Beacon Behavioral Hospital, LLC

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview the hospital failed to provide care in a safe setting as evidenced by failure to prevent unsupervised patient access of restricted items in 10 (a-j) of 16 (a-p) rooms observed with assigned patients. Of the 10 rooms, 7 (#R1-#R7) of these patients were on suicidal precautions and/or aggressive/assault precautions. Findings: Review of hospital policy provided by S1CNO titled “Control of Contraband and Dress Code”, last revised 3/21/2018, revealed in part: “Policy: Beacon Behavioral Hospital is committed to providing a safe, secure, therapeutic environment. As part of this endeavor, clinical staff have identified items that are considered a risk to safety and/or are counter-therapeutic. Such items are considered “contraband.” At Beacon Behavioral Hospital there are three categories of Contraband, in part: (1) Restricted: Items that are secured away from patient access but may be used by the patient with staff supervision and/or at scheduled times. Contraband: 1. Restricted items: This category includes any items that a patient will be permitted to access during his hospitalization on a limited basis or with supervision. Items may be secured in a designated locked room or in the nurses’ station. Generally included in this category are: a. Toiletries: Toothpaste, Toothbrush, Deodorant (stick or roll-on), Shampoo, Conditioner, Chap stick (unmedicated), Shaving cream (non-aerosol), Shower gel, Hairbrush, and Comb.” On 04/23/2025 at 2:14 PM observation of patient rooms revealed the following with contraband: ‘a’: bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel. ‘b’: bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel. ‘c’: bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel. ‘d’: bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table. ‘e’: bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table ‘f’: bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table ‘g’: deodorant on bedside table. ‘h’: bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table ‘i’: bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash, large comb, and shower gel on bedside table ‘j’: bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table Review of Patient Bed Board dated 04/23/2025 revealed Patient #R1 was assigned to room ‘a’ and on suicide precautions and assault / aggression precautions. Review of Patient Bed Board dated 04/23/2025 revealed Patient #R2 was assigned to room ‘b’ and on suicide precautions. Review of Patient Bed Board dated 04/23/2025 revealed Patient #R3 was assigned to room ‘d’ and on suicide precautions. Review of Patient Bed Board dated 04/23/2025 revealed Patient #R4 was assigned to room ‘e’ and on suicide precautions. Review of Patient Bed Board dated 04/23/2025 revealed Patient #R5 was assigned to room ‘h’ and assault / aggression precautions. Review of Patient Bed Board dated 04/23/2025 revealed Patient #R6 was assigned to room ‘i’ and assault / aggression precautions. Review of Patient Bed Board dated 04/23/2025 revealed Patient #R7 was assigned to room ‘j’ and on suicide precautions. During an interview on 04/23/2025 at 2:16 PM, S2DC confirmed the restricted products were not secured away from patient access as above per hospital policy and should be picked up after shower time and placed in the locked patient belonging room until next scheduled use.”

“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: 44495 Based on record review and interview, the facility failed to ensure routine maintenance was performed at the offsite location. The deficient practice is evidenced by 1) non-working light bulbs; 2) stained and damaged ceiling tiles; 3) missing laminate covering on restroom doors; and 4) dirty window coverings throughout the facility. Findings: 1)Non-working light blubs Tour of the off-site facility on 04/23/2025 between 1:45 PM and 2:20 PM revealed one non-working light bulb in room A, 1 non-working light in room B, 2 non-working light bulbs in room C, 3 non-working light bulbs in room G, 5 non-working light bulbs in room L, and 3 non-working light bulbs in room P. 2) Stained and damaged ceiling tiles Tour of the off-site facility on 04/23/2025 between 1:45 AM and 2:20 PM revealed a partially down tiles in rooms E, G, H, K, and Q. Stained ceiling tiles in rooms D, K, M and Q and a hole in ceiling tile in room N. 3) Missing laminate covering on restroom doors Tour of the off-site facility on 04/23/2025 between 1:45 PM and 2:20 PM revealed the laminate had been removed from the edge of the both stall doors in room B and room C and the laminate was also missing along the inside edge of the door frame exposing the particle board. 4) Dirty window coverings Tour of the off-site facility on 04/23/2025 between 1:45 PM and 2:20 PM revealed fine granular grey material on the blinds and window ledges located in rooms F, G, H, K, and L. During the tour at the time of discovery, S3RDOO, S4RVP, and S5PD verified the above findings.”

