River Place Behavioral Health

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to ensure a psychiatric patient with self-injurious behaviors in the seclusion room received care in a safe setting resulting in patient injuries for 1 (#1) of 2 patients placed in seclusion room reviewed. Findings: Review of hospital policy titled “Seclusion,” last approved 02/2026, revealed in part: “Definition: Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Procedure: 5. The patient shall be monitored and reassessed through continuous in-person observation. Evaluation includes the patient’s immediate situation, reaction to the intervention, medical. 6. The nurse in charge will assign trained staff to continuously monitor the patient during the seclusion event.” Review of the “Hospital/Licensed Provider Abuse/Neglect Initial Report” finalized on 06/17/2026 revealed, in part, Patient #1 had self-harm. Review of the report revealed on 06/09/2026 at 11:33 PM, Patient #1 assaulted a BHA, noted with extreme aggression and attempted to hit staff. The patient continued with agitation, aggression, and psychosis and a danger to himself and staff. Patient #1 was escorted to seclusion room and orders obtained for seclusion and 1:1. Review of the report revealed at 11:55 PM, Medical Provider notified and informed Patient #1 injured bilateral hands during noted psychosis, punching the wall in his room. Review of the report revealed new orders noted: site care to be performed once the patient is calm and no longer aggressive. Assess joint mobility, apply ice, and it is okay to order an X-ray of the bilateral hands in the A.M. if the patient’s medical status appears stable. Review of the report revealed (06/10/2026) at 1:24 AM, Informed by staff BHA that is 1:1 on patient while in the seclusion room, that the patient was in the seclusion room, hitting his head up against the wall, and now has a hematoma over his right and left eye. Nurse contacted on-call Psychiatric NP and updated on the patient’s mental status and ongoing psychosis. Informed NP that the patient will not be able to come out of seclusion in four hours as continues to be a danger to himself and others. Informed the Psychiatric NP that the as needed intramuscular injections were ineffective at this time. Psychiatric NP advised nurse to continue to monitor and continue seclusion orders for another four hours, as it is unsafe for the patient to come out of seclusion at this time. At 1:42 AM, Contacted M.D. and updated on the patient’s medical status. Informed M.D. that the patient continues to cause injuries to himself. Informed M.D. that the patient was banging his head on the wall in the seclusion room, and now has hematomas to his head and swelling above both eyes. New order noted per M.D. to transfer to the E.D. to rule out fractures to the bilateral hands and evaluate for possible skull fractures. EMS notified. Informed by staff BHA 1:1 on patient in seclusion that the patient fell off the bed and onto his face while in the seclusion room, staff BHA reports swelling noted on the patient’s face. Staff BHA reports that the patient has been falling repeatedly prior to this fall from the bed onto the floor. Review of Patient #1’s medical record revealed, in part, 06/10/2026 at 1:45 AM, patient left the hospital via EMS and transferred to Hospital A. Patient left the unit with two large hematomas noted above his left eye and to his forehead. Also noted abrasion to bridge of patient’s nose. Review of Patient #1’s medical record from Hospital A revealed, in part, CT (Computed Tomography) Head without Contrast. Impression: Multifocal facial soft tissue swelling with acute appearing minimally displaced left nasal bone fracture. Subtle remote left orbital (eye socket) floor fracture. In an interview on 06/30/2026 at 12:56 PM, S1DRM confirmed Patient #1 had nasal bone fracture and orbital floor fracture. S1DRM confirmed the hospital identified issues with Patient #1 while in the seclusion room and with staff timely reporting patient’s condition to the provider and hospital administration. S1DRM confirmed the hospital was in the process of correcting those issues.