Seaside Health System

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 50453 Based on observation and interview, the facility 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 quality for all patients. Findings: Observations during a tour on 01/05/2026 from 9:12 AM - 10:30 AM revealed the following: Room ‘a’: -Overhead light not working in bathroom. Room ‘b’: -Toilet seat cracked. -Wall light cover cracked. Room ‘c’: -Overhead light not working in bathroom. Room ‘d’: -Peeling paint on the doorframe to bathroom. Room ‘e’: -Sink faucet not working. Room ‘f’: -Toilet not secured to wall. Room ‘g’: -Floor laminate not flush with floor near entrance. -Bathroom vent covered in white/gray substance. -Sink faucet not working. -White substance covering the fire sprinkler head. Room ‘h’: -Shower drain missing drain cover. Room ‘i’: -Bathroom vent covered in white/gray substance. Room ‘j’: -Bathroom vent covered in white/gray substance. Patio ‘a’: -Interior light cover contains multiple dead bugs. -Gate 1 warped wood to bottom left side exposing screw on exterior of gate. -Gate 2 has peeling wood to top right side of gate. In an interview during the tour, S2QAD confirmed the above-mentioned findings.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48051 Based on record review and interview, the psychiatric hospital failed to ensure all patients who presented to the hospital for evaluation of a possible emergency medical/psychiatric condition received an appropriate medical screening exam (MSE). This deficient practice was evidenced by the failure to perform an appropriate MSE in 2 (#F2, #F3) of 10 (#F1 - #F10) medical records reviewed for MSE being performed prior to admission, transfer or discharge. Findings: A review of Patient #F2’s medical record revealed the “Triage and Preassessment Note” indicating the patient arrived to the hospital on 06/20/2025 at 11:55 PM via private vehicle with a chief complaint of “ETOH Detox.” Further the note revealed: “Mental Status: cooperative and intoxicated; Substance Abuse: BAL: 0.17 and UDS: negative.” This note was completed by SFRNAS on 06/20/2025 at 12:10 AM. The date of patient’s arrival and nurse signature do not coincide, however the hospital’s admissions log revealed the patient arriving on 06/20/2025 at 11:55 PM and departing the facility at 12:42 AM with the disposition of, “DID NOT MEET CRITERIA.” The evaluating staff member failed to identify how the patient failed to meet admission criteria and failed to ensure documentation of the performance of a MSE by a qualified medical personnel (QMP) to determine if an emergency medical condition (EMC) existed. A review of Patient #F3’s medical record revealed the “Triage and Preassessment Note” indicating the patient arrived to the hospital on 06/17/2025 at 10:45 AM via private vehicle with a chief complaint of, “Lets get this on” and “I drank 1.65 ounces.” The note further revealed, in part: “Mental Status/Behavior: uncooperative, delayed, slurred speech; Oriented: person, only able to say year; Substance Abuse: BAL: 290, UDS: Benzo; Other relevant information: Pt with slurred speech unsteady gait; Disposition: Transferred to [Hospital A] - SF8CL took to ER for eval; and MD Consulted: SF9NP; with note completion on 06/17/2025 at 11:10 AM. The medical record failed to ensure documentation of the performance of a MSE by a qualified medical personnel (QMP) to determine if an emergency medical condition (EMC) existed. In an interview on 06/26/2025 at 3:00 PM SF6QD confirmed the above mentioned findings and Patient #F2 and #F3 did not receive a MSE by a QMP prior to leaving the hospital.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 48051 Based on record review and interview, the psychiatric hospital failed to ensure the appropriate transfer of a patient for further evaluation and treatment. This deficient practice was evidenced by the failure of the facility to ensure the transfer was initiated on the order of a physician, failure to document a discussion and acceptance of the transfer by the receiving hospital, and failure to ensure protective measure to ensure the safety of the patient during the transfer in 1 (#F3) of 10 (#F1 - #F10) patient medical records reviewed for an appropriate transfer. Findings: Review of the hospital policy #LD-044, “EMTALA,” effective 05/26/2025, revealed in part, “1. The transferring hospital must (i) Establish personal contact through a telephone conference with clinical staff at the receiving hospital to establish the need for transfer and all other requirements for and appropriate transfer.” “(v) Agee to conduct the transfer through qualified personnel and transportation equipment, as required, including the use, if necessary, of medically appropriate life support measures during the transfer. 2. The admitting physician at the receiving hospital must agree to accept the responsibility for the individual’s continuing treatment.” Review of the provided document “Triage and Preassessment Note,” no date of initiation and no date of review, revealed in part, “A physician must give the order for disposition for any individual on site that does not want to be admitted or that does not meet criteria.” A review of Patient #F3’s medical record revealed the “Triage and Preassessment Note” indicating the patient arrived to the hospital on 06/17/2025 at 10:45 AM via private vehicle with a chief complaint of, “Lets get this on” and “I drank 1.65 ounces.” The note further revealed, in part: “Mental Status/Behavior: uncooperative, delayed, slurred speech; Oriented: person, only able to say year; Substance Abuse: BAL [blood alcohol level]: 290, UDS [urine drug screen]: Benzo [benzodiazapines]; Other relevant information: Pt [patient] with slurred speech unsteady gait; Disposition: Transferred to [Hospital FA] - SF8CL took to ER [emergency room] for eval [evaluation]; and MD Consulted: SF9NP; with note completion on 06/17/2025 at 11:10 AM. The medical record contained no documentation of a medical screening examination (MSE) performed by a qualified practitioner, no physician’s order initiating the transfer, no documentation of discussion and acceptance of the transfer by the receiving hospital, and no documentation of protective measures being initiated to ensure the safety of a potentially suicidal patient. A review of Patient #F3’s medical record from Hospital FA revealed in part, a Serum Alcohol (ETHANOL) Level at 261.2 mg/dl on 06/17/2025 at 1:30 PM. The results indicated anything over 100 mg/dl as Toxic. In an interview on 06/26/2025 at 3:00 PM SF6QD confirmed the above mentioned findings, Patient #F3’s transfer was not arranged by this hospital and Patient #F3 was not placed under a Physician’s Emergency Certificate or any precautions after verification of suicidal thoughts. Patient #F3 was taken to the hospital via private vehicle by SF8CL, an acquaintance of the patient.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48050 Based on observation, record review, and interview, the hospital failed to ensure each patient’s right to receive care in a safe setting. The deficient practice was evidenced by failure to maintain a safe outdoor recreation environment as evidenced by a two broken picnic tables with exposed screws displaying sharp ends posing a potential risk of injury. Findings: During a tour of the facility on 04/07/2025 between 11:15 AM to 12:00 PM tow broken picnic tables with exposed screws noted in the patient outside area. In an interview on 11:25 AM, S1QAPID verified the two broken picnic tables with exposed screws displaying sharp ends posing a potential risk of injury.”