“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: 14442 Based on record review and interview, the hospital failed to have adequate numbers of mental health technicians to provide care to all patients as needed. This deficient practice was evidenced by failing to meet the minimal staffing requirements as per the hospital staffing grid. Findings: Review of the hospital policy and procedure titled, Nursing Service effective 09/01/2011 and last revised on 08/11/2023 revealed, in part, numbers and types of nursing staff provided will be based on the needs of the patients, the qualifications and training of the nursing staff members, and the acuity of the department or unit. Further review revealed Inpatient Units: Additional nursing staff (registered nurses, practical nurses, or mental health technicians) will be scheduled and present onsite to meet the needs of the patients. Review of the hospital nursing staffing grid revealed, in part, for a census of 15 and 16 on the inpatient unit, there should be 1 RN, 1 LPN, and 3 MHTs the day and night shift. Review of the hospital inpatient Daily Nursing Assignment Sheet dated 10/13/2024, night shift revealed a patient census of 15. Further review revealed staffing consisted of 1 RN, 1 LPN, and 2 MHTs. Review of the hospital inpatient Daily Nursing Assignment Sheet dated 10/15/2024, night shift revealed a patient census of 16. Further review revealed staffing consisted of 1 RN, 1 LPN, and 2 MHTs. In an interview on 10/16/2024 at 2:24 p.m., S1Administrator confirmed the hospital inpatient unit did not meet the minimal staffing requirements on 10/13/2024 and 10/15/2024 night shifts. S1Administrator confirmed the inpatient unit should have had 3 MHTs.”

“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 record review and interview, the psychiatric hospital failed to provide care in a safe setting. This deficient practice is evidenced by: 1) failure to observe/monitor patient per physicians orders in 1 (#3) of 3 (#1-#3) medical records reviewed; 2) failure to implement elopement precautions as per hospital policy in 1 (#3) of 1 (#3) patients reviewed for elopement precautions; 3) failure to implement seizure precautions as per hospital policy in 1 (#3) of 1 (#3) patients reviewed for seizure precautions. Findings: 1) Failure to observe patient per physicians order in 1 (#3) of 3 (#1-#3) medical records reviewed. A review of psychiatric hospital policy titled “Levels of Observation” revision 09/25/2020, revealed, in part: Policy, in part: Note: The level of Observation may never be decreased without an order from an authorized licensed prescriber. Electronically Enhanced Observation, in part: ...both Line of Sight and 1:1 Observation require continuous observation ...Procedure, in part: Upon admission or when warranted by a change in the patient’s condition, a registered nurse may assign a Level of Observation, followed immediately by obtaining an order for a Level of Observation from an authorized licensed prescriber. The Level of Observation may never be decreased without an order from an authorized licensed prescriber. Line of Sight, in part: Line of sight is defined as maintaining visual observation of a patient at all times. Review of Patient #3’s medical record revealed a document titled “Orders for Patient #3”, start date 10/06/2023 at 10:22 a.m.; discontinued on 10/07/2023 at 22:33 p.m. Continued review revealed order #6 which read as follows: Line of Sight Daily, Request Type: Now, Comments: Line of sight monitoring until discontinued by physician. Review of Patient #3’s medical record revealed a document titled “Behavioral Health-Patient Observation Sheet”, dated 10/06/2023. Further review revealed a notation stating Patient checked in on 10/06/2023 at 10:35 a.m. with an observation interval of every 15 minutes. Review of Patient #3’s medical record revealed a document titled “Note Discipline: Licensed Practical Nurse”, dated 10/07/2023 at 4:00 p.m. Further review revealed the following note: It was noticed during the 15-minute rounding that patient was not in her room. Patient was not in the facility and had eloped around 3:50 p.m. Coroner found patient and brought her back to facility at 4:10 p.m. At 4:50 p.m., Patient noted running down hall and busted open back door and left facility. Sheriff’s Office A contacted, patient was brought back to facility. Review of Patient #3’s medical record revealed a document titled “Note Discipline: Registered Nurse”, dated 10/07/2023 at 5:28 p.m. Further review revealed the following note: At around 3:50 p.m. on every 15-minute rounding patient was noted not in facility. Patient eloped from facility around 3:50 p.m., patient was found by coroner around 4:10 p.m. and brought back to facility. In an interview on 11/06/2023 at 11:28 a.m., S1DON confirmed there was no evidence that this patient was on line of sight precautions as ordered by physician. S1DON stated the patient should not have been on every 15-minute rounding as noted in medical record but should have been on line of sight observation level as per physician order. 