2024 Site: Right Upper Extremity Etiology: Bruise Origin: Not present on admission Comment: Right breast bruising Date: 11/05/2024 Site: Right lower extremity Etiology: Bruise Origin: Not present on admission Comment: Outer right leg bruising Date: 11/05/2024 Site: Left Lower Extremity Etiology: Bruise Origin: Not present on admission Comment: Left thigh bruising Date: 11/05/2024 Site: Face Etiology: Bruise Origin: Not present on admission Comment: Eye/mouth bruising Date: 11/05/2024 Site: Right Knee Etiology: Bruise Origin: Not present on admission Comment: Right inner knee bruising Date: 11/05/2024 Site: Left Upper Extremity Etiology: Bruise Origin: Not present on admission Comment: Left breast bruising Review of Patient #3’s Nursing Notes dated 11/05/2024 revealed the following note: 11/05/2024 at 7:20 AM - It was reported to me at shift change on the evening of 11/04/2024, by S11RN day shift, that bruises were observed by her on the patient in question. Also, S11RN informed me that the S10FADON and Medical MD was notified. On 11/05/2024 at 7:20 a.m. after report was given to day nurse S11RN. I was called into the shower room by S18LPN to observe the patient’s skin. While standing at the distance I was, I clearly saw that the patient bilateral breast was bruised, left side of her face bruised and her bilateral lower legs had some discolored blue-black streaks. I notified S10FADON. Electronically signed by: S12RN on 11/06/2024 at 4:49 a.m. 11/05/2024 at 1:38 PM - Patient #3’s daughter-in-law notified that patient had bruising of unknown source. Family informed they will be provided with developing findings. Signed by: S11RN Review of Patient #3’s Medical Progress Notes dated 11/05/2024 by S9NP revealed the following in part: On 11/05/2024, Patient #3 stated to S9NP, “I was beat up last night.” Patient has multiple bruises throughout body. Patient states staff twisted her breast and hit her in the head. Patient has bruising to bilateral breast. RN took pics of wounds. Patient also has bruising to left orbit, and temple. Patient has multiple bruising to extremities and toes. Wounds do appear to be from assault differential causes, unreported fall. Patient to be sent to ER for evaluation of wounds and have radiographs done since she is on Plavix. Physical exam revealed skin documentation of “Other: chronic ecchymosis and skin tears to arms, no active bleeding, bandages noted on forearms, bruising to bilateral breast. RN took pics of wounds. Patient also has bruising to left orbit, and temple. Patient has multiple bruising to extremities and toes. Assessment: 16. Bruising/multiple wounds: most likely from assault. Patient sent to ER for evaluation. Electronically signed by S9NP on 11/05/2024 at 3:13 PM Review of the facility Grievance Logs for October and November 2024 revealed no documented grievances for Patient #3 related to allegations of abuse. Review of the facility Incident Logs for October and November 2024 revealed no documented incidents involving staff to patient abuse for Patient #3. An incident report was completed on 11/05/2024 at 2:01 PM Patient #3 for a change in condition related to bruising of unknown source with “area of concern per Provider due to patient being on a daily regimen of Plavix and Aspirin” and no mention of suspected assault as mentioned in S9NP’s progress note. On 12/02/2024 at 3:15 p.m., a telephone interview was conducted with S9NP. He stated he was notified by S11RN who was caring for the Patient #3 when he made rounds at the facility on the morning of 11/05/2024 of new generalized bruising to Patient #3. He stated he went into Patient #3’s room to assess her and S11RN and S10FADON were taking pictures of the bruising. He stated Patient #3’s bruising was new to what he had seen the day prior (11/04/2024) when he had made rounds on her at the facility, however, he stated he does not usually do a full skin assessment on every patient daily unless the nurse notifies him of a new wound or reason to perform a skin assessment on a patient. He agreed the skin areas commonly visible on patients he would see during routine exams would be a patient’s face, lower arms or legs if they were wearing a short-sleeved shirt or gown, he would be able to visualize any newly bruised areas. He stated the bruising to Patient #3’s left eye/temporal region and face were new to him when he saw her on the afternoon of 11/05/2024 and she did not have that bruising when he made rounds on her on 11/04/2024. He confirmed Patient #3 verbally reported to him on 11/05/2024 staff had “beat her up” on the prior shift, but did not hold much weight to it because she was “demented”. He stated she had been exhibiting aggressive behaviors towards staff and self-harm towards herself recently and took daily Plavix and Aspirin so his main concern was her increased risk for bleeding. He stated he included that in his progress note as well as the potential allegation the patient had made of assault and sent her out for further evaluation to the local emergency department for further evaluation and treatment. He stated he did not further report the allegation of assault to anyone else because the S11RN and S10FADON were in the room with him and heard the patient report the allegation as well. On 12/02/2024 at 4:04 p.m., an interview was conducted with S11RN. She stated Patient #3 had reported to her prior to 11/05/2024 that night shift staff had assaulted her. S11RN stated she had completed a hand written report and gave it to S10FADON. S11RN stated she could not recall the exact date of when Patient #3 reported the assault to her, but stated it was around the time of when the 11/05/2024 incident with the generalized bruising had occurred but was prior to that event. S11RN stated she had “started to become suspicious” of the increased bruising on Patient #3, but was aware Patient #3 was on Plavix and a daily aspirin which increased her risk for bleeding and knew it was why she was on bleeding precautions. S11RN stated she had never personally seen any other staff members be physical or assault Patient #3. S11RN stated when Patient #3 reported the assault to her, she asked Patient #3 if she could tell her who the person or persons were who assaulted her and she stated Patient #3 could not provide her with a name of a staff member, but she did describe them which was what she included in her report. S11RN stated she put in her report word for word what Patient #3 said regardless of what she stated if it was appropriate or not. S11RN stated once she completed the report, she gave it to her superior, which at the time was S10FADON. S11RN stated she was never contacted about the incident after that from anyone so she was unsure if S10FADON escalated the issue to anyone above her. S11RN stated when she arrived to work on the morning of 11/05/2024, she went to assess Patient #3 and found multiple new bruises to Patient #3’s left eye/temporal region, bilateral breasts, right outer leg, left thigh, right inner knee and facial bruising. S11RN stated as soon as she observed the new bruising to Patient #3, she notified S9NP who was at the facility making rounds on patients at that time, and requested he come to assess Patient #3’s skin with her and S10FADON. She stated while S9NP assessed Patient #3, S10FADON and herself photographed the new bruises for her medical record. S11RN stated she voiced her concerns to S9NP regarding the bruises being suspicious in nature and not having received any reported falls in shift report. She stated S9NP placed an order for Patient #3 to be transferred to the local emergency department for further evaluation and treatment. On 12/03/2024 at 10:15 AM, an interview was conducted with S1DON. She stated she was unaware of the allegation of assault Patient #3 had made to S11RN which she had reported to S10FADON in a handwritten report. She confirmed if an allegation of assault and/or abuse towards a patient was made and/or witnessed, it should be reported immediately to be investigated. 2) Failure to thoroughly investigate and report allegations of elopement within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#1) of 3 (#1-#3) patients reviewed for elopement. Review of Patient #1’s Nursing Progess Notes dated 09/30/2024 9:20 a.m. revealed in part: Patient #1 lingering at exit door with clothes packed. Patient unable/unwilling to follow directive to remove self from exit door. Patient later removed herself from the exit door and sat in the hall seated in the middle of the floor with her legs folded. Patient #1 witnessed running behind a nurse as she exited the unit, Patient #1 reported catching exit door and pushing it open. Patient #1 reached outside ramp where charge nurse was standing. Patient returned to unit without further episodes. An interview on on 12/03/2024 at 10:05 a.m., S1DON verified neither the local law enforcement agency or the Louisiana Department of Health (LDH) was notified of Patient #1 elopement.”