“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 ensure the QAPI program analyzed adverse patient events that impacted patient safety and quality of care. This deficient practice was evidenced by failure of the hospital to conduct a thorough investigation involving 2 patients identified on the LDH Self Report Log 2025. Findings: Review of LDH Self Report dated 03/06/2025 verified that on 03/05/2025 Patient #1 went into Patient #2’s room and pulled Patient #2’s undergarments down. Review of video footage dated 03/05/2025 between 9:35 PM and 9:51 PM with S3POD and S1QAPID revealed the following: 03/05/2025 at 21:35.48 reveals Patient #1 exiting his room walking down the hallway in front of the nurses’ station and getting water from the water fountain. 03/05/2025 at 21:36.24 Patient #1 is seen walking around the corner going down the female hallway into Patient #2’s room 03/05/2025 at 21:51.00 Patient #1 is seen walking around the corner from the female hallway walking in front of the nurses’ station returning to his room. Review of Patient #1’s Night Observational Checklist dated 03/05/2025 reveals at 9:15 PM, 9:30 PM, and 9:45 PM MHT documented Patient #1 was in his room cooperative/appropriate. Review of Patient #2’s Night Observational Checklist dated 03/05/2025 reveals at 9:15 PM and 9:30 PM Patient #2 was in bed cooperative/appropriate. Further review revealed at 9:45 PM Patient #2 was in the hallway nervous, jumpy, and shaky. In an interview on 04/09/2025 at 1:15 PM S1QAPI confirmed that the investigation into the incident with Patient #1 and Patient #2 that all employees followed hospital policies/procedures eventhough Night Observational Checklists for Patient #1 and Patient #2 do not match the video footage reviewed.”

“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 plan of 1 (#3) of 3 (#1-#3) patient reviewed for completed and updated care plans. 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. POLICY: It is the policy of the hospital to provide an individualized plan of care that is based on assessment of the patient’s mental, physical, and psychosocial needs and that is reflective of a multidisciplinary approach to the patient care. A review of the hospital policy number NUR 004 last reviewed 10/04/2023 titled, “Precautions”, revealed in part: PURPOSE: the purpose of the policy is to provide staff with guidelines for monitoring patients that are placed on special precautions. PRECAUTIONS: 5. Seizure- A patient who has a history of a seizure disorder, on a Detox Protocol, or that has had a seizure during their hospitalization. PROCEDURE: 5. A. When a patient is placed on seizure precautions, all nursing staff are made aware and fall precautions orders will be initiated. A review of Patient #3’s medical record revealed Patient #3 was admitted on 03/26/2025 with ETOH Dependence and past medical history included seizures. Further review revealed Detox Protocol ordered on 03/28/2025. Review of Patient #3’s Multidisciplinary Treatment Plan did not reveal seizure precautions or fall precautions as per hospital policy for a patient with diagnosis of seizures and/or detox protocol order. In an interview on 04/09/2025 at 11:40 AM, S1QAPID verified above mentioned findings.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48050 Based on observation and interview, the hospital failed to ensure supplies were maintained to an acceptable level of safety and quality. This deficient practice was evidence by expired patient care supplies available for patient use. Findings: Observations during a walk-through of the hospital on 04/07/2025 from 11:15 AM to 12:00 PM revealed expired patient care supplies available for patient use and included: 1) Transystem Sterile Transport Swab suitable for aerobes and anaerobes, quantity 50 swabs, with expiration date of 07/31/2023; and 2) Anaerobic Vacutainer Purple Top Vials 40ml, quantity 2 vials, with an expiration of 04/03/2025. In an interview on 04/07/2025 and present on the hospital walk-through, S1QAPID confirmed the above mentioned findings.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 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 MD 1(#3) 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 mult-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. Review of Patient #3’s medical record revealed Patient #3 was admitted on 03/26/2025 for ETOH abuse on a formal voluntary admission. Further review of Patient 3’s Multidisciplinary Integrated Master Treatment Plan initiated on 03/26/2025 did not reveal a signature by a physician. In an interview on 04/09/2025 at 11:35 AM, S1QAPID confirmed Patient #3’s Multidisciplinary Integrated Master Treatment Plan was not signed by a MD.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals to comply with 42 CFR §489.24, special responsibilities of Medicare hospitals in emergency cases. This deficient practice was evidenced by the hospital failing to adopt and enforce a policy to ensure compliance with EMTALA requirements of §489.20 and §489.24. Findings: A review of hospital policies and procedures including bylaws, rules, and regulations revealed that there was not a policy or procedure addressing EMTALA requirements related to §489.20 and §489.24. In an interview on 03/27/2025 at 9:15 AM, S1ADM confirmed the hospital does not have a policy related to EMTALA. He further confirmed the only policy related to emergency services had been presented.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure a central log was maintained on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This deficient practice was evidenced by 20 (#1 - #20) of 20 (#1 - #20) patients not being identified on the hospital’s EMTALA log. Findings: The hospital was unable to provide a policy related to maintaining a log of every patient that would be admitted voluntarily or involuntarily, a log of every patient that enters the hospital for psychiatric or detoxification treatment but are assessed and determined to need medical clearance prior to being admitted or a log of every patient that unknowingly enters the hospital for emergency treatment of a condition that is not related to a psychiatric or detoxification condition. A review of the hospital’s log that was identified by S7RNAS as the hospital’s EMTALA log from 01/01/2025 to 03/26/2025 failed to reveal 20 (#1 - #20) of 20 (#1 - #20) patients that were admitted to this hospital. In an interview on 03/25/2025 at 11:15 AM, S7RNAS confirmed if a patient were to walk in for services and be turned away, the patient would not appear on the log in which the facility had identified as its “EMTALA Log.” In an interview on 03/25/2025 at 12:45 PM, S7RNAS confirmed the log in which the facility had identified as its “EMTALA Log” does not contain all the patients admitted to the facility and would not contain FVA (formal voluntarily admission) patients. In an interview on 03/25/2025 at 4:30 PM, S6QD confirmed the facility does not have a log of every patient that would be admitted voluntarily or involuntarily, a log of every patient that enters the hospital for psychiatric or detoxification treatment but are assessed and determined to need medical clearance prior to being admitted or a log of every patient that unknowingly enters the hospital for emergency treatment of a condition that is not related to a psychiatric or detoxification condition.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the medical staff was accountable for the quality of care provided to patients. This deficient practice was evidenced by the failure to provide psychiatric progress notes as dictated by hospital policy on 1 (#1) of 3 (#1 - #3) patient medical records reviewed. Findings A review of hospital policy, “Documentation,” Policy Number: IM-005, with an effective date of 02/05/2015, last revised on 02/01/2017 and last reviewed 09/19/2024, revealed in part: “Policy: It is the policy of Seaside Health System that the medical record is a legal document, an accounting record and the blueprint for treatment during hospitalization. The patient’s record is the sole document from which third party payers decide upon payment. Increased scrutiny by external review agencies and accrediting bodies’ necessitates a careful and planned approach to documentation. A problem-oriented record that clearly identifies the need for treatment based on admission criteria for that level of care, as well as the critical problems to which all staff will be documenting is required. The best safeguard to avert denial of reimbursement and assure smooth and collegial relationships with review organizations and managed care representatives is to document in the prescribed time frame, and with sufficient