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to ensure all patients were free from abuse as evidenced by a patient (#3) physically assaulting patients (#2, #4, #5) resulting in injuries to those patients for 3 of 5 sampled patients Findings: Review of the hospital policy titled “Patient Rights,” date of last revision: 04/2020, revealed, in part: “Procedure. Patient Rights: 1. g. Patients have the right to be protected by the hospital from neglect; from physical, verbal and emotional abuse.” Review of the “Hospital/Licensed Provider Abuse/Neglect Initial Report” finalized on 06/02/2026 revealed, in part, Patient #3 and Patient #2 involved in patient-to-patient physical assault. Review of the report revealed, that on 05/27/2026 at approximately 10:10 AM, Patient #3 struck Patient #2 several times in the face. Patient #2 then fell to the ground. Patient #2 did not lose consciousness but appeared dazed. Patient #2 was transported to Hospital A for evaluation. At Hospital A, Patient #2 received an X ray. The Emergency Department note states: “Left mid shaft tibia (shinbone) fracture, mildly displaced, and fibula (calf bone) neck fracture.” Further review revealed, in part, Patient #2 was standing in front of the nursing station when Patient #3 approached and struck him twice. Patient #2 was diagnosed with a displaced distal tibia shaft fracture and a displaced, overlapped proximal fibula shaft fracture. Patient #2 was transferred to Hospital B where he was admitted for further treatment. In an interview on 06/29/2026 at 1:43 PM, S1DRM confirmed Patient #3 physically assaulted Patient #2. S1DRM confirmed Patient #2 was diagnosed with tibia and fibula fractures. S1DRM confirmed Patient #3 was on every 15 minute observation at the time of the incident. S1DRM confirmed Patient #3 was seen by a provider after the incident with Patient #2 and provider felt Patient #3 was no longer aggressive after assessment completed and to continue every 15 minute observation. Review of the “Hospital/Licensed Provider Abuse/Neglect Initial Report” finalized on 06/02/2026 revealed, in part, Patient #3 and Patient #4 involved in patient-to-patient physical assault. Review of the report revealed that on 05/28/2026 at approximately 1:00 PM, Patient #3 entered Patient #4’s room and struck him while he was asleep. Patient #4 sustained a small, superficial laceration to the forehead. Patient #4 was transferred to Unit B and Patient #3 was placed on 1:1 observation. Further review revealed, in part, Patient #3 exited his room, walked down the hallway, and entered Patient #4’s room. Moments later, Patient #4 was observed running out of his room with Patient #3 following behind him. Patient #4 sustained a small, superficial laceration to his forehead and was transferred to Unit B. Patient #3 was placed on 1:1 observation. In an interview on 06/29/2026 at 1:49 PM, S1DRM confirmed Patient #3 physically assaulted Patient #4. S1DRM confirmed Patient #4 sustained a small, superficial laceration to the forehead. S1DRM confirmed Patient #4 and was transferred to Unit B. Patient #3 was placed on 1:1 observation. Review of the “Hospital/Licensed Provider Abuse/Neglect Initial Report” finalized on 06/02/2026 revealed, in part, Patient #3 and Patient #5 involved in patient-to-patient physical assault. Review of the report revealed that on 05/28/2026 at approximately 2:20 PM, Patient #5 was standing in front of the nursing station when Patient #3 struck him in the face. Patient #5 was transported to Hospital C, where he was diagnosed with a broken jaw. Patient #3 was placed in seclusion and on 2:1 observation. Further review revealed, in part, Patient #5 was standing in front of the nursing station when Patient #3 struck him in the face. Patient #5 was transported to Hospital C, where he was diagnosed with a broken jaw. Patient #3 was placed in seclusion and will be placed on 2:1 observation. In an interview on 06/30/2026 at 12:56 PM, S1DRM confirmed Patient #3 physically assaulted Patient #5. S1DRM confirmed Patient #5 was transported to Hospital C, where he was diagnosed with a broken jaw. S1DRM confirmed Patient #3 was placed on 1:1 observation after the incident with Patient #4. S1DRM confirmed the 1:1 BHA assigned to Patient #3 did not observe Patient #3 for a short period of time and that was when Patient #3 assaulted Patient #5.”

“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: 14442 Based on record review and interview, the hospital failed to ensure the registered nurse assigned the nursing care for patient observations in accordance with hospital policy. Findings: Review of hospital policy titled “Observations, Patient,” last approved 04/2026, revealed in part: Charge RN/RN Designee. A. Assignment for Observations will be done by the Charge RN/RN Designee.” Review of Unit A “Patient Care Assignment Sheet” dated 05/27/2026 and 05/29/2026 failed to reveal patient assignment/room numbers assigned to staff for 05/27/2026 day shift and 05/29/2026 night shift. In an interview on 06/30/2026 at 8:44 AM, S1DRM confirmed patient care assignments for observations should be done each shift by the RN. S1DRM confirmed that Patient Care Assignment Sheets for 05/27/2026 and 05/29/2026 did not include patient assignment/room numbers assigned to staff.