“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: 48537 Based on record review and interviews, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. The deficient practice was evidenced by: 1) failure of the hospital to self-report and investigate allegations of staff physical abuse to a patient after being reported to nursing staff and medical provider; and 2) failure of the hospital to self-report and investigate an elopement attempt made by patient. Findings: Review of the QAPI Meeting Minutes provided were from January 31, 2024; July 24, 2024; and October 16, 2024. No further QAPI Meetings were held after the above incidents. 1) Failure of the hospital to self-report and investigate allegations of staff physical abuse to a patient after being reported to nursing staff and medical provider. Review of the hospital’s current QAPI projects for 4th quarter 2024 revealed no open projects related to abuse and/or abuse reporting. On 12/03/2024 at 12:45 PM, an interview was conducted with S3DQ. She confirmed there were no open QAPI projects currently related to abuse, self-reporting or investigating allegations. 2) Failure of the hospital to self-report and investigate an elopement attempt made by patient. Review of the hospital’s current QAPI projects for 4th quarter 2024 revealed no open projects related to elopements. On 12/03/2024 at 12:45 PM, an interview was conducted with S3DQ. She confirmed there were no open QAPI projects currently related to elopements, self-reporting or investigating elopements.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure an adequate number of licensed nursing and other personnel were scheduled to provide nursing care to all patients. This deficient practice was evidenced by the inadequate number of MHT’s scheduled to work on the 7:00 PM - 7:00 AM shift on 11/01/2024. Review of the hospital’s policy number NSG-06 titled “Staffing Plan” last revised on 09/01/2022, indicated the following, in part: “Purpose: To establish criteria that provides guidelines for meeting anticipated needs of the nursing staff and to provide for safe deliver of care to the patients in a fiscally responsible manner. Policy: The Governing Body has adopted, implemented and enforces a written Nurse Staffing policy to ensure that an adequate number and skill mix of nurses are available to meet the level of patient car needed. The Director of Nursing, or designee plans a master schedule for each discipline within the nursing department. The master schedule is adjusted as needed to provide for patient needs and ensure positive patient outcomes. The charge nurse or nursing supervisor, in the absence of the DON, makes necessary changes to staffing units to meet unit needs.” Review of the hospital’s staffing matrix revealed the following in part: 13 patients on 7:00 PM - 7:00 AM 3 MHTs Review of the hospital’s policy number CS-23 titled, “Level of Observations” last revised on 03/01/2023, revealed the following in part: Purpose: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient’s need for autonomy while ensuring safety. 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: 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 arm’s reach of a staff member at all times and in all circumstances. Procedure: Line of Sight Observation -Patient is under constant observation and within line of sight at all times. -Line of Sight observation level may be required for the patient assessed as high or increased risk in the context of their illness and their environment. -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. -In some instances, it may be clinically identified that the assigned observer is to remain in the same room as the patient at all times. This can include assigning one observer to a shared room with two patients, if appropriate. This must be clearly documented on the inpatient observation record. -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 Physician/NPP -Provides order for -one-to-one observation based on assessed risk and individual needs. -The physician/NPP must give the order to discontinue a one-to-one level of observation once it is begun. Charge Nurse -Assesses patient’s condition regarding danger to self, others, fall risk, psychological factors, elopement and psychosis which places the patient at risk. -Reassesses patient status, at a minimum of every 4 hours for continued risk and need for the one-to-one level of care. The rationale for the continued one-to-one will be documented in the multidisciplinary progress notes every 4 hours. If the patient is assessed and it is found that the patient no longer needs the one-to-one level of care, then the physician/NPP MUST be notified and an order received to discontinue the one-to-one. Review of the hospital census for 11/01/2024 revealed a total of 13 patients, 6 males and 7 females. Review of the nursing assignment sheet for 11/01/2024 for the night shift (7:00 PM - 7:00 AM) revealed a starting census of 13 patients with a total of 3 admissions during the shift, a total of 4 staff members - 1 charge RN, 1 medication LPN and 2 MHTs. Based on the nursing assignment sheet there were two patients on 1:1/LOS observation, but it did not differentiate which observation status they were on. Review of the Observation Check Sheet/Graphic Flowsheet for 11/01/2024 for the 7:00 PM to 7:00 AM shift revealed the following: Observational Level MHT who initialed direct observation of patient Patient #3 LOS S23MHT #R1 Q15 S23MHT #R2 Q15 S23MHT #R3 Q15 S23MHT #R4 Q15 S23MHT #R5 Q15 S23MHT #R6 Q15 S23MHT On 12/02/2024 at 3:00 PM an interview was conducted with S1DON. S1DON confirmed there were 2 MHTs on staff working on 11/01/2024 7:00 PM - 7:00 AM shift and the staff matrix called for 3 MHTs.”

“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 an interview, the hospital failed to ensure the RN received a provider’s order to modify an observation level for 1 (#3) of 3 (#1-#3) patients reviewed for observation statuses. Findings: Review of the hospital’s policy number CS-23 titled, “Level of Observations” last revised on 03/01/2023, indicated the following, in part: “Purpose: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient’s need for autonomy while ensuring safety. Policy: 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: 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 arm’s reach of a staff member at all times and in all circumstances. Procedure: Line of Sight Observation -Patient is under constant observation and within line of sight at all times. One-to-one Observation Physician/NPP -Provides order for -one-to-one observation based on assessed risk and individual needs. -The physician/NPP must give the order to discontinue a one-to-one level of observation once it is begun. Charge Nurse -Assesses patient’s condition regarding danger to self, others, fall risk, psychological factors, elopement and psychosis which places the patient at risk. -Reassesses patient status, at a minimum of every 4 hours for continued risk and need for the one-to-one level of care. The rationale for the continued one-to-one will be documented in the multidisciplinary progress notes every 4 hours. If the patient is assessed and it is found that the patient no longer needs the one-to-one level of care, then the physician/NPP MUST be notified and an order received to discontinue the one-to-one.” Review of Patient #3’s Providers Orders from admission on 10/08/2024 to 11/08/2024 revealed the following, in part: 10/26/2024 at 9:00 AM - 1:1 Observation Continuous Rationale: Danger to others, Comments: Psychotic Behavior, High Fall Risk, Aggressive towards others. Ordered by S8NP (Order was discontinued on 11/08/2024 at 9:37 PM) Review of Patient #3’s Observation Check Sheet/Graphic Flowsheet dated 11/01/2024 revealed a documented observation level of “Line of Sight”. On 12/03/2024 at 12:15 p.m., an interview was conducted with S1DON. She reviewed Patient #3’s Observation Check Sheet/Graphic Flowsheet dated 11/01/2024. She confirmed the observation level checked on the paper was “Line of Sight”. She reviewed Patient #3’s Providers’ Orders for 11/01/2024 and confirmed Patient #3 had an order for 1:1 Observation Continuous on 11/01/2024 and no order for Line of Sight observation.”

“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 hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. This deficient practice is evidenced by the failure to update the nursing care plans on 1 (#1) of 3 (#1-#3) sampled patients reviewed for completed and updated nursing care plans. Findings: A review of facility policy number CS-02 titled, “Treatment Planning; Integrated/Multidisciplinary” revealed in part, under the section “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 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: implementing immediate treatment interventions for safety and stabilization of the patient. 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 orders will be incorporated into the Treatment Plan”. A medical record review on 12/03/2024 at 10:00 a.m. revealed Patient #1 had a diagnosis of Diabetes during nursing assessments completed during hospitalizations dated 09/20/2024 and 10/07/204 by RNs. There was no documentation indicating Patient #2’s nursing care plans had initiated or been updated to include this medical diagnosis or treatment interventions. In an interview on 12/03/2024 at 10:40 a.m. S1DON confirmed there had been no initiation intervention related to the Patient #1’s diagnosis of Diabetes or updates to the nursing care plan.”