frequency to substantiate both that the treatment was provided and that the treatment program is providing treatment of required intensity. The expectation is that the medical record will reflect the patient’s illness in behavioral specific terminology and support why the patient cannot be treated at a lower level of care. Procedure: Documentation should present a concise, problem-oriented record with representation from all disciplines. Key documents include physician admission orders, history and physical exam, a psychiatric evaluation, psychological evaluation if applicable, nursing assessment, a psychosocial assessment, nutritional assessment and recreational therapy assessment. Assessments must include an evaluation, summary and recommendations for treatment. If complete assessment information cannot be obtained, then the information gathered and reason for its in-completeness will be noted. Assessments are completed prior to the development of the multi-disciplinary treatment plan. 4. Psychiatric Progress Notes: Psychiatric Progress Notes should minimally be completed five times per week (Psychiatric Evaluation may count as one) by the psychiatrist or appropriately licensed provider. It should denote whether it was a continuing care visit or treatment team visit. It should contain: a. Updated behaviors, symptoms, mental status, physical status and medications; b. Patient Interview; c. Identified problems in contract to admission; d. Reason for continued stay; e. Plan.” A review of Patient #1’s medical record failed to reveal 5 Psychiatric Progress Notes per week as the above policy indicated. Documentation of Psychiatric Progress Notes were as follows, counted by calendar week (Sunday - Saturday) and admission/discharge weeks were not considered full weeks in this review for 5 notes per week: Week of 01/16/2025 (day of admission) - 01/18/2025: Psychiatric Progress note on 01/16/2025, 01/17/2025 and 01/18/2025; Week of 01/19/2025 - 01/25/2025: Psychiatric Progress note on 01/22/2025, 01/23/2025, 01/24/2026, and 01/25/2025. Total Psychiatric entries: 4; Week of 01/26/2025 - 02/01/2025: Psychiatric Progress note on 01/29/2025, 01/30/2025 and 02/01/2025. Total Psychiatric entries: 3; Week of 02/02/2025 - 02/08/2025: Psychiatric Progress note on 02/03/2025, 02/07/2025, and 02/08/2025. Total Psychiatric entries: 3; Week of 02/09/2025 - 02/15/2025: Psychiatric Progress note on 02/11/2025 and 02/15/2025. Total Psychiatric entries: 2; Week of 02/16/2025 - 02/22/2025: Psychiatric Progress note on 02/17/2025 and 02/22/2025. Total Psychiatric entries: 2; Week of 02/23/2025 - 03/01/2025: Psychiatric Progress note on 02/28/2025 and 03/01/2025. Total Psychiatric entries: 2; and Week of 03/02/2025 - 03/05/2025 (day of discharged). Psychiatric Progress note on 03/03/2025 and 03/04/2025. In an interview on 03/06/2025 at 3:00 PM, S3DON confirmed the above mentioned findings.”

“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: 48051 Based on record review and interview, the hospital failed to ensure the patient’s right to participate in the development and implementation of his or her plan of care. This deficient practice was evidenced by the failure to document patient participation in 1 (#1 - #3) of 3 (#1 - #3) medical records reviewed for patient participation in the development of a plan of care. Findings: A review of hospital policy, “Multidisciplinary Treatment Plans,” Policy Number PC-018, with an effective date of 07/01/2015, last revision on 02/27/2019 and last reviewed on 11/11/2021, revealed in part: “Policy: It is the policy of Seaside Health System to provide an individualized plan of care that is based on assessment of the patient’s mental, physical, and psychosocial needs and that is reflective of a multidisciplinary approach to patient care. Procedure: 2. The Master Treatment Plan shall be completed within 3 to 5 days of admission and consist of the following: o. Reflect the patient’s opportunity for participation in the treatment planning process. q. Patient/Guardian Participation: Patients/Guardians are involved in the development of the Treatment Plan and every review. The Master Treatment Plan problems, goals and interventions should be reviewed with the patient/guardian as appropriate. This is evidenced by the patient’s signature and/or guardian’s signature within 5 days of admission. 4. The patient signs the Treatment Plan and updates indicating that he/she has discussed his/her Treatment Plan with the Team and had the opportunity to have input. 5. Patients are encouraged to participate in the development of their treatment plan and continued care.” A review of Patient #1’s medical record revealed the document, “Multidisciplinary Integrated Master Treatment Plan (Con’t),” with a date of completion on 01/20/2025. The document failed to reveal a signature of the patient or any indication the patient was unwilling or unable to participate. In an interview on 03/05/2025 at 4:00 PM, S2AADN and S4ADON confirmed the above mentioned findings.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by: 1) Failure to ensure items considered contraband were not allowed in the patient care area; 2) Failure to ensure allegations and/or suspicion of abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations; and 3) Failure to ensure all healthcare workers who provide direct care to patients received education and training of the hospital’s workplace violence plan at orientation and at least annually education. Findings: 1) Failure to ensure items considered contraband were not allowed in the patient care area A review of hospital policy, “Contraband,” Policy Number: PC-042, being effective on 02/01/2017 and last revised on 12/21/2023, revealed in part: “Policy: It is the policy of Seaside Health System (SHS) that staff shall ensure the strict control of contraband and unauthorized use of permitted items in order to provide a secure and safe environment for patients, staff, and visitors. 1. Contraband shall be defined and controlled according to applicable state laws, rules, regulations, and SHS policies and procedures. The most restrictive definition shall prevail. Only the hospital administrator of designee shall authorize exception to this policy or respective procedures. 2. Contraband shall include articles permissible for patient or staff use but which may be harmful or dangerous if misapplied, altered, or kept in excess amounts. 4. The nurse shall have the authority to prevent the introduction of any unlisted items pending review of the Hospital administrator or designee. 5. Contraband list: a. The following is a list of items but is not limited to that are considered contraband. They are prohibited from being brought into SHS by staff or patients. They may not be sent in packages or brought into the facility by any visitors. vii. Tools. c. To further ensure safety of the patients, this list may be expanded on a case-by-case basis.” A review of the hospital’s Initial Report to HSS, dated 02/14/2025 revealed an incident on 02/11/2025 at 5:36 PM involving Patient #1 being in the possession of safety scissors. A review of the hospital’s incident log confirmed the findings of the hospital’s Initial Report. This would be considered contraband and have the potential use for self-injurious behavior and/or harm to others. A review of a written statement provided by S1ADM on 03/06/2025 at 11:30 AM, revealed the scissors were not the provider’s scissors, Patient #1’s room and the entire unit was searched for additional contraband. In an interview on 03/06/2025 at 11:30 AM, S3DON confirmed the above mentioned findings, it was suspected the scissors arrived on the unit via items Patient #1’s mother brought to the facility for Patient #1’s use doing recreational activities, and the scissors were not identified during a belongings search prior to Patient #1 receiving personal items from a family member. 2) Failure to ensure allegations and/or suspicion of abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or LDH. This statute would include any issue under review for the determination whether the facility failed to take prudent action to prevent, and/or respond to an alleged occurrence such as a potential self-injurious behavior or an elopement. A review of hospital policy, “Contraband,” Policy Number: PC-042, being effective on 02/01/2017 and last revised on 12/21/2023, revealed in part: “Policy: It is the policy of Seaside Health System (SHS) that staff shall ensure the strict control of contraband and unauthorized use of permitted items in order to provide a secure and safe environment for patients, staff, and visitors. 