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure each patient or patient representative consented to treatment and was informed of his or her patient rights. This deficient practice is evidenced by failure to obtain signed consent for treatment or signed patient rights information form for 1 (#2) of 3 (#1-#3) records reviewed. Findings: Review of hospital policy number RR-07, titled “Patient Rights,” date of last revision: 06/2025, revealed in part: “POLICY: It is the policy of the Hospital to ensure that patient rights are communicated to all patients and their legal guardian and employees to avoid any misunderstandings of those rights, and to provide a list of patients’ rights to all patients or their legal guardian upon admission. PROCEDURE: Patient Rights: 1. The following rights shall be afforded to all patients and are not subject to modification: a. Patients have the right to be fully informed before or upon admission about their rights and responsibilities and about any limitation on these rights imposed by rules of the hospital. The hospital must ensure that the patient is given information about his or her rights that shall include at least the following: i. A statement of the specific rights guaranteed the patient by these rules and applicable state and federal laws. m. Patients have the right to be informed about their care in a language they understand. 2. The following rights must be afforded to all patients unless modified in accordance with LAC 48:1, Chapter 93-9319 and Louisiana RS 28:171 PART VI. a. Patients have the right to participate in the development of their individual program or treatment plans and to receive sufficient information about proposed and alternative interventions and program goals to enable them to participate effectively.” Review of Patient #2’s medical record revealed Patient #2 was admitted on 12/03/2025 on a Physician Emergency Certificate (PEC) for Suicidal Ideation. Further review failed to reveal documented evidence that the patient or their parent/guardian were notified of their rights or that a consent for treatment was obtained. In an interview on 01/21/2026 at 1:48 PM, S2DOQ confirmed there was no documented evidence that Patient #2 was notified of their patient rights or that a consent for treatment was obtained prior to discharge from the hospital.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by: 1) failure to monitor Patient #1 per physician order during the evening that an alledged sexual assault occurred; and 2) failure to perform observations according to hospital policy for 2 (#1, #2) of 3 patient records reviewed. Findings: Review of hospital policy titled “Observations, Patient,” last approved 09/2025, revealed in part: “POLICY: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. Level of observations can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level. DEFINITIONS: Q5 Minute Observations - Patient is monitored at minimum once in every 5-minute block of time. Q15 Minute Observations - Patient is monitored at minimum once in every 15-minute block of time. PROCEDURE: 1. The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient’s condition warrants a change: a. 15 minute, b. 5 minute, c. One-to-one. 6. Documentation of Observations: a. Proximity-Based Electronic Technology: i. Staff documents all levels of observation on each patient’s profile on the facility issued device using proximity-based electronic technology. The observation report is then printed and becomes a part of the patient record at discharge. Each entry is to include the following: Location, Behavior/Activity, Time is recorded when the entry is made, Signatures are completed electronically by the assigned staff using their unique login to the system. ii. Ordered precautions should be entered into the patient profile and are visible to the staff rounding on the patient. iii. Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and/or to back fill time frames that were not completed in a timely manner. 7. Q 15 Minute Observations: i. All patients are monitored at minimum once in every 15 minute block of time. ii. In order to minimize the chance that patients may anticipate the timing of the observations; the staff are instructed to vary the order in which patients are observed within each 15 minute period. 8. Q 5 Minute Observations: a. Patient is placed on Q 5 minutes if their behavior is unpredictable and there is potential risk for harm to self and others yet behavior is not at the point requiring constant 1:1 observation. b. Patient is monitored at minimum once in every 5 minute block of time. i. During the observations staff are to: i. Make direct visual contact; look for signs of danger or distress, even if the patient is in the bathroom. ii. Observe sleeping patients close enough to confirm they are breathing and not in any physical distress such as bleeding, lying on the floor, very restless, etc. iii. Remain vigilant for specific risks for patients on Special Precautions. iv. Allow reasonable privacy for dressing and bathing- visualize through a slightly open bathroom door. v. If awake, address the patient. vi. Observe the patient’s environment for potential hazards that can be corrected.” 