“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: 48050 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. This deficiency is evidenced by failing to ensure a Registered Nurse made all patient care assignments. Findings: A review of hospital policy number NSG-06 last revised date 09/10/2022 titled, “Staffing Plan,” revealed in part: “PURPOSE: To establish criteria that provides guidelines for meeting anticipated needs of the nursing staff and to provide for safe delivery of care to the patients in a fiscally responsible manner. PROCEDURE: Inpatient: Factors considered in determining staffing needs: Patient census and staffing matrix are used to determine staffing needs. A registered nurse plans, assigns, supervises, and evaluates the nursing care of each patient daily. A registered nurse is responsible for supervising all License Practical/Vocational Nurses (LPN/LVN), Mental Health Techs (MHT) and Certified Nursing Assistants (CNA)”. A review of the following staff assignments failed to reveal that all patient assignments were made by the RN for each shift: 10/26/2024 Day Shift (07:00- 19:00) Patient census 15 10/26/2024 Night Shift (19:00- 07:00) Patient census 16 11/02/2024 Day Shift (07:00- 19:00) Patient census 15 11/02/2024 Night Shift (19:00- 07:00) Patient census 17 11/06/2024 Day Shift (07:00- 19:00) Patient census 17 11/06/2024 Night Shift (19:00- 07:00) Patient census 17 11/07/2024 Day Shift (07:00- 19:00) Patient census 17 11/07/2024 Night Shift (19:00- 07:00) Patient census 15 11/09/2024 Day Shift (07:00- 19:00) Patient census 17 11/10/2024 Day Shift (07:00- 19:00) Patient census 16 11/11/2024 Day Shift (07:00- 19:00) Patient census 17 11/11/2024 Night Shift (19:00- 07:00) Patient census 18 11/12/2024 Day Shift (07:00- 19:00) Patient census 18 11/12/2024 Night Shift (19:00- 07:00) Patient census 16 11/13/2024 Day Shift (07:00- 19:00) Patient census 16 11/13/2024 Night Shift (19:00- 07:00) Patient census 14 11/14/2024 Day Shift (07:00- 19:00) Patient census 15 11/14/2024 Night Shift (19:00- 07:00) Patient census 14 11/15/2024 Day Shift (07:00- 19:00) Patient census 13 11/15/2024 Night Shift (19:00- 07:00) Patient census 13 11/16/2024 Day Shift (07:00- 19:00) Patient census 15 11/17/2024 Day Shift (07:00- 19:00) Patient census 16 11/18/2024 Day Shift (07:00- 19:00) Patient census 18 In an interview on 12/03/2024 at 1:30 p.m., S3DQ confirmed RN makes patient assignments for the MHTs for all patients on the unit. S3DQ verified that the above assignment sheets did not have all patients assigned to MHTs. S1DON also confirmed that the hospital policy states the RN on each shift is responsible for delegating patient care assignments.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 48537 Based on record review and an interview, the hospital failed to ensure the medical record contained information to describe the patient’s response and effectiveness of PRN (as needed) medications for 1 (#3) of 3 (#1 - #3) sample patients reviewed for PRN medications. Findings: A review of the hospital policy #MM-01 titled “Medications” last revised on 12/01/2024, indicated the following, in part: “Purpose: To establish protocols for inpatient medications related to: -Documentation Policy: The hospital will ensure that all medications related to the patient’ inpatient stay are documented in the medical record in accordance with Federal and State Law and industry best practice. Procedure: Documentation RN/LVN/LPN 5. Documents on the patient’s MAR any PRN and STAT medications administered, with cause and effect noted. 7. Documents PRN medication effectiveness of any new medication prescribed by physician.” A review of the Provider Orders for Patient #3 from 10/23/2024 to 11/08/2024 revealed the following orders: 10/23/2024 7:38 PM Zyprexa 10mg IM one time only - Do not give at the same time or within 2 hours of Ativan eSignature: S7MD on 10/26/2024 at 5:39 AM 10/25/2024 4:20 PM Ativan 2mg/mL, 1mg(0.5mL) Im one time only - Medication joined with Haldol 2.5mg IM injection Indication: psychotic disorder eSignature: S8NP on 10/29/2024 on 10:47 AM 10/25/2024 4:20 PM Haldol 5mg/mL, 2.5mg (0.5mL) IM one time only - Medication joined with Ativan 1mg IM Indication: psychotic disorder eSignature: S8NP on 10/29/2024 on 10:47 AM 10/26/2024 3:20 AM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: psychotic disorder eSignature: S7MD on 10/26/2024 on 5:39 AM 10/26/2024 3:20 AM Haldol 5mg/mL, 5mg (1mL) IM one time only Indication: psychotic disorder eSignature: S7MD on 10/26/2024 on 5:39 AM 10/27/2024 12:53 PM Ativan 2mg/mL, 2mg (0.5mL) IM one time only - Medication joined with Haldol 2.5mg Indication: agitation and aggression eSignature: S7MD on 10/26/2024 on 5:39 AM 10/27/2024 12:53 PM Haldol 5mg/mL, 5mg (0.5mL) IM one time only - Medication joined with Ativan 1mg Indication: agitation and aggression eSignature: S7MD on 10/26/2024 on 5:39 AM 11/03/2024 9:00 AM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: agitation eSignature: Mohammad Anwar on 11/04/2024 on 6:15 PM 11/04/2024 4:04 PM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: preoperative anxiety eSignature: S8NP on 11/06/2024 on 10:32 AM 11/05/2024 9:04 AM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: physical aggression eSignature: S8NP on 11/06/2024 on 10:32 AM 11/06/2024 2:12 AM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: agitation eSignature: S7MD on 11/06/2024 on 1:54 PM A review of the of MAR for Patient #3 from 10/23/2024 to 11/08/2024 revealed the following PRN medications given with no documented effectiveness after receiving the medication: Zyprexa 10mg IM: 10/23/2024 at 7:38 PM given by S15LPN; no effectiveness follow-up documented Ativan 0.5mg IM: 10/25/2024 at 4:30 PM given by S16LPN; no effectiveness follow-up documented Haldol 2.5mg IM: 10/25/2024 at 4:30 PM given by S16LPN; no effectiveness follow-up documented 10/27/2024 at 12:55 PM given by S16LPN; no effectiveness follow-up documented Ativan 1mg IM: 10/26/2024 at 3:15 AM given by S17LPN; no effectiveness follow-up documented 10/27/2024 at 12:55 PM given by S16LPN; no effectiveness follow-up documented Haldol 5mg IM: 10/26/2024 at 3:15 AM given by S17LPN; no effectiveness follow-up documented Ativan 2mg IM: 11/03/2024 at 9:15 AM given by S19LPN; no effectiveness follow-up documented 11/04/2024 at 4:04 PM given by S16LPN; no effectiveness follow-up documented 11/05/2024 at 9:05 AM given by S16LPN; no effectiveness follow-up documented 11/06/2024 at 2:12 AM given by S18LPN; no effectiveness follow-up documented On 12/02/2024 at 1:24 PM, an interview was conducted with S3DQ. While reviewing the MAR for Patient #3 for PRN medication administration, it was discovered none of the PRN medications administered to Patient #3 had been evaluated for effectiveness after being administered to Patient #3. S3DQ stated the charting system used by the nursing staff “prompted staff with a reminder to document effectiveness when a PRN medication is administered to a patient.” S3DQ confirmed none of the PRN medications listed above between 10/23-11/06/2024 administered to Patient #3 had a documented effectiveness and should have.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44495 Based on record review and interview the psychiatric hospital failed to ensure care in a safe setting. The deficient practice is evidenced by failure to assess 1(#2) of 1 reviewed patient with symptoms of alcohol withdrawal as ordered by the licensed practitioner. Findings: Review of the medical record for Patient #2 revealed admission on 06/07/2024 with a diagnosis of major depressive disorder, suicidal ideations, and alcohol use. Review of the orders for Patient #2 revealed on 06/08/2024 at 11:50 a.m. an order was placed for, “CIWA [Clinical Institute Withdrawal Assessment], Every four hours. Request Type: Routine.” Review of the psychiatric evaluation for Patient #2 performed on 06/08/2024 at 2:01 p.m. revealed in part, “Patient also reported ‘crawling out of my skin,’ ongoing anxiety, and tremors noted to bilateral hands.” Further review of the medical record revealed the CIWAs were performed as listed: 06/08/2024 at 9:55 a.m.; Score 3; 06/08/2024 at 12:40 p.m.; Score 14; 06/08/2024 at 2:20 p.m.; Score 1; 06/08/2024 at 9:00 p.m.; Score 4; 06/09/2024 at 8:03 a.m.; Score 11; 06/09/2024 at 3:15 p.m.; Score 11; 06/09/2024 at 9:23 p.m. ; Score 16; 06/10/2024 at 3:39 p.m.; Score 19; 06/10/2024at 8:58 p.m.; Score 11; 06/11/2024 at 4:54 p.m.; Score 12; 06/11/2024 at 9:20 p.m.; Score 11; 06/12/2024 at 6:13 p.m.; Score 11; 06/13/2024- 7:30 a.m.; Score 2. In interview on 06/24/2024 at 2:25 p.m., S2QD verified the assessments were rarely done within 4 hours of the previous assessment.”