1. Contraband shall be defined and controlled according to applicable state laws, rules, regulations, and SHS policies and procedures. The most restrictive definition shall prevail. Only the hospital administrator of designee shall authorize exception to this policy or respective procedures. 2. Contraband shall include articles permissible for patient or staff use but which may be harmful or dangerous if misapplied, altered, or kept in excess amounts. 4. The nurse shall have the authority to prevent the introduction of any unlisted items pending review of the Hospital administrator or designee. 5. Contraband list: a. The following is a list of items but is not limited to that are considered contraband. They are prohibited from being brought into SHS by staff or patients. They may not be sent in packages or brought into the facility by any visitors. vii. Tools. c. To further ensure safety of the patients, this list may be expanded on a case-by-case basis.” A review of the hospital’s Initial Report to HSS, dated 02/14/2025 revealed an incident on 02/11/2025 at 5:36 PM involving Patient #1 being in the possession of safety scissors. A review of the hospital’s incident log confirmed the findings of the hospital’s Initial Report. This would be considered contraband and have the potential use for self-injurious behavior and/or harm to others. The Initial Report was received by HSS on 02/14/2025 at 3:23 PM. The requirement to report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation was not met. A review of a hospital document titled, “Incident Report Form (IRF),” dated 03/01/2025, revealed Patient #2 followed a staff member out of an exit door and lobby of the hospital at approximately 4:13 PM. Patient #2 was able to elope. As of 03/05/2025 at 10:05 AM, this elopement had occurred 4 days prior to the review of this incident report and had not been reported to HSS. The requirement to report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation was not met. In an interview on 03/05/2025 at 10:15 AM, S4ADON confirmed the above mentioned findings. In an interview on 03/06/2025 at 7:45 AM, S1ADM confirmed the above mentioned findings and further indicated the above mentioned elopement would be reported today. 3) Failure to ensure all healthcare workers who provide direct care to patients received education and training of the hospital’s workplace violence plan at orientation and at least annually education. A review of hospital policy, “Workplace Security,” Policy Number 6.6, with an effective date of 01/01/2014 and no revisions, did not reveal any references to the hospital’s “Workplace Violence Prevention Program Plan 2025.” A review of the hospital’s “Workplace Violence Prevention Program Plan 2025,” revealed in part: “Training, Education, & Resources: All new employees are required to go through hospital orientation. All current employees go through annual education. Documentation will be placed in the employees’ personnel file kept by Human Resources.” A record review of 3 (S9MHT, S10MHT, S11MHT) of 3 (S9MHT, S10MHT, S11MHT) new hire personnel records since 12/15/2024 did not reveal evidence of the hospital’s Workplace Violence Prevention Program Plan’s training, education, and resources review. A record review of 2 (S7RN, S8LPN) of 2 (S7RN, S8LPN) current personnel records did not reveal evidence of the hospital’s Workplace Violence Prevention Program Plan’s training, education, and resources review. In an interview on 03/06/2025 at 4:00 PM, S5HR confirmed the above mentioned findings. In an interview on 03/06/2025 at 4:20 PM, S1ADM confirmed the above mentioned findings.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by: 1) Failure of the Registered Nurse to document the performance of patient observations every 3 hours in 1 (#1) of 3 (#1 - #3) medical records reviewed; 2) Failure to document an assessment of the patient after an identified incident in 1 (#1) of 3 (#1 - #3) medical records reviewed; 3) Failure to document the contact of a provider upon a change in the condition of 1 (#3) of 3 (#1 - #3) medical records reviewed; and 4) Failure to appropriately document the transfer of a patient in 1 (#3) of 3 (#1 - #3) medical records reviewed. Findings: 1) Failure of the Registered Nurse to document the performance of patient observations every 3 hours in 1 (#1) of 3 (#1 - #3) medical records reviewed A review of hospital policy, “Patient Observations,” Policy Number: Nur-032, with an effective date of 12/13/2013, last revised on 12/21/2023 and last reviewed 06/28/2024, revealed in part: “Policy: It is the policy of Seaside Health System to observe patients for safety, signs of life, location and behavior. Definitions: 1. Standard Observation: Visual contact and signs of life are observed between staff member and patient at least every 15 minutes. This observation must be documented in real time per every visual contact performed. Procedure: 2. A nurse must round on each patient every 3 hours. Rounding includes performing an observation of the patient with or without the MHT present. Signs of life must be observed.” A review of Patient #1’s medical record revealed an order for Standard Observation Every 15 minutes. A review of the observation logs titled “Seaside Health System Day Observational Checklist” and “Seaside Health System Night Observational Checklist” revealed no documentation of Nursing Rounds being completed on 01/25/2025 at 3:00 PM, 02/12/2025 at 3:00 AM and 6:00 AM, 02/18/2025 at 6:00 AM, and 02/23/2025 at 6:00 AM. In an interview on 03/05/2025 at 4:00 PM, S4ADON confirmed the above mentioned findings. 2) Failure to document an assessment of the patient after an identified incident in 1 (#1) of 3 (#1 - #3) medical records reviewed A review of hospital policy, “Incident Reporting,” Policy Number: CMP-013, with an effective date of 02/51/2015, last revised on 12/19/2023, and no date available for last reviewed, revealed in part: “Policy: 4. If the incident involves an injury or suspected injury, the injured party will be assessed by the nurse and the appropriate healthcare provider will be notified for further actions. 5. If the incident involves a patient, the necessary information is to be entered in the medical record. Document precisely what occurred.” A review of hospital policy, “Contraband,” Policy Number: PC-042, being effective on 02/01/2017 and last revised on 12/21/2023, revealed in part: “Policy: It is the policy of Seaside Health System (SHS) that staff shall ensure the strict control of contraband and unauthorized use of permitted items in order to provide a secure and safe environment for patients, staff, and visitors. 1. Contraband shall be defined and controlled according to applicable state laws, rules, regulations, and SHS policies and procedures. The most restrictive definition shall prevail. Only the hospital administrator of designee shall authorize exception to this policy or respective procedures. 2. Contraband shall include articles permissible for patient or staff use but which may be harmful or dangerous if misapplied, altered, or kept in excess amounts. 4. The nurse shall have the authority to prevent the introduction of any unlisted items pending review of the Hospital administrator or designee. 5. Contraband list: a. The following is a list of items but is not limited to that are considered contraband. They are prohibited from being brought into SHS by staff or patients. They may not be sent in packages or brought into the facility by any visitors. vii. Tools. c. To further ensure safety of the patients, this list may be expanded on a case-by-case basis.” A review of the hospital’s Initial Report to HSS, dated 02/14/2025 revealed an incident on 02/11/2025 at 5:36 PM involving Patient #1 being in the possession of safety scissors. A review of the hospital’s incident log confirmed the findings of the hospital’s Initial Report. This would be considered contraband and have the potential use for self-injurious behavior and/or harm to others. A review of Patient #1’s medical record did not reveal any documentation related to the assessment of the patient after the identified incident or any documentation related to the patient being in the possession of safety scissors. In an interview on 03/05/2025 at 3:00 PM, S4ADON confirmed the above mentioned findings. 3) Failure to document the contact of a provider upon a change in the condition of 1 (#3) of 3 (#1 - #3) medical records reviewed A review of hospital policy, “Acute Changes in Patient Conditions,” Policy Number: PC-038, with an effective date of 07/01/2016, last revised on 11/11/2021 and last reviewed 11/11/2021, revealed in part: “Procedure: 1. Upon admission, staff will assess and document the patient’s status. After assessment is completed, the documented norms will be accepted as the patient’s current baseline. 