2) Failure to implement elopement precautions as per hospital policy in 1 (#3) of 1 (#3) patients reviewed for elopement precautions. Review of psychiatric hospital document titled” Precautions”, revised 03/21/2028, revealed, in part: Standardized Precautions used by Hospital include, in part: Elopement. Note: Precautions may never be discontinued without an order from an authorized licensed prescriber. Elopement precautions, in part: applied when a patient presents a risk of eloping (i.e. leaving without authorization) from the hospital or an area within the hospital. The following are components of Elopement Precautions, in part: Unit Restriction ...In the event that the patient must leave the unit the patient will be placed on at least 1:1 Observation when off the unit (2:1 Observation should be considered if the patient is physically strong and /or highly motivated to elope). 1-Foot Door Parameter-A patient on Elopement Precautions must remain at least 10 feet away from any access door on the unit. Review of psychiatric hospital document titled “Hospital /Licensed Provider Abuse/Neglect Initial Report”, dated 10/07/2023, revealed in part: Patient #3 eloped at 4:30 p.m. on 10/07/2023. Patient eloped again after powering through maglock door. Patient was pursued, obtained, and returned to the facility. Patient was placed in seclusion and medicated per orders. Patient soon after busted through the locked seclusion room door and ran to the exit door and powered through. Staff contacted the police for assistance and pursued looking though the area for patient. Search was conducted by staff, and local law enforcement, Sheriff’s office A and Police Department B. Search by Sheriff’s Office C, patient found safely with her mother and taken to local hospital for evaluation. Director of Plant ops contacted and on site to evaluate external door access for proper operation. Review of Patient #3’s medical record revealed a document titled “Orders for Patient #3” dated 10/06/2023, 10:21 a.m.-10/07/2023, 10:33 p.m. Further review failed to reveal Elopement Precautions were ordered and implemented following her first elopement on 10/07/2023 at 3:50 p.m.. In an interview on 11/06/2023 at 11:30 a.m., S1DON verified that documentation failed to reveal evidence Elopement Precautions were implemented as per policy. S1DON stated Elopement Precautions should have been implemented as per hospital policy immediately following the return of Patient #3 after her first elopement at 3:50 p.m. on 10/07/2023. 3) Failure to implement seizure precautions as per hospital policy in 1 (#3) of 1 (#3) patients reviewed for seizure precautions. Review of psychiatric hospital document titled” Precautions”, revised 03/21/2028, revealed, in part: Standardized Precautions used by Hospital include, in part: Seizure. Seizure Precautions are typically ordered for patient that have documented or verbalized) diagnoses of seizure disorders (such as Epilepsy) ... Review of Patient #3’s medical record revealed Patient #3 admitted on 10/06/2023 at 10:21 a.m. and discharged on 10/07/2023 at 10:33 p.m. after eloping to her mother’s home. Further review revealed a document titled “History and Physical Examination” dated 10/07/2023 at 8:27 a.m. Further review revealed patient’s past medical history included epilepsy and seizures. Patient reported before admission being hit across the head by her stepfather’s hand, resulting in lightheadedness. Continued review revealed physician recommendations stating the following, in part: Seizures: Home Depakote and Seizure Precautions. Review of Patient #3’s medical record revealed a document titled “Orders for Patient #3” dated 10/06/2023, 10:21 a.m.-10/07/2023, 10:33 p.m. Further review failed to reveal Seizure Precautions were ordered and implemented. In an interview on 11/06/2023 at 11:28 a.m. S1DON confirmed there was no evidence that this patient, diagnosed with seizures, was on seizure precautions. S1DON further stated the patient should have been on seizure precautions.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 47397 Based on record review and interview, the psychiatric hospital failed to obtain a physician’s order for the use of the seclusion room for 1 (#3) of 1 (#3) patients reviewed for use of the seclusion room. Findings: Review of psychiatric hospital document titled, “Restraint or Seclusion”, revised 03/21/2018 revealed, in part: Policy, in part: The use of ...Seclusion requires an order from an authorized licensed prescriber. Procedure, in part: 3. The registered nurse ensures that an order has been obtained from an authorized licensed prescriber and that all documents are accurately initiated. Review of Patient #3’s medical record revealed an admit date of 10/06/2023 with a primary diagnosis of Suicidal Ideations, Seizures, and Schizoaffective disorder, bipolar type. Review of Patient #3’s medical record revealed a document titled “Note Discipline: Registered Nurse” dated 10/07/2023 at 5:45 p.m. Further review revealed the following: Patient was noted using her body to ram up against seclusion door. Patient took 3 steps back 3 times then used her body to bust open the seclusion door. Once out of seclusion patient was not able to be redirected. Patient then proceeded past nurses station, started to run fast then busted out of back door that she had previously eloped out of within the last hour. Review of Patient #3’s medical record revealed a document titled “Orders for Patient #3” dated 10/06/2023, 10:21 a.m.-10/07/2023, 10:33 p.m. Further review of “Orders for Patient #3” failed to reveal physician orders for the use of the seclusion room. In an interview on 10/06/2023 at 12:17 p.m., S1DON confirmed there was no order for Patient #3 for the use of the seclusion room and that there should have been an order obtained before patient was placed in seclusion.”