“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: 44495 Based on record review and interview, the psychiatric hospital failed to ensure the use of chemical restraints was documented according to facility policy. The deficient practice is evidenced by failure to document the use of a chemical restraint in 1 (#4) of 4 (#1-#4) reviewed patient records. Findings: Review of Policy #NSG-71, “Seclusion and Restraints,” revealed in part,” Definitions: Restraint: . . . A restraint may also be a drug or medication (chemical restraint) when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom for movement and is not a standard treatment or dosage for the patient’s condition.” Further review of the policy revealed, “PROCEDURE: 1. Initiation: . . . 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 the duration of seclusion or restraint. . . . 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. . . . 7. Monitoring: . . . . The RN must assess the patient upon initiation of seclusion/restraint, after the first 15 minutes of seclusion/restraint, during the one-hour face-to-face assessment, every hour the patient remains in seclusion/restraint, and upon discontinuation of seclusion/restraint. . . . Emergency psychoactive medication administration follows the same protocol and procedure: every 15 minutes an assessment and vital signs must be conducted, and the one-hour RN assessment is performed. All patients receiving intramuscular psychoactive medication will be assessed at a minimum of every 15 minutes for one hour for vital signs, nutritional needs, and safety. A complete RN assessment will be performed at one hour and documented on the flow sheet . . . 9. Debriefing: Identify what led to the episode and what could have been handled differently.” Review of the medical record for Patient #4 revealed admission on 06/17/2024 with a diagnosis of dementia with behavioral disturbance. Review of the orders for Patient #4 revealed on 06/18/2024 at 1:17 a.m. orders were entered for “haloperidol lactate (Haldol injectable) 5 MG/ML, 5 mg (1 mL) intramuscularly One Time Only. Medication Indication: agitation,” and “diphenhydramine HCl (Benadryl) 50 MG/ML, 50 mg (1mL) intramuscularly One Time Only- Medication Indication: agitation.” Review of the medical record for Patient #4 revealed on 06/18/2024 at 1:24 a.m. S4LPN documented, “Patient in quiet room sitting on mattress taking off his gown and bed sheets when techs attempt to change patient and fix bedding patient becomes violent trying to hit and spit on staff, order received from S5NP for Benadryl 50 mg and Haldol 5 mg injection given in the right deltoid and tolerated well at this time. Care ongoing for patient.” Further review of the medical record revealed a restraint/seclusion flowsheet was not filled out. In interview on 06/27/2024 at 9:10 a.m., S2QD verified the medications administered were not part of the regular behavior management for the patient and qualified as a chemical restraint. S2QD verified the hospital’s policy was not followed and there was no additional documentation of the incident in the medical record. S2QD verified there was no flow sheet in the medical record with documentation of the interventions and assessments.”

“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: 44495 Based on record review and interview, the psychiatric hospital failed to ensure a one-hour face-to-face asssessment was performed with the initiation of chemical restraints. The deficient practice is evidenced by failure to document a one-hour face-to-face in 1 (#4) of 1 reviewed patient record with the use of restraint. Findings: Review of Policy #NSG-71, “Seclusion and Restraints,” revealed in part,” Definitions: Restraint: . . . A restraint may also be a drug or medication (Chemical restraint) when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom for movement and is not a standard treatment or dosage for the patient’s condition.” Further review of the policy revealed, “PROCEDURE: 1. Initiation: . . . 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 the duration of seclusion or restraint. . . . 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. . . . 7. Monitoring: . . . . The RN must assess the patient upon initiation of seclusion/restraint, after the first 15 minutes of seclusion/restraint, during the one-hour face-to-face assessment, every hour the patient remains in seclusion/restraint, and upon discontinuation of seclusion/restraint. . . . Emergency psychoactive medication administration follows the same protocol and procedure: every 15 minutes an assessment and vital signs must be conducted, and the one-hour RN assessment is performed. All patients receiving intramuscular psychoactive medication will be assessed at a minimum of every 15 minutes for one hour for vital signs, nutritional needs, and safety. A complete RN assessment will be performed at one hour and documented on the flow sheet . . . 9. Debriefing: identify what led to the episode and what could have been handled differently.” Review of the medical record for Patient #4 revealed admission on 06/17/2024 with a diagnosis of dementia with behavioral disturbance. Review of the orders for Patient #4 revealed on 06/18/2024 at 1:17 a.m. orders were entered for “haloperidol lactate (Haldol injectable) 5 MG/ML, 5 mg (1 mL) intramuscularly One Time Only. Medication Indication: agitation,” and “diphenhydramine HCl (Benadryl) 50 MG/ML, 50 mg (1mL) intramuscularly One Time Only- Medication Indication: agitation.” Review of the medical record for Patient #4 revealed on 06/18/2024 at 1:24 a.m. S4LPN documented, “Patient in quiet room sitting on mattress taking off his gown and bed sheets when techs attempt to change patient and fix bedding patient becomes violent trying to hit and spit on staff, order received from S5NP for Benadryl 50 mg and Haldol 5 mg injection given in the right deltoid and tolerated well at this time. Care ongoing for patient.” Further review of the medical record revealed a restraint/seclusion flowsheet was not filled out. In interview on 06/27/2024 at 9:10 a.m., S2QD verified the medications administered were not part of the regular behavior management for the patient and qualified as a chemical restraint. S2QD verified the hospital’s policy was not followed and there was no documentation the registered nurse performed a face-to-face assessment one hour after the restraint was initiated.”

“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: 44495 Based on record review and interview, the psychiatric hospital failed to ensure medications were administered as ordered and according to standard of care. The deficient practice is evidenced by failure to administer medications as ordered for 1 (#4) of 4 (#1-#4) reviewed patient records. Findings: Review of the medical record for Patient #4 revealed admission on 06/17/2024 with a diagnosis of dementia with behavioral disturbance. Review of the orders for Patient #4 revealed an order from admission for “clonidine HCl 0.1 mg (1 tablet(s)) by mouth; Every 4 hours; PRN Systolic>160; Diastolic >90; Indication: hypertension.” Review of the vital signs revealed on 06/22/2024 at 1:00 a.m. Patient #4 had a blood pressure of 162/91 mmHg. Review of the Medication Administration Record (MAR) revealed the medication was not administered. In interview on 06/26/2024 at 9:04 a.m., S2QD verified the medication was not administered as ordered.”

“PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s): 482.13(b)(4) The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to ensure timely notification of the patient’s family member of admission. The deficient practice is evidenced by failure to notify a patient’s wife of admission for more than 2 1/2 days after admission in 1 (#1) of 3 (#1-#3) reviewed patient records. Findings: Review of the medical record for Patient #1 revealed admission on 03/26/2024 at 7:40 p.m. On admission the patient signed the release of information to allow his wife to participate in his care. Further review revealed the patient’s wife was not contacted until 03/29/2024 at 12:16 p.m. for collateral information. In interview on 05/06/2024 at 9:32 a.m., S2QD verified the wife of Patient #1 was not contacted until several days after admission.”

“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 ensure care in a safe setting. The deficient practice is evidenced by staff allowing patients to use pointed objects during art therapy. Findings: Tour of the facility on 05/06/2024 between 1:15 p.m. and 1: 30 p.m. revealed a watercolor paint brush with a wooden handle on the cabinetry. Further observation revealed a patient using fine felt tipped pens. In interview at the time of discovery, S2QD verified the items could be used as weapons and were prohibited items.”