3. In the event of a Medical Acute change in the patient’s condition: Staff should make all necessary attempts to do the following: b. perform general assessment; administer first aid if required. d. Obtain Vital Signs g. Notify attending physician as appropriate 4. Medical changes in patient condition may include but are limited to: b. Difficulty breathing h. Chest Pain 7. The physician must be notified on all episodes of acute changes in patient conditions. 8. Any acute changes in the patient’s condition will also be documented in the nurse’s notes, located in the patient’s chart. 9. A complete assessment, including vitals must be taken following any acute change in the patient condition event.dd.” A review of Patient #3’s medical record revealed the patient being admitted on 02/09/2025 at 6:20 PM for opioid dependence and detox. The patient had vital signs performed at upon arrival. A nursing note entry on 02/09/2025 at 7:30 PM revealed in part: “33 y/o WM admitted to Seaside on FVA for detox from heroin and meth abuse. Notes: though pt arrived at 1820, this nurse had not arrived yet. Vitals upon arrival were 120/83, 106, 20, 98% 99.0. First attempt at assessment was at 1930 and pt. was laying in bed with the blanket over his head refusing to answer questions. Pt told nurse to return later and refused to participate. CIWA=3 at this time but was UTA pupil size. Pt later c/o chest pain, difficulty breathing, and was sweating profusely. Was sent to [Hospital A] via EMS at 2121.” The medical record failed to include a complete assessment of the patient and the documentation of provider contact related to the acute changes of this patient. In an interview on 03/06/2025 at 10:23 AM, S13RNAS confirmed the above mentioned findings. 4) Failure to appropriately document the transfer of a patient in 1 (#3) of 3 (#1 - #3) medical records reviewed The hospital was unable to provide a policy related to the transfer of a patient to higher level of care or the return of a patient from a higher level of care. However, the hospital was able to provide the documents titled, “Memorandum of Transfer” and “Memorandum of Return.” These documents had information related to the patient’s current condition with a brief assessment upon the transfer and the return of a patient. A review of Patient #3’s medical record failed to reveal the above mentioned documentation related to Patient #3’s transfer to Hospital A and his subsequent return from Hospital A. In an interview on 03/06/2025 at 10:30 AM, S13RNAS confirmed the above mentioned findings.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This deficient practice was evidenced by the Registered Nurse failing to delegate and assign nursing responsibilities to Mental Health Technicians. Findings: A review of hospital policy, “Nursing Assignments,” Policy Number NUR-029, with an effective date of 02/01/2017, last revised on 10/19/2020 and last reviewed on 07/02/2024, revealed in part: “Responsibility: It is the responsibility of the Director of Nursing and/or designee to implement this policy. It is the responsibility of the Director of Nursing to disseminate this information to employees under their direction. Policy: It is the policy of Seaside Health System to ensure that all nursing assignments are designed to accomplish optimal, achievable level of nursing care and a safe patient environment. Procedure: 1. An RN plans, supervises, and evaluates the nursing care of the patients. 2. An RN Delegates and assigns nursing responsibilities to RNs, LPNs, MHTs, that are commensurate with the competence and qualifications of each staff member. 3. The Assignment Sheet is completed at the beginning of each shift and kept in a binder. Assignments take into consideration unexpected emergencies (i.e. fire/disaster, staff education, removal of patient in an emergency, and restraint). 4. Staffing must be maintained to ensure all assignments are carried out.” A review of daily assignment sheets from 03/01/2025 to 03/05/2025 did not reveal which patients were assigned to each individual MHT. In an interview on 03/05/2025 at 11:00 AM, S4ADON confirmed S6MHTS will make the MHT assignments. In an interview on 03/05/2025 at 12:54 PM S6MHT confirmed he makes the MHT shift assignments. In an interview on 03/05/2025 at 1:08 PM, S7RN confirmed the MHT’s make their assignments and this is usually accomplished by the MHTs assigning the male patients to the male MHTs and female patients to the Female MHTs. S7RN further indicated the Female MHTs generally end up with male patients because male patients usually outnumber the female patients.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to administer drugs in accordance with accepted standards of practice. This deficient practice was evidenced by the failure to document the effects of an administered as needed medication in 2 (#1, #2) of 3 (#1 - #3) patient medical records reviewed. A review of hospital policy, “Administration of Medications,” Policy Number: NUR 002, with an effective date of 07/17/2015, last revised on 11/11/2021 and last reviewed 07/03/2024, did not reveal a procedure for the documentation of the effectiveness after an as needed medication was administered. Further the hospital was unable to produce a policy and procedure related to the documentation of the effectiveness after an as needed medication was administered. A review of Patient #1’s medical record revealed the following as needed medications on the Medication Administration Worksheet being administered with no subsequent documentation of effectiveness follow up: 01/16/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 4:30 PM, no effectiveness documented; 01/22/2025: Ibuprofen tab, 400 mg tablet by mouth every 6 hours as needed for pain, administered at 6:00 AM, no effectiveness documented; 01/27/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM and 3:00 PM, no effectiveness documented either dose; 01/27/2025: Capsaicin Cream 0.1% apply to affected area three times daily as needed for pain, administered at 9:00 AM, no effectiveness documented; 01/28/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, no effectiveness documented; 01/31/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, no effectiveness documented; 02/01/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM and 11:30 AM, no effectiveness documented on either dose; 02/02/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, no effectiveness documented; 02/03/2025: Ibuprofen tab, 400 mg tablet by mouth every 6 hours as needed for pain, administered at 4:15 PM, no effectiveness documented; 02/10/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM and 11:00 AM, no effectiveness documented on either dose; 02/11/2025: Cyclobenazprine (Flexeril) Tab 10mg, give one-half tab (5mg) by mouth twice daily as needed, administered at 9:00 AM; no effectiveness documented; 02/12/2025: Cyclobenazprine (Flexeril) Tab 10mg, give one-half tab (5mg) by mouth twice daily as needed, administered at 9:00 AM; no effectiveness documented; 02/16/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, 11:00 AM and 2:00 PM, no effectiveness documented on each dose; 02/21/2025: Capsaicin Cream 0.1% apply to affected area three times daily as needed for pain, administered at 9:00 AM, no effectiveness documented; 02/22/2025: Capsaicin Cream 0.1% apply to affected area three times daily as needed for pain, administered at 9:00 AM, no effectiveness documented; 02/24/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, 11:00 AM and 1:00 PM, no effectiveness documented on each dose; 02/25/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, 11:00 AM, 1:00 PM, and 3:00 PM no effectiveness documented on each dose; 02/12/2025: Cyclobenazprine (Flexeril) Tab 10mg, give one-half tab (5mg) by mouth twice daily as needed, administered at 9:00 PM; no effectiveness documented; and 03/03/2025: Ibuprofen tab, 400 mg tablet by mouth every 6 hours as needed for pain, administered at 4:50 AM, no effectiveness documented. In an interview on 03/06/2025 at 1:00 PM S4ADON confirmed the above mentioned findings.”