1) Failure to monitor Patient #1 per physician order during the evening that an alleged sexual asault occurred.. Review of Patient #1’s medical record revealed that Patient #1 was admitted on 12/02/2025 with Oppositional Defiant Disorder and aggression. Further review of Patient #1’s medical record revealed that on the night of 12/06/2025, Patient #1 and Patient #2 were involved in an alleged patient to patient sexual assault. Review of Patient #1’s orders revealed in part the following: 12/06/2025 at 5:32 PM- Order for Q 5 minute observations entered via telephone order by S6RN. 12/06/2025 at 7:16 PM- Q 5 minute observation order acknowledged by S5RN. Further review of Patient #1’s medical record failed to reveal documentation from the nurse or provider why Patient #1’s observation level was changed from Q 15 minute observations to Q 5 minute observations on 12/06/2025. Review of Patient #1’s Patient Observation sheets revealed in part the following: 12/06/2025: 5:32 PM - 11:47 PM Observations documented Q 15 minutes. 12/07/2025: 12:02 AM - 6:17 AM Observations documented Q 15 minutes. 12/07/2025 at 6:30 AM Q 5 minute observations were initiated. Further review of Patient #1’s medical record failed to reveal that Q 5 minute observations were documented per physician order prior to 12/07/2025 at 6:30 AM (13 hours after physician order was initiated). In an interview on 01/20/2026 at 3:46 PM, S1ICNO and S2DOQ confirmed the above-mentioned findings. S1ICNO and S2DOQ further confirmed that Patient #1 was not being observed Q 5 minutes per physician orders. 2) Failure to perform observations according to hospital policy for 2 (#1, #2) of 3 patient records reviewed. Patient #1 Review of Patient #1’s Observation Flowsheet failed to reveal observations performed every 15 minutes per policy for the following dates/times: 12/06/2025: 7:02 AM - 7:32 AM (20 minutes) 12/08/2025: 9:59 AM - 10:25 AM (26 minutes) 12/09/2025: 4:33 AM - 4:50 AM (17 minutes) 12/20/2025: 3:35 AM - 5:07 AM (92 minutes) Review of Patient #1’s Observation Flowsheet failed to reveal observations performed every 5 minutes per policy for the following dates/times: 12/07/2025: 9:30 AM - 9:40 AM (20 minutes) 12/07/2025: 1:45 PM - 1:55 PM (10 minutes) In an interview on 01/21/2026 at 9:24 AM, S2DOQ confirmed the above-mentioned findings. Patient #2 Review of Patient #2’s Observation Flowsheet failed to reveal observations performed every 15 minutes per policy for the following dates/times: 12/06/2025: 11:42 AM - 12:02 PM (20 minutes) 12/06/2025: 12:02 PM - 1:04 PM (62 minutes) 12/06/2025: 6:50 PM - 7:12 PM (22 minutes) In an interview on 01/20/2026 at 12:38 PM, S3DRM confirmed that on the night of 12/06/2025 staff were forcing their rounding entries and not visualizing Patient #1 and Patient #2 who were roommates. She did not disclose or provide documentation as to which observations were and were not performed and the facility did not keep the video for review by the surveyor. In an interview on 01/21/2026 at 10:02 AM, S2DOQ confirmed the above-mentioned findings.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficient practice is evidenced by failure to self-report incidents involving allegations of abuse/neglect within 24 hours to the Department of Health and Hospitals in 1 (#1) of 3 medical records reviewed for abuse/neglect. Findings: Review of hospital policy number, RR-09 titled “Required Reporting - State of Louisiana,” last revised 04/2025, revealed in part: “POLICY: River Place Behavioral Health will follow the State of Louisiana’s Revised Statutes required reporting of the following: Abuse/Neglect. PROCEDURE: I. Allegations of Abuse/Neglect (Louisiana RS: 40:2009:20): a. Any allegations of abuse/neglect must be reported immediately to the Risk Manager or Administrator on Call (if afterhours or on weekends). b. Any allegations of abuse/neglect must be reported within 24 hours of receiving knowledge of the allegation to the respective agencies associated with the Louisiana Department of Health. c. The 24 hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence of lack of supporting evidence.” Review of hospital policy titled “Contraband,” last approved 05/2025, revealed in part: “PROCEDURE: 2. Staff will consider the following to be contraband: a. General: i. Any item deemed unsafe by any staff member. iii. Any item with sharp edges.” Patient #1 Review of Patient #1’s medical record revealed an admit date of 12/02/2025 for Oppositional Defiant Disorder and aggression. Review of Patient #1’s Nursing Notes revealed in part the following incidents: 12/15/2025 at 6:56 PM: Patient #1 took it upon himself to “defend” other patients and staff on the unit because of vulgar statements made by Patient #R1. Patient #1 approached Patient #R1 with closed fists and engaged in physical contact, striking Patient #R1 several times. Patient #R1 in turn engaged in physical contact with Patient #1. Staff intervened and separated the two patients. Moments later Patient #1 and Patient #R1 engaged in a second physical altercation exchanging several more blows before being separated by staff for a second time. 12/18/2025 at 11:40 AM: Order received from nurse practitioner for Xray of patient bilateral hands related to physical altercation. 