“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: 44495 Based on record review and interview, the facility failed to ensure drugs and biologicals were administered according to the physician’s order. The deficient practice is evidenced by failure of the nursing staff to administer medication as ordered for elevated blood pressure. Findings: Review of the orders for Patient #1 revealed an order initiated on 03/27/2024 at 1:00 a.m. for “clonidine HCL 0.1 milligram; One tablet by mouth every four hours PRN for Systolic >160; Diastolic >90.” The order was discontinued 04/02/2024 at 10:42 a.m. Review of the vital signs revealed the following elevated blood pressures: On 03/27/2024 at 7:15 a.m., the patient’s blood pressure was 148/96 mmHg. On 03/ 28/2024 at 9:15 a.m., the patient’s blood pressure was 147/95 mmHg. On 03/29/2024 at 6:44 p.m., the patient’s blood pressure was 155/101 mmHg. Review of the Medication Administration Record for the above dates and times revealed the medication was not administered. In interview on 05/06/2024 at 10:05 a.m., S2QD verified the medication was not administered as ordered.”

“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: 14442 Based on observation and interview, the hospital failed to ensure patients requiring acute inpatient psychiatric care received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety by having an unlocked supply room accessible to patients. Findings: Observation on 04/09/2024 at 9:19 a.m. revealed patients ambulating in the hallway where the supply room located. Observation revealed the door to the supply room not locked and staff not present in the room. Further observation of supplies in the room revealed, in part, germicidal disposable wipes, wound cleansers, needles, oxygen tubing, and syringes along with other various patient care supplies. In an interview on 04/09/2024 at 9:22 a.m., S2DON confirmed the supply room should be locked at all times when staff not present to ensure patient safety.”

“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 review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failing to ensure capillary blood glucose levels were obtained for 1 (#3) of 3 sampled patients with a diagnosis of diabetes mellitus. Findings: Review of the hospital Glucometer Method for Obtaining CBGs policy, revised date: 07/01/2022 revealed, in part: Purpose: To establish procedural guidelines for obtaining capillary blood glucose levels (CBG’s) for the purpose of diagnosis and treatment. Policy: CBG’s will be performed with physician orders by licensed nursing staff and mental health tech (MHTs) who are deemed competent to perform the procedure. Review of Patient #3’s medical record revealed an admit date of 04/02/2024. Review of Patient #3’s History & Physical Examination dated 04/03/2024 revealed, in part: Past Medical History: Diabetes. Assessment & Plan. 6. Diabetes Mellitus: Cardiac/ADA diet. Januvia 50 mg (used to treat type 2 diabetes) every day. Insulin Sliding Scale with coverage per protocol. Review of Patient #3’s medical record revealed no physician orders or plan for obtaining CBGs. Further review revealed Patient #3 had CBGs obtained twice on 04/03/2024. There were no other CBGs documented. In an interview on 04/08/2024 at 3:03 p.m., S2DON confirmed Patient #3 did not have physician orders or plan for obtaining CBGs. S2DON confirmed a RN should have contacted the physician to clarify the plan for diabetes treatment and obtain orders for CBGs. In an interview on 04/09/2024 at 8:57 a.m., S2DON confirmed Patient #3’s physician was contacted regarding the plan for diabetes treatment. S2DON confirmed Patient #3’s physician ordered CBGs before meals and bedtime starting 04/09/2024.”

“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: 14442 Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. This deficient practice was evidenced by the failure to develop a care plan to address diabetes mellitus for 1 (#3) of 3 sampled patients with a diagnosis of diabetes mellitus. Findings: Review of Patient #3’s medical record revealed an admit date of 04/02/2024. Review of Patient #3’s History & Physical Examination dated 04/03/2024 revealed, in part: Past Medical History: Diabetes. Assessment & Plan. 6. Diabetes Mellitus: Cardiac/ADA diet. Januvia 50 mg (used to treat type 2 diabetes) every day. Insulin Sliding Scale with coverage per protocol. Review of Patient #3’s medical record revealed no documented evidence a nursing care plan had been developed to include diabetes mellitus or treatment interventions. In an interview on 04/09/2024 at 9:58 a.m., S2DON confirmed Patient #3 did not have nursing care plan developed for diabetes mellitus.”

“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 thoroughly investigate and report all incidents of possible neglect. The deficient practice is evidenced by 1) failure to report possible neglect as required by R.S. 40:2009.20 for 3 incidents involving 1 (#4) of 4 (#1- #4) reviewed records; and 2) failure to thoroughly investigate all reported cases of possible abuse or neglect in 1(#3) of 1 reviewed incident that was reported to Louisiana Department of Health/ Health Standards Section. Findings: Review of LA R.S. 40:2009.20 revealed in part, “Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse’s aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician’s assistant, physical therapist, or any other direct caregiver having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect.” Review of Policy Number CS-23, “Level of Observations,” effective 01/11/2016 and last revised 03/01/2023, revealed in part, “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. . . .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 the bathroom and bathing.” 1) Failure of the facility to report possible abuse or neglect as required by R.S. 40:2009.2.0. Review of the medical record for Patient #4 revealed admission on 02/26/2024 under a Corner’s Emergency Certificate for suicidal ideation. The patient had a history of previous suicide attempts and was diagnosed with anxiety, borderline personality disorder, and depression. The patient was admitted with suicide precautions. Review of the incident reports revealed 3 incidents of attempted self-injury for Patient #4. Review of the binder with the incidents reported to Louisiana Department of Health failed to reveal the incidents for Patient #4 were reported. In interview on 03/05/2024 at 11:17 a.m., S3LPN verified the incidents were not reported to Louisiana Department of Health as possible neglect. Review of the first incident revealed on 02/27/2024 at 4:30 p.m., the patient was in her room on one-to-one observation and was found to have several cuts to both arms. First aid was rendered and the physician and supervisor were notified. A body search was completed and the patient gave them a small piece of glass. The patient reported having brought the small piece of glass into the facility in her mouth. In interview on 03/05/2024 between 1:00 p.m. and 1:30 p.m., S2NS verified the patient had been on one-to-one observation and suicide precautions at the time of the incident. S2NS verified the incident happened in the bedroom while the patient was in the bed under the covers. S2NS verified the one-to-one observation is to prevent such occurrences and should not have happened. S2NS verified there was no documentation the room was searched after the incident to remove other objects that could be used for self-injury. S2NS verified those involved were re-educated on the importance of a thorough search at the time of admission. Review of the second incident revealed on 02/28/2024 at 10:30 a.m., the Patient #4 cut herself across the arms again with a second piece of glass in the bathroom. Patient #4 was still on one-to-one observation. The patient was examined by the physician and the wounds were documented in the wound care section of the medical record and the care plan was updated. Staff was again counseled on body search at the time of admission. In interview on 03/05/2024 between 1:00 p.m. and 1:30 p.m., S9NS verified Patient #4 was still on one-to-one observation and suicide precautions at the time of the incident. S9NS verified the incident occurred in the patient’s restroom, but was discovered when the patient was meeting with the treatment team. S9NS said she immediately went into Patient #4’s room with the mental health technician and nurse and searched the room thoroughly. S9NS verified the search was documented in the medical record. S2NS verified patients on one-to-one are not allowed in the bathroom alone and there was no documentation the staff providing the one-to-one observation were questioned as part of the investigation. Review of the third incident revealed on 03/01/2024 at 4:45 p.m., Patient #4 was found sitting on the floor of the dayroom, behind a chair, cutting her forearm. Patient #4 had “2 EKG leads” that were being used to cut her arm. The nurse practitioner and the nursing supervisor were notified, first aid rendered, and a search was performed. In interview on 03/05/2024 between 1:00 p.m. and 1:30 p.m., S2NS verified Patient #4 should not have been “found sitting in the dayroom behind a chair cutting her forearm,” because she was on one-to-one observation. S2NS verified there was no documented interview of the staff providing one to one observation. S2NS stated the patient did not tell them where she got the EKG equipment, but it was assumed to have been brought into the facility by her roommate, who returned to the facility after midnight on 03/01/2024 after an emergency department visit. S2NS verified there was no documentation the roommate, Patient #FR1, had been searched upon return to the facility. During the tour of the facility on 03/05/2024 between 10:23 a.m. and 10:45 a.m., Patient #4 was observed in her room lying in the bed on one-to-one observation. The patient was noted to have a solid deodorant stick in a plastic container on the shelf beside the bed. At the time of discovery, S2NS verified it should not be in the room and promptly removed it. In interview on 03/05/2024 at 1:30 p.m., S2NS verified the incidents should have been self-reported to Louisiana Department of Health. 2) Failure of the facility to thoroughly investigate all reported cases of possible abuse or neglect. Review of the final report sent to Louisiana Department of Health/ Health Standards Section on 02/26/2024 revealed on 02/15/2024 at 4:33 p.m., Patient #3 was witnessed leaving the room of Patient #2. When interviewed Patient #3 reported “she had had sex with Patient #2.” When Patient #2 was interviewed he “denied the encounter took place.” The report indicates that the police and the physician were notified and Patient #3 was sent for a forensic rape examination. Video from the hall where the room was located was reviewed and Patient #3 was seen entering the room of Patient #2 at 4:24 p.m. and exit the room at 4:33 p.m. The door was noted to be open and staff could be seen in the vicinity. The report concluded that the facility was unable to substantiate the allegation due to lack of evidence. Review of the medical record for Patient #2 revealed admission on 02/12/2024 under a Corner’s Emergency Certificate with suicidal and homicidal hallucinations. Patient #2 was admitted with a diagnosis of schizoaffective disorder- bipolar type, methamphetamine use, and cocaine abuse. Patient #2 was on 15 minute observation and was noted to be in his room at the time of the event. Review of the medical record for Patient #3 revealed admission on 02/13/2024 under a Physician’s Order of Protection. Patient #3 was admitted with a diagnosis of bipolar disorder- manic state and delusional disorder. Patient #3 was on 15 minute observation. Review of the observation sheet revealed Patient #3 was in the dayroom from 3:45 p.m. until 4:45 p.m. In interview on 03/05/2024 at 12:18 p.m., S2NS verified Patient #3 could not have been in the dayroom at 3:30 p.m. as documented on the observation sheet when video proved she was in the room of Patient #2. S2NS verified the mental health technician should have been searching for her when she was not seen in the dayroom at 3:30 p.m. and was negligent in his observations. In interview on 03/05/2024 at 2:10 p.m., S1ADM verified the conclusion in the report was there was not enough evidence to substantiate the allegation of sexual abuse and the possibility of neglect of care by the mental health technician was not investigated.”