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure a medical history and physical was completed and placed on the medical record within 24 hours of admissions on 1 (#2) of 3 (#1 - #3) patient medical records reviewed. A review of hospital policy, “Documentation,” Policy Number: IM-005, with an effective date of 02/05/2015, last revised on 02/01/2017 and last reviewed 09/19/2024, revealed in part: “Policy: It is the policy of Seaside Health System that the medical record is a legal document, an accounting record and the blueprint for treatment during hospitalization. The patient’s record is the sole document from which third party payers decide upon payment. Increased scrutiny by external review agencies and accrediting bodies’ necessitates a careful and planned approach to documentation. A problem-oriented record that clearly identifies the need for treatment based on admission criteria for that level of care, as well as the critical problems to which all staff will be documenting is required. The best safeguard to avert denial of reimbursement and assure smooth and collegial relationships with review organizations and managed care representatives is to document in the prescribed time frame, and with sufficient frequency to substantiate both that the treatment was provided and that the treatment program is providing treatment of required intensity. The expectation is that the medical record will reflect the patient’s illness in behavioral specific terminology and support why the patient cannot be treated at a lower level of care. Procedure: Documentation should present a concise, problem-oriented record with representation from all disciplines. Key documents include physician admission orders, history and physical exam, a psychiatric evaluation, psychological evaluation if applicable, nursing assessment, a psychosocial assessment, nutritional assessment and recreational therapy assessment. Assessments must include an evaluation, summary and recommendations for treatment. If complete assessment information cannot be obtained, then the information gathered and reason for its in-completeness will be noted. Assessments are completed prior to the development of the multi-disciplinary treatment plan. 2. History and Physical Examination: the history and physical exam is completed within 24 hours and includes the complete systems review and comprehensive neurologic screening. The neurologic exam should include cranial nerves, sensory-moto functions, coordination, and deep tendon reflexes. The history and physical impressions can substantially support the necessity of hospitalization by identifying physical illness or medical complications exacerbated by a psychiatric condition.” A review of Patient #2’s medical record revealed an admission date of 02/26/2025 at 2:26 PM. A review of the document titled, “New Patient Evaluation/History and Physical,” revealed the completion of this exam on 02/28/2025 at 9:15 AM. This would be approximately 43 hours after the admission of the patient. In an interview on 03/06/2025 at 1:00 PM S4ADON confirmed the above mentioned findings.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by the failure to clean the ventilation system’s vents of a grey, fuzzy substance resembling dust. Findings: Observations during a hospital walk-through on 03/05/2025 from 12:35 PM to 1:25 PM revealed the hospital’s ventilation system having a grey, fuzzy substance resembling dust accumulated on ceiling vents and the surrounding ceiling in Rooms “a,” “b” and “c.” In an interview on 03/05/2025 and present during the hospital walk-thru, S4ADON confirmed the above mentioned findings.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 44495 Based on record reviews and interviews, the registered nurse failed to ensure each patient received care according to hospital policy and physician’s orders. The deficient practice is evidenced by 1) failure of nursing staff to complete a progress note each shift per hospital policy; and 2) failure of nursing staff to perform the Clinical Opiate Withdrawal Scale (COWS) as ordered. Findings: 1) Failure of nursing staff to complete a progress note each shift per hospital policy. Review of Policy Number IM-005, “Documentation,” reviewed 11/11/2021, revealed in part, “Progress Note Frequency . . . Nursing- One per shift.” Review of the medical record for Patient #1 revealed admission on 10/06/2024 and discharge on 10/17/2024. Review of the nursing progress notes revealed there was no nursing progress note in the record for 10/11/2024 for the 7:00 a.m. to 7:00 p.m. shift. In interview on 12/02/2024 at 3:19 p.m., S4QARM verified the nursing progress note for the shift was missing and could not be found. 2) Failure of nursing staff to perform the Clinical Opiate Withdrawal Scale (COWS) as ordered. Review of the medical record for Patient #2 revealed admission on 11/28/2024 for detox treatment and discharge on 12/02/2024. Review of the physician’s orders revealed , “Complete COWS every shift and always notify MD if score is greater than 7. Discontinue COWS 24 hours after last dose of Subutex is given.” Further review of the orders revealed the orders were not altered or discontinued during the admission. Review of the medical record revealed no COWS were performed. In interview on 12/02/2024 at 2:54 p.m., S4QARM verified the COWS were not in the record and were not found on the unit.”

“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 hospital failed to ensure drugs and biologicals were administered according to the physician’s orders. The deficient practice is evidenced by failure of the nursing staff to monitor blood glucose and administer medications as indicated. Findings: Review of the orders for Patient #1 revealed checks of the patient’s blood glucose levels were to be performed before each meal, at bedtime and at 1:00 a.m. The patient was to be administered insulin on a sliding scale before meals and at bedtime. The patient was to be administered glucagon 1 milligram intramuscularly if the blood sugar was less than 60. Further review of the orders revealed the orders were never altered or discontinued. Review of the Diabetic Flow Sheet revealed the 1 a.m. check of the blood glucose level was not performed on 10/07/2024, 10/09/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/15/2024, 10/16/2024 or 10/17/2024. In interview on 12/02/2024 at 3:15 p.m., S4QARM verified the glucose checks were not performed as ordered.”

“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 is evidenced by failure to ensure patient safety by failing to prevent a patient with a loaded firearm from being admitted into the hospital. (See findings under tag A0144) An Immediate Jeopardy was identified on 11/15/2023 at 3:06 p.m. and reported to S11Admin, S6QA, S10Sup and S12ADON, S13DON, and S14CD. The Immediate Jeopardy situation was the result of the hospital failing to ensure direct care staff were correctly trained in the protocol and procedure for pre-admit contraband searches and failing to implement corrective actions to ensure that this break in procedure would not reoccur. On 11/16/2023 at 10:25 a.m., S6QA and S11Admin presented the plan for lifting the immediacy of the IJ which included the assurance that all direct care staff working with patients on this day were trained in the new protocol and procedure for pre-admit contraband searches. The hospital conducted trainings related to contraband searches beginning 11/15/2023 at 4:00 p.m. and throughout the day on 11/16/2023 until 2:00 p.m. Interviews and record review verified the MHT and nursing competencies were completed on all of the direct care staff present during 11/15/2023 at 4:00 p.m. and 11/16/2023 until 2:00 p.m. On 11/16/2023 at 2:06 p.m. the IJ was removed; however, there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared. Therefore, noncompliance remains at the Condition Level.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 26351 Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked qulaity indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice is evidenced by: 1. the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators (see findings in A-0273), 2. the hospital’s Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement, implement effective action, measure success and track performance related to an identified damaged hand-held metal detector (see findings in A-0283), 3. the hospital failed to track and analyze all dangerous patient events. The deficient practice is evidenced by failure to complete an incident report for a documented dangerous event regarding the discovery of a loaded 22-caliber pistol under the pillow of Patient #1 (see findings in A-0263), 4. the hospital’s governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program (see findings in A-0309) and 5. the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital’s performance by having insufficient staff designated to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital. This deficient practice is evidenced by assigning this responsibility to S6QA who is also assigned the duties of Risk Manager; Infection Control Director; Compliance Officer and Treatment Team Nurse. (see findings in A-0315).”