12/18/2025 at 5:30 PM: Around 10:50 AM Patient #1 was involved in an altercation with Patient #R1. Patients were separated by staff and fellow peers. Patient was assessed by nurse and Patient #1 complained of mild pain to his right pinky. Both hands were swollen. 12/19/2025 at 9:10 PM: Patient #1 became aggressive towards Patient #R2 for talking about Patient #3’s mom. Patient #1 ran up to Patient #R2 and started punching her and pulling her hair. Staff begin to break the two of them apart. The hostile and aggression continued for a few minutes afterwards until patients separated by staff on unit. 12/22/2025 at 12:53 PM: Around 12:00 PM the BHA (Behavioral Health Associate) came to the nurse and stated that she found a broken spoon and markers in Patient #1’s pocket. When asked why by the patient, he stated that he was using it as a shank. Review of Patient #1’s Psychiatry Progress notes revealed in part the following: 12/16/2025: Patient #1 had altercation with peer last night. He was placed on Q 5 minute observations for assault. Medical consult done for complaints of wrist pain last night. He denies pain this morning. Xray was done, results pending. In an interview on 01/20/2025 at 2:12 PM, S1ICNO confirmed there were no Self-Reports for the above-mentioned incidents. S1ICNO also confirmed that they were unable to find incident reports for the above-mentioned incidents on 12/15/2025, 12/18/2025, or 12/19/2025.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failing to accurately self-report an incident involving alleged patient to patient sexual assault. Findings: Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: “4. Self-Reporting: In the interest of providing information that will indicate the facility’s compliance with CMS Regulation 482.13(c) (3) regarding abuse, neglect, and harassment, as well as La R.S. 40:2009.20, the following processes have been developed. It should be noted that a facility’s decision to self-report does not eliminate the possibility of an onsite investigation being conducted in response to allegations and/or relevant information received. Although LA R.S. 40:2009.20 requires a facility to report knowledge of incidents of abuse, within twenty-four hours, to either the local law enforcement agency or LDH (or the Medicaid Fraud Unit as applicable), many facilities find it beneficial to self-report to LDH, even if they have notified law enforcement. It is important to note that contacting law enforcement on behalf or at the request of the patient/complainant (e.g. to press charges, etc.) does not satisfy the statute’s intent regarding facility notification. 8: Initial Report (within 24 hours of knowledge): NOTE: Patient-to-patient assaults should be categorized as “Neglect” in relation to “Patient-to-Patient Physical Assault” or “Patient-to-Patient Sexual Assault.” From a LDH standpoint, the issue under review is to determine whether the facility failed to take prudent action to prevent, and/or respond to, the (alleged) occurrence. These incidents should be assessed as alleged “Neglect” (i.e. the hospital’s failure to act with due diligence). Also indicate what the allegation of neglect involves (i.e. sexual assault, physical assault, elopement, death, or other). The requirement (per statute) is that potential abuse or neglect be reported within 24 hours of knowledge (awareness) of the allegation, suspicion, or occurrence. 12. Special Settings and Considerations: This document describes the type of information needed by the HSS to conduct a thorough review of a hospital’s actions in relation to an allegation that abuse and/or neglect has occurred within the facility. In certain settings, including, but not limited to behavioral health facilities, pediatric units, and geriatric units, incidents involving physical or emotional abuse or sexual acting out between patients may be reportable, as the facility has specific responsibilities relative to providing adequate supervision to prevent these occurrences.” Patient #2 Review of Patient #2’s medical record revealed an admit date of 12/03/2025 for Suidical Ideation. Review of Patient #2’s orders revealed in part the following: 12/03/2025 (on admission) - Q 15 minute observations. 