“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, interview and record review, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. This was evidenced by: 1) failure to inform patients or patients’ representative of patients’ rights in advance in a language or manner non-English speaking Patient #3 could understand (See findings under Tag A0117); 2) failure to ensure non-English speaking Patient #3 had a translator to assist with the development and implementation of the patient’s plan of care (See findings under Tag A0130); 3) failure to use an interpreter/translator to assist non-English speaking patient #3 in understanding and agreeing with multiple consents found in the In-Patient Admission Packet (See findings under Tag A0131); 4) failure to ensure the hospital was free of ligature risks (See findings under Tag A0144); 5) failure to have mechanisms/methods in place that ensure non-English speaking patients have the use of an interpreter/translator to assist with the communication of needs (See findings under Tag A0145).”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital failed to inform the patients or patients’ representative of the patients’ rights in advance as evidenced by failure to explain in a language or manner Patient #3 could understand. Findings: Review of hospital policy titled “Patient Rights”, dated 09/01/2023, revealed, in part: Purpose, in part: To ensure that all patients are aware of their rights while being treated at this facility ....Policy:, in part: 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. Review of hospital policy titled “Communication with Persons of Limited English Proficiency”, dated 02/01/2021, revealed, in part: Purpose: The purpose of this policy is to ensure proper services to anyone who is Limited English Proficient (LEP). All patients have a right to communications in a language and format understandable to the individual for all services provided. Policy, in part: It is the policy of the facility to provide communication aids at no cost to individuals who are LEP, including current and prospective patients, and family. Patients will be provided with alternative communication methods, which allow them to participate more fully in their care. Procedure, in part: 2. The facility will provide oral and written translation services, free of charge to any patient in need of such services. This may be accomplished by utilizing the facility’s contracted language interpretation services. Review of hospital document titled “Job Description, Director of Nursing”, dated 11/01/2023, revealed, in part: Position Summary, in part: ...demonstrates...cultural sensitivity. Essential Functions, in part: 8. ensures staff compliance with patient care, documentation, hospital/unit policies and procedures, protocols, and guidelines... Review of hospital document titled “Job Description, Assistant Director of Nursing”, dated 11/01/2023, revealed, in part: Essential Functions, in part: 36. Upholds and enforces the policies and procedures, governing patient rights, confidentiality and safety. Review of Patient #3’s medical record revealed patient #3 was admitted on 12/22/2023 with a diagnosis of Dementia, Psychosis, and behavior disturbances, Traumatic Brain Injury with cerebral hemorrhage, Alcohol abuse, and Depression with suicidal ideations. Further review revealed a document titled hospital “Multidisciplinary Progress Note”, dated 12/22/2023 at 7:15 a.m. Continued review revealed Patient #3 was non-English speaking. Review of Patient #3’s Inpatient Admission Packet dated 12/28/2023 (6 days after admission) failed to reveal evidence the hospital used an interpreter/translator to assist with Patient #3’s understanding and agreement with the acknowledgment of his rights as a patient, privacy rights, safe keeping of his personal property, and end of life decisions. In an interview on 01/10/2023 at 4:35 p.m., S3DON confirmed the Inpatient Admission Packet was dated 12/28/2023, 6 days after admission and further verified that there was no evidence the hospital used an interpreter/translator to aid in Patient #3’s understanding of his rights as a patient, including but not limited to, privacy rights, safe keeping of his personal property, and end of life decisions.”

“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 Spanish speaking Patient #3 had a translator to assist with the development and implementation of the patient’s plan of care Findings: Review of hospital policy titled “Patient Rights”, dated 09/01/2023, revealed, in part: Policy:, in part: Treatment, in part: 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 instead on the patient’s behalf will be respected in accordance law and regulations. Review of Patient #3’s Interdisciplinary Treatment Plan Master Sheet, dated 12/22/2023, revealed “Language Preference”-Hispanic. Further review revealed the patient was unable to participate in the development of this treatment plan because patient was non-English speaking, unable to process what was being educated on and asked. Continued review failed to reveal evidence the hospital used an interpreter/translator to assist Patient #3 with his right to participate in the development of his treatment plan. Review of Patient #4’s Interdisciplinary Treatment Plan 01/10/2024 failed to reveal Problem, Outcomes/Goals and interventions for “Communication Barriers”. Further review failed to reveal evidence the hospital used an interpreter/translator to assist Patient #3 with understanding treatment goals, agreeing with the individual treatment plan and participating in his plan of care. In an interview on 01/10/2024 at 4:01 p.m., S3DON confirmed their was no documented evidence of the use of an interpreter/translator to assist Patient #3 with his right to participate in the development of his treatment plan, to understand treatment goals and to agree with the individual treatment plan as developed.”

“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 patients/representatives had the right to make informed decisions regarding care. This is evidenced by failing to use an interpreter/translator to assist non-English speaking patient (#3) in understanding and agreeing with multiple consents found in the Inpatient Admission Packet. Findings: Review of non-English speaking Patient #3’s medical record revealed an admission date of 12/22/2023. Continued review revealed an In-Patient Admission Packet dated 12/28/2023 (6 days after admission). Further review failed to reveal evidence that the hospital used an interpreter/translator to assist Patient #3 in understanding and agreeing with the following consents and forms found within the Inpatient Admission Packet: a) Consent for Treatment; b) Consent for Transportation; c) Consent to Photograph; d) Consent for Emergency Treatment and Transfer; e) PCP acknowledgment; f) Certification that Patient #3 read fully and completely understood, and agreed with the above provisions; g) acknowledgement of receipt of Patient Handbook. h) Consent & Authorization for Alcohol and Substance Use; i) Health Insurance Portability and Accountability Act acknowledgement; j) Consent for Involvement in Treatment; k) Advanced Directives. In an interview on 01/10/2023 at 4:22 p.m., S3DON confirmed that there was no documented evidence the hospital used an interpreter/translator to assist non-English speaking Patient #3 in understanding and agreeing with the consents and forms found in the Inpatient Admission Packet.”