“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 interview, the hospital failed to ensure patients received care in a safe setting as evidenced by: 1) failure to detect a loaded firearm on Patient #1 prior to hospital admittance; 2) failure to complete safety rounds every shift as per hospital policy; 3) failure to implement effective policies and procedures addressing the detection of a loaded firearm on a patient prior to hospital admittance; 4) failure to educate staff on policies and procedures to detect and disarm a patient with a loaded firearm prior to hospital admittance; 5) failure to replace a damaged hand-held weapons detector. Findings: 1) Failure to detect a loaded firearm on Patient #1 prior to hospital admittance. Review of hospital policy titled “Patient Rights”, revised 11/11/2021, revealed, in part: Policy: it is the policy of the hospital to maintain, protect, and respect the fundamental human, civil, constitutional, and statutory rights in accordance with Federal and State laws of all patients. Patient Rights, in part: The right to an environment that assures the patient’s safety, health and wellbeing ... Review of hospital policy titled “Rights of Involuntary Patients”, revised 11/11/2021, revealed, in part: Purpose: The purpose of this policy is to ensure that rights of involuntary patients are upheld in accordance with federal and state laws and the philosophy of the hospital. Rights of the Involuntary Patients, in part: 4. A humane treatment environment that affords reasonable protection from harm ... Review of hospital document titled “Hospital Occurrence Report-HOR”, dated 11/06/2023 at 6:25 a.m., revealed, in part: Patient #1, located on hall ‘a’ in room ‘b’. During the morning MHT safety rounds, S9MHT found a gun in Patient #1’s bed. The gun was in a pillowcase, under a pillow. The gun was placed in a patient belonging bag with a patient label and placed in the administration office. In an interview on 11/15/2023 at 9:28 a.m., S6QA reported the video revealed Patient #1 was not wanded, he was left alone behind the privacy screen for an extended time and that he did not remove all of his clothes but still had his pants and shoes on when exiting room ‘c’ to be brought to his room. 2) Failure to complete safety rounds every shift as per hospital policy. Review of hospital document titled “Safety Rounds” revealed, in part: Safety Rounds are completed by one or more off going MHT’s on every shift. Not completing the rounds or documenting them will result in disciplinary action. The purpose of these rounds is to ensure the safety and security of the patients and staff. Review of hospital document titled “Mandatory Shift Change Environmental Safety Rounds Checklist Education”, revealed, in part: Outgoing MHT and incoming MHT should perform together whenever possible. Findings should (i.e. incomplete tasks) should be documented in the comments. The assigned MHT is responsible for ensuring all items are complete. If the checklist is not found or there are incomplete assignments, the assigned MHT will be held accountable. Review of hospital log titled “MHT Safety Rounds Log Book” failed to reveal evidence that safety rounds were completed every shift as per psychiatric hospital policy. The only completed safety round sheets in the MHT Safety Rounds Log Book for October and November of 2023 were dated 10/28/2023 and 11/04/2023. In an interview on 11/15/2023 at 11:25 a.m., S6QA reported a loaded 22-caliber pistol was discovered in Patient #1’s room on the morning of 11/06/2023 during safety rounds. S6QA stated that the policy is for safety rounds to occur every shift. S6QA continued by stating that Patient #1 was always in his bed in room ‘c’ during safety rounds, but on the morning of the 6th, the patient was not in his bed and the MHT preceded to search the bed and found the 22-caliber pistol under the pillow. S6QA confirmed that the patient had been admitted to the hospital for over a week before the loaded 22-caliber pistol was found during safety rounds. In an interview on 11/16/2023 at 1:20 p.m., S6QA reported that she could not locate the safety rounding sheets for most of October and November 2023 for hall ‘a’ that houses room ‘b’. 3) Failure to implement effective policies and procedures addressing the detection of a loaded firearm on a patient prior to hospital admittance. Review of hospital policy titled “Hand Held Metal Detector”, reviewed 10/05/2021, revealed, in part: Purpose: The purpose of this policy is to improve security and safety of patients and staff. Policy: It is the policy of the hospital to use a hand-held weapons detector to improve security of patients and staff. Procedure, in part: 1. the hand-held weapons detector will be used on screening of patients for potential weapons or contraband upon arrival to the facility prior to the initiation of the assessment screening. Review of hospital policy titled “Contraband” last revised 11/11/2023, revealed, in part: Purpose: To define contraband and outline policies regarding the control of contraband. Policy: It is the policy of the hospital that staff shall ensure the strict control of contraband and unauthorized use of permitted items in order to provide a secure and safe environment for patients, staff, and visitors. Procedure, in part: 1. Contraband shall be defined and controlled according to applicable state laws, rules, regulations, and hospital policies and procedures. The most restrictive definition shall prevail. 5. Contraband list, in part: a. the following is a list of items but is not limited to that are considered contraband. They are prohibited from being brought hospital by staff or patients. iii., part: Firearm. Review of document titled “Admit Protocol for All Patients for Searches”, failed to reveal the use of a hand-held metal detector as part of the admission search protocol. In an interview on 11/15/2023 at 9:28 a.m., S6QA verified that the procedure for admissions did not include the use of the metal detector in the lobby before entering the facility. S6QA further stated that staff did not use the hand-held metal detector on Patient #1 in the lobby. S6QA stated the procedure was to have the patient in room ‘c’ behind a privacy screen where the patient is to completely disrobe and put on two green gowns. The MHT is responsible for being behind the privacy screen while patient is changing; using the hand-held metal detector to wand the patient and placing all of their clothes in a bag to be brought to the laundry room. S6QA interviewed S5MHT who reported that he wanded the patient and it never went off. When asked if it was on, he said he thought so. S6QA verified that there was no evidence of metal detector use noted in the video while patient #1 was in room ‘c’ on 10/30/2023. S6QA reported the video revealed Patient #1 was not wanded, he was left alone behind the privacy screen for an extended time and that he did not remove all of his clothes but still had his pants and shoes on when exiting room ‘c’ to be brought to his room on 10/30/2023. 4) Failure to educate staff on policies and procedures to detect and disarm a patient with a loaded firearm prior to hospital admittance. Review of document titled “Admit Protocol for All Patients for Searches and Inventory Competency-Old Process”, undated, failed to reveal that the patient is scanned with the metal detector in the lobby and a second time in room ‘c’. Review of unapproved document titled “Admission Security Competency-New Process”, revealed, in part: 3. the MHT is to successfully use the metal detector wand to scan each patient in the lobby. 7. The patient will be scanned with the metal detector again. All contraband will be removed at this time. In an interview on 11/15/2023 at 10:20 a.m., S6QA and S10Sup reported that all of the MHTs and nurses had not been educated on the new procedure for admit and contraband search. S6QA further stated the new procedure had not been approved by the governing board, but some of the staff had been verbally educated on the procedure. S6QA verified there was no sign-in sheet confirming which staff had been educated. In an interview on 11/15/23 at 11:00 a.m., S7MHT, who was scheduled to conduct the next new admission, was unaware of the new admit process for contraband search. S6QA confirmed S7MHT failed to describe the new admit process for contraband search. In an interview on 11/15/23 at 11:05 a.m., S8MHT who was scheduled to conduct the next new admission after S7MHT, was unaware of the new admit process for contraband search. S6QA confirmed S7MHT failed to describe the new admit process for contraband search. In an interview on 11/16/2023 at 10:42 a.m., S8MHT stated discomfort in handling a potential discovery of a firearm that requires disarming. S8MHT reported being less uncomfortable if the hospital had a more specific procedure detailing what is required of the MHT during the discovery of a firearm. 5) Failure to replace a damaged hand-held weapons detector. Observation of hand-held metal detector on 11/15/23 at 11:17 a.m located on unit’d’, revealed the hand-held metal detector was held together by clear tape. In an interview, S6QA reported that the tape was holding the batteries in place. That the hand-held metal detector had been dropped causing the damage requiring the batteries to be taped. S6QA stated she was not sure if a new hand-held metal detector was ordered. S6QA further stated that a nurse had verbalized that the facility needed a better hand-held metal detector, she said “it is more than the battery”.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators. Findings: Review of hospital policy titled “Committee Structure” last reviewed 11/11/2021, revealed in part: Policy, in part: It is the policy ...to promote ongoing performance improvement. Procedure. in part: 5. Quality Council. a, in part: The purpose of the Quality Assurance Committee is to improve the safety and quality of health services. c. The committee shall convene a minimum of 10 times per year. Review of hospital document titled “Quality Improvement Plan 2023”, revealed, in part: Continuous Quality Improvement Departmental Monitoring, in part: ...indicators will be tracked and monitored by the QI department. B. The QI Director will track clinical indicators selected by the hospital’s leadership team. The clinical indicators will be discussed monthly and used to identify trends, establish possible corrective action plans, and then to show sustained improvements. Review of the hospital’s QAPI records revealed no documented evidence of current data collection for quality indicators. In an interview on 11/16/2023 at 2:05 p.m., S6QA confirmed “Incident Reports” and “Outliers Action Plan” revealed June 2023 as the date of the last tracked clinical indicators. S6QA verified the most recent Governing Council-Quality Assurance and Patient Safety and clinical Practice meeting was held July 11, 2023. S6QA reported the QAPI meetings should be 10 times a year per policy and the last meeting was held in July.”