“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 and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failure to ensure the hospital was free of ligature risks. Findings: Review of hospital policy titled “Environmental Services Guidelines”, dated 05/01/2023, revealed, in part: Procedure: 9. Plastic bags are never allowable in patient care areas. An observation on 01/10/2024 at 8:55 a.m. of patient area A revealed a blue plastic trash liner in trashcan. In an interview on 01/10/2024 at 8:55 a.m., S1HIM confirmed the blue plastic trash liner in the trashcan of patient area A. In an interview on 01/10/2024 at 9:21 a.m., S3DON verified that there should be no plastic liners in any trashcans in any patient areas. An observation on 01/10/2024 at 8:58 a.m. of room g revealed bathroom with non-ligature resistant paper towel dispenser attached to wall creating a ligature risk. An observation on 01/10/2024 at 9:01 a.m. of rooms e and f revealed shared bathroom with non-ligature resistant paper towel dispenser attached to wall creating a ligature risk. An observation on 01/10/2024 at 9:03 a.m. of rooms c and d revealed shared bathroom with non-ligature resistant paper towel dispenser attached to wall creating a ligature risk. An observation on 01/10/2024 at 9:04 a.m. of rooms h and i revealed shared bathroom with non-ligature resistant paper towel dispenser attached to wall creating ligature risk. An observation on 01/10/2024 at 9:13 a.m. of rooms a and b revealed shared bathroom. Further observation revealed commode booster seat made with pvc-like piping, damaged safety box around pipes under sink falling out of the wall with two loose screws hanging from holes and non-ligature resistant paper towel dispenser attached to wall, all creating ligature risks. An observation on 01/10/2024 at 10:55 a.m. of room j revealed a non-ligature resistant air-conditioning grille located in the ceiling, easily reached by standing on the bed; a non-ligature resistant paper towel dispenser in room j’s bathroom. In an interview on 01/10/2024 at 10:55 a.m., S18DQ confirmed ligature risks located in room j and room j’s bathroom. In an interview on 01/10/2024 at 9:33 a.m., S3DON confirmed ligature risks located in shared bathroom of rooms a and b; c and d; e and f; and h and i. In an interview on 01/10/2024 at 10:30 a.m., S4RN reported 7 of 15 patients on the census were on suicide precautions. In an interview on 01/10/2024 at 11:26 a.m., S5PM confirmed paper towel dispensers were installed using four B brand anchors each with weight limit of 75-100 lbs. S5PM stated paper towel dispensers were ligature risks. An observation on 01/10/2024 at 12:29 p.m. revealed S3ADON and S18DQ demonstrating the paper towel dispensers were ligature risks.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the hospital failed to provide an environment free from all forms of neglect. This is evidenced by failing to have mechanisms/methods in place that ensure non-English speaking patients have the use of an interpreter/translator to assist with their communication of needs. Findings: Review of hospital policy titled “Communication with Persons of Limited English Proficiency”, dated 02/01/2021, revealed, in part: Purpose: The purpose of this policy is to ensure proper services to anyone who is Limited English Proficient (LEP). All patients have a right to communications in a language and format understandable to the individual for all services provided. Policy, in part: It is the policy of the facility to provide communication aids at no cost to individuals who are LEP, including current and prospective patients, and family. Patients will be provided with alternative communication methods, which allow them to participate more fully in their care. Procedure, in part: 2. The facility will provide oral and written translation services, free of charge to any patient in need of such services. This may be accomplished by utilizing the facility’s contracted language interpretation services. Observation on 01/10/2024 at 9:00 a.m. revealed Patient #3 attempted to leave the dining room and walk down the hallway. He attempted to communicate his needs in Spanish to S16MHT but was unable to communicate his needs to S16MHT in English. Continued observation failed to reveal S16MHT was proficient in Spanish. Further observation failed to reveal S16MHT used a translator. In an interview on 01/10/2024 at 9:01 a.m., S16MHT stated that she could use a translator on her phone to communicate with Patient #3 but she believed he understood what she communicated to him in English. S16MHT believed he wanted to go to his room and lay down; therefore, she did not need to use a translator. In an interview on 01/10/2024 at 9:02 a.m. S2ADON stated they attempt to use phone translators to communicate to non-English speaking patients and she was not sure why S16MHT was not using one since she was not speaking Spanish.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the nursing services department of the hospital failed to provide adequate numbers of support personnel to provide nursing care to all patients as needed. This deficient practice was identified for 11 (11/11/23PM, 11/17/2023PM, 11/18/2023PM, 11/19/23PM, 11/23/23PM, 11/24/23PM, 11/25/23PM, 11/26/23PM, 11/27/23PM, 11/29/23PM and 01/10/2024AM) of the 31 shifts (11/11/23AM and PM, 11/16/23AM and PM, 11/17/2023AM and PM, 11/18/2023AM and PM, 11/19/23AM and PM, 11/20/23AM and PM, 11/21/23AM and PM, 11/22/23AM and PM, 11/23/23AM and PM, 11/24/23AM and PM, 11/25/23AM and PM, 11/26/23AM and PM, 11/27/23AM and PM, 11/28/23AM and PM, and 11/29/23AM and PM and 01/10/2024AM) reviewed and had the potential to affect any of the 16 inpatients receiving care and services during the time of the survey. Findings: Review of hospital document titled “Job Description, Director of Nursing”, dated 11/01/2023, revealed, in part: Essential Functions, in part: 2. Supervises nursing personnel including: Determining workload and delegating assignments ...8. ...Ensures appropriate nursing staff for each unit to meet patient needs. Review of hospital document titled “Job Description, Assistant Director of Nursing”, dated 11/01/2023, revealed, in part: Position Summary, in part: ...Communicates, coordinates and facilitates adequate staffing of all nursing units under the supervision of the Director of nursing. Essential Functions, in part: 3. Supervises subordinate personnel including: determining workload and delegating assignments ...24. Ensures appropriate nursing staff for each unit to meet patient needs. Review of hospital policy titled “Staffing Plan”, dated 09/01/2022, revealed, in part: Procedure, in part: Patient census and staffing matrix are used to determine staffing needs. Review of hospital document titled “Governing Board 2022 4th Quarter and Annual for 2023 Meeting Minutes”, dated February 15, 2023, revealed, in part: Current Hospital Staffing, in part: Geri Unit 1:6 ratio Mental Health Technician (MHT). Review of sixteen daily nursing staffing sheets for day and night shifts revealed on the following shifts, nursing services failed to meet the ratio of 1 MHT to 6 patients: 11/11/2023 on the PM shift with a census of 10 patients, the required ratio of 1 MHT to 6 patients called for 2 MHTs; review of the daily staffing sheet revealed 1 MHT making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/10/2024 at 1:30 p.m., S18DQ verified the deficient staffing. 11/17/2023 on the PM shift with a census of 14 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/10/2024 at 1:32 p.m., S18DQ verified the deficient staffing. 11/18/2023 on the PM shift with a census of 15 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/10/2024 at 1:35 p.m., S18DQ verified the deficient staffing. 11/19/2023 on the PM shift with a census of 16 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/11/2024 at 12:15 p.m., S3DON verified the deficient staffing. 11/23/2023 on the PM shift with a census of 17 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/10/2024 at 1:37 p.m., S18DQ verified the deficient staffing. 11/24/2023 on the PM shift with a census of 15 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/11/2024 at 10:29 a.m., S18DQ verified the deficient staffing. 11/25/2023 on the PM shift with a census of 16 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/11/2024 at 10:30 a.m., S18DQ verified the deficient staffing. 11/26/2023 on the PM shift with a census of 16 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/11/2024 at 10:32 a.m., S18DQ verified the deficient staffing. 11/27/2023 on the PM shift with a census of 14 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/11/2024 at 10:34 a.m., S18DQ verified the deficient staffing. 11/29/2023 on the PM shift with a census of 14 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and, In an interview on 01/11/2024 at 12:15 a.m., S13DON verified the deficient staffing. 01/10/2024 at 8:45 a.m. observation of the hospital unit revealed the following staff: S16MHT, S17MHT and S4RN. Review of census for 01/10/2024 revealed 15 patients, 7 patients on suicide precautions, 1 on 1:1 observation and 1 on Line of Sight Observation. The required ratio of 1 MHT to 6 patients called for 3 MHTs. 01/10/2024 at 8:59 a.m. observation of room h revealed Patient R1 lying in bed with no sheets and no pillow. Patient R1s medical record revealed he was admitted on 01/03/2024 with diagnosis of Dementia with behavioral disturbance and psychosis with MDD and anxiety. Placed on high fall risk with Q 15 minute observation. In an interview on 01/10/2024 at 9:04 a.m., S2ADON confirmed that the patient had made his way to his room, was sleeping without sheets, on bare mattress with no pillow and stated he should have sheets and a pillow. In an interview on 01/10/2024 at 9:28 a.m., R4RN reported she had one patient who was 1:1 and one patient who was “Line of Site”, only 2 MHTs and one patient acting out which made it difficult to keep track of Patient R1 who was on high fall risk precautions. In an interview on 1/10/2024 at 1:30 p.m. S18DQ confirmed staffing was short on the days indicated on staffing sheets above.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47397 Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient upon admission in accordance with accepted standards of nursing practice and hospital policy. This deficiency is evidenced by failure to use an interpreter/translator to complete the Nursing Admit Assessment, which also included the Columbia Suicide Severity Rating Scale, for non-English speaking Patient #3. Findings: Review of hospital policy titled “Communication with Persons of Limited English Proficiency”, dated 02/01/2021, revealed, in part: Purpose: The purpose of this policy is to ensure proper services to anyone who is Limited English Proficient (LEP). All patients have a right to communications in a language and format understandable to the individual for all services provided. Policy, in part: Patients will be provided with alternative communication methods, which allow them to participate more fully in their care. Procedure, in part: 2. The facility will provide oral and written translation services, free of charge to any patient in need of such services. This may be accomplished by utilizing the facility’s contracted language interpretation services. Review of hospital policy titled “Suicide/Homicide Risk Assessment” 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. Procedure: Inpatient, in part: 2. The Registered Nurse will complete the Suicide ...risk Assessment as a part of the Admit Nursing Assessment. Suicide ...risk level will be determined, and appropriate precautions are implemented and incorporated into the treatment plan if applicable. Review of hospital document titled “Job Description, Director of Nursing”, dated 11/01/2023, revealed, in part: Essential Functions, in part: 8. Ensures staff complaince with patient care, documentation, hospitalunit policies and procedures, protocols, and guidelines. Review of hospital document titled “Job Description, Assistant Director of Nursing”, dated 11/01/2023, revealed, in part: Essential Functions, in part: 36. Upholds and enforces the policies and procedures, governing patient rights, confidentiality and safety. Review of Patient #3’s Admit Nursing Assessment dated 12/22/2023 revealed patient was non-English speaking. Continued review failed to reveal documented evidence the nurse used an interpreter/translator to assist with the process of the Admit Assessment, which also included the Columbia Suicide Severity Rating Scale. In an interview on 01/10/2024 at 4:01 p.m., S3DON verified the Admit Nursing Assessment dated 12/22/2023, revealed patient was non-English speaking. S3DON confirmed the Admit Assessment failed to reveal documented evidence the nurse used an interpreter/translator to assist with the process of the Admit Assessment, which also included the Columbia Suicide Severity Rating Scale.”