“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: 47397 Based on record review and interview, the hospital’s Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement, implement effective action, measure success and track performance related to an identified damaged hand-held metal detector. Findings: Observation on 11/15/2023 at 11:17 a.m. of hand-held metal detector located at the nurses’ station on Hall ‘a’, revealed the hand-held metal detector was held together by clear tape. Review of most recent Governing Council-Quality Assurance and Patient Safety and clinical Practice Minutes dated July 11, 2023 failed to reveal Equipment Maintenance listed. Further review failed to reveal discussion, recommendations and actions regarding the damaged hand-held metal detector. In an interview, S6QA reported that the tape was holding the batteries in place. S6QA stated the wand had been dropped causing damage requiring the batteries to be taped into place. S6QA further reported she was not sure if a new hand-held metal detector was ordered. S6QA stated that a nurse had verbalized that the facility needed a better hand-held metal detector, “it is more than the battery”. In an interview on 11/15/2023 at 2:30 p.m., S6QA confirmed there was no evidence that the issue regarding the damaged hand-held metal detector was discussed as a QAPI issue.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to track and analyze all dangerous patient events. The deficient practice is evidenced by failure to complete an incident report for a documented dangerous event regarding the discovery of a loaded 22-caliber pistol under the pillow of Patient #1. Findings: Review of hospital document titled “Hospital Occurrence Report-HOR”, dated 11/06/2023 at 6:25 a.m., revealed, in part: Patient #1, located on Hall ‘a’ in Room ‘b’. During the morning MHT safety rounds, S9MHT found a gun in Patient #1’s bed. The gun was in a pillowcase, under a pillow. The gun was placed in a patient belonging bag with a patient label and placed in the administration office. Further review of the HOR failed to reveal corrective measures, analysis, or the signature of the risk manager. Review of hospital document titled “Framework for Root Cause Analysis and Corrective Actions” (RCA), undated. The 19-page report included video footage dated 10/30/2023 from 10:31 p.m.-11:34 p.m. It was noted that Patient #1 was left by himself behind the privacy screen of room ‘c’ at 10:34 p.m. Patient #1 came from behind the screen at 10:38 p.m. with a green gown and dark colored pants on his body. Patient #1 exited room ‘c’ at 11:34 p.m. wearing shoes, pants, beige jacket. It was noted that Patient #1 was favoring left side upon entry and exit from the room ‘c’. The left arm did not rise. The video footage failed to reveal staff use the hand-held metal detector per policy. The RCA reported the patient’s medications and past medical/psychiatric history. On Page 7 of 19 pages Analysis question #1, “What was the intended process flow?”, revealed Analysis findings “See document Security ‘Admission Old Process’ Sheet. Also on page 7 was Analysis question #2, “Were there any steps in the process that did not occur as intended?” “Analysis Findings” revealed “See document Security Admission ‘Process Performed’ Sheet. Pages 8-19 were not completed. Review of the list of incident reports provided failed to reveal the above incident. In an interview on 11/15/2023 at 12:15 p.m., S6QA confirmed that the hospital did not submit a self-report to LDH because they did not know what category to place the incident. S6QA also verified the RCA was not completed.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) 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: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital’s governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program. Findings: Review of all QAPI information presented to the survey team as current revealed it only included the following: 1) Review of hospital document titled “Incident Reports” and “Outliers Action Plan” revealed June 2023 as the date of the last tracked clinical indicators. The “Incident Reports” and “Outliers Action Plan” for the months of July, August, September, and October, 2023 were blank. 2) Review of most recent Governing Council-Quality Assurance and Patient Safety and clinical Practice Minutes dated July 11, 2023. These meeting minutes stated that incidents were not addressed because the incidents document was not completed for the month of June. 3) Review of hospital document titled “Quality Improvement Plan 2023” provided by the hospital staff failed to reveal the Quality improvement Plan 2023 was approved and signed by the governing board. In an interview on 11/16/2023 at 2:05 p.m., S6QA verified that the QAPI documents provided did not indicate an ongoing program for quality improvement and patient safety because the committee meetings and indicators were not current. S6QA did not know why the Quality Improvement Plan for 2023 was not signed.”

“PROVIDING ADEQUATE RESOURCES CFR(s): 482.21(e)(4) [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:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients. This Standard is not met as evidenced by: 47397 Based on record review and interview, the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital’s performance by having insufficient staff designated to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital. This deficient practice is evidenced by assigning this responsibility to S6QA who is also assigned the duties of Risk Manager; Infection Control Director; Compliance Officer and Treatment Team Nurse. Findings: Review of hospital document titled “Quality Improvement Plan 2023”, revealed, in part: Continuous Quality Improvement Departmental Monitoring, in part: ...The ...indicators will be tracked and monitored by the QI department. B. The QI Director will track clinical indicators selected by the hospital’s leadership team. The clinical indicators will be discussed monthly and used to identify trends, establish possible corrective action plans, and then be used to show sustained improvements. Review of Organizational Chart provided by hospital staff, dated 01/21/2022, revealed, in part: S6QA listed as QA/Risk Manager; Infection Control; Compliance; and Treatment Team Nurse. Review of hospital document titled “Incident Reports” and “Outliers Action Plan” revealed June 2023 as the date of the last tracked clinical indicators. Review of most recent Governing Council-Quality Assurance and Patient Safety and clinical Practice Minutes revealed the the last meeting was held on July 11, 2023. In an interview on 11/16/2023 at 2:05 p.m., S6QA reported that duties as QA/Risk Manager, Infection Control Director; Compliance Officer and Treatment Team Nurse has made it difficult to track the clinical indicators monthly as per policy.”