“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: 47397 Based on record review and interview the hospital failed to ensure all nursing staff followed the policies and procedures of the hospital. This deficiency is evidenced by failure of the hospital to complete performance evaluations on 1 (S7ARN) of 1 (S7ARN) Agency Registered Nurse personnel files reviewed for performance evaluations. Findings: Review of hospital policy titled “Nursing Staff Orientation”, dated 12/01/2021, revealed, in part: Policy: New nursing personnel will receive orientation to their position and to (hospital) policies and procedures. The orientation program shall include a review of the policy/procedures, job descriptions, competency evaluation, on-the-job orientation and performance expectations. Procedure, in part: 5. Evidence of all components of the nursing employee orientation and competency assessment are maintained in the employee’s human resource file. Review of hospital document titled “Job Description, Director of Nursing”, dated 11/01/2023, revealed, in part: Essential Functions, in part: 2. Supervises nursing personnel including: ...evaluating performance. Conducts and reviews evaluations on individual staff ....3. Accountable for nursing performance improvement ...9. Directs appropriate training activities for all permanent and temporary nursing employees ... A review of S7ARN’s personnel file revealed year of hire 2015. Further review revealed S7ARN was an agency acquired Registered Nurse. Continued review of S7ARN’s personnel file failed to reveal documented evidence of a completed performance evaluation since hire. In an interview on 01/11/2024 at 12:45 p.m. S17HR confirmed there was no evidence of a completed performance evaluation for S7ARN. S17HR stated she was not aware that agency staff were expected to undergo performance evaluations.”

“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: 47397 Based on observations and interviews, 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, staff, and visitors. This deficient practice was evidenced by failure to maintain the physical plant in good repair and failure to maintain a safe patient care environment. Findings: Review of hospital policy titled “Environmental Services Guidelines”, dated 05/01/2023, revealed, in part: Policy: Facility shall provide the necessary services required to maintain a clean, sanitary, and safe environment in accordance with industry best practices. Procedure, in part: Patient rooms-Daily. 3. Cleaning in patient rooms is always conducted with a top-to-bottom cleaning method. Bathrooms and Showers-Daily, in part: 1. Bathrooms are to be cleaned a minimum of one time per day by environmental services staff. Review of hospital document titled “Job Description, Housekeeping”, revealed, in part: Position Summary, in part: ...Aspects of services include, but are not limited to , cleaning occupied and discharged patient rooms ...Essential functions, in part: 2. Cleans and disinfects patients’ rooms and baths daily. 3. Performs terminal cleaning after transfer or discharges 100% of the time. 4. Cleans, empties, dusts, and sanitizes ...restrooms ...9. Reports broken, defective patient care/room equipment ... Observations on 01/10/2024 beginning at 8:45 a.m. with S1HIM, 9:04 a.m. S2ADON joined, 9:27 a.m., S3DON joined and 9:31 a.m. S18DQ joined. Observed the following: 8:57 a.m.: Rooms e and f revealed a shared bathroom with crackled, flaking and peeling paint created exposed areas of drywall above the commode. 9:04 a.m.: Room i revealed crackled, flaking, and peeling paint with cracked plaster and a hole in the wall above air conditioning unit. Bathroom shared with rooms h and i revealed crackled, flaking, and peeling paint created exposed areas of drywall above the commode. 9:13 a.m.: Rooms a and b revealed a shared bathroom with toilet paper shoved into crevices along rail next to commode. Brown substance smeared on commode. Crackled, flaking, and peeling paint created exposed areas of drywall above the commode and the sink. Room a revealed ceiling with large water stain with crackled, flaking and peeling paint over patient bed. 9:15 a.m.: Room b revealed bare mattress and no sheets, bedside table with exposed particleboard and peeling paint. Exposed metal with sharp edges and loose metal parts attached to bedside table. 9:20 a.m.: Rooms c and d revealed shared bathroom with room c’s bathroom door hanging off velcro hinges; crumpled tissue on the floor by commode; loose faucet coming out of the sink; brown substance smeared above sink; peeling paint next to commode. Room c with baseboard flap coming off wall next to air conditioning unit. 9:22 a.m.: Room k revealed crackled, flaking and peeling paint on wall and windowsill with peeling paint above air conditioning unit. 10:55 a.m.: Room j revealed the patient side of the door had peeling paint with exposed wood and white cloudy dried substance dripping from window; bed with dirt and dirty cotton balls under mattress; bathroom trashcan containing toilet paper with brown substance; crackled, flaking, and peeling paint above commode with safety box covering pipes pulling away from the wall. In an interview on 01/10/2024 at 10:56 a.m., S3DON and S18DQ confirmed the above observations failed to reveal a clean, safe and sanitary environment.”