12/08/2025 at 9:45 AM - order for Q 5 minute observations. Review of Patient #2’s nursing notes revealed in part the following: 12/08/2025 at 11:14 AM - BHA and nurse reported to charge nurse that patient stated that he was raped by Patient #1. Patient verbalized that there was no penetration with penis to anus. Patient denies what Patient #1 stated about him performing oral sex on him. Patient verbalized that Patient #1 told him that he wanted to have sex with him and that Patient #1 tried to pull his pants down after Q15 minute check on Saturday. Patient verbalized that he told Patient #1 to stop because he had a girlfriend. Patient verbalized that he did not report it to staff. Informed patient to inform of any issues he’s having. Patient verbalized that last night Patient #1 told him that he wanted to fight him and poured water in his face. Patient verbalized that they were moved into separate rooms. Left unit to inform house supervisor due to not being able to reach. Walked back to unit and was informed by staff nurse that patient was hit in face by Patient #1. Provider notified, verbal order: change patient to Q 5 minute observation. Review of Patient #2’s progress notes revealed in part the following: 12/08/2025 at 12:23 PM - At approximately 9:30 AM, Patient #2 “had a physical altercation with peer. Patient #2 reported to his male peers a situation that happened a few nights ago and the conversation was heard by the peer he’s at the moment speaking about. Patients then began arguing and cursing at each other and then the fight began. On duty techs were able to separate the patient’s and escort them back to their rooms.” Patient #1 Review of Patient #1’s medical record revealed an admit date of 12/02/2025 for Oppositional Defiant Disorder and aggression. Review of Patient #1’s orders revealed in part the following: 12/06/2025 at 5:32 PM- Order for Q 5 minute observations. 12/07/2025 at 7:27 PM- Order for Q 15 minute observations. 12/08/2025 at 9:44 AM- Order for 1:1 observation for assault and sexually acting out. Review of Patient #1’s Patient Observation sheets revealed in part the following: 12/06/2025: 5:32 PM - 11:47 PM Observations documented Q 15 minutes. 12/07/2025: 12:02 AM - 6:17 AM Observations documented Q 15 minutes. 12/07/2025 at 6:30 AM Q 5 minute observations were initiated (discontinued on 12/07/2025 at 7:27 PM). Further review of Patient #1’s medical record failed to reveal that Q 5 minute observations were documented per physician order prior to 12/07/2025 at 6:30 AM (13 hours after physician order was initiated). Review of Patient #1’s nursing notes revealed in part the following: 12/08/2025 at 11:44 AM - BHA (Behavioral Health Associate) and nurse reported to charge nurse that Patient #1 verbalized that he performed oral sex on Patient #2. Patient #1 verbalized that there was no penetration with penis to anus. Patient #2 denied that he was raped by Patient #1. Patient #1 initially verbalized that he performed oral sex on Patient #2. Then Patient #1 verbalized that they performed oral sex on each other. Was informed by staff nurse that Patient #1 hit Patient #2 in the face. Provider notified, verbal order: change patient to Q 5 minute observation. Review of Patient #1’s Social Worker notes revealed in part the following: 12/08/2025 5:53 PM - LMSW (Licensed Master Social Worker) met with risk analysis manager and was informed that the patient had engaged in sexual contact with another patient here on the unit. It was then asked that the social worker speak to the patient at this time to get the patient’s version of the story: -at 1:00 PM: the risk manager, SW (Social Worker) and Patient met to discuss this instance: The patient stated that: he was sitting next to the patient on Unit A, when Patient #2 stated that Patient #1 was “handsome.” He then stated that he wanted to act on that so they agreed to kiss. That night Patient #1 went to Patient #2’s room to kiss more, after asking the night nurse to put them in the same room. Afterward, Patient #1 stated that they performed oral sex on one another and then went to sleep ten minutes later. Review of the Hospital/Licensed Provider Abuse/Neglect Initial Report finalized on 12/22/2025 revealed in part the following documentation: Incident Type: Alleged Sexual Abuse (Patient to Patient Sexual Assault). Date/Time of Incident: 12/06/2025 at 10:53 PM. Date/Time of Discovery: 12/08/2025 at 9:20 AM. Patient #1 as Aggressor. Patient #2 as Victim. Incident Details revealed in part: Patient #1 reported that both he and Patient #2 requested a shared room, which was approved. They occupied the same room, took showers, and engaged in oral sex with each other before going to sleep. Patient #1 reported that he threw ice in Patient #2’s face after Patient #2 laughed at him. The following day, 12/08/2025, Patient #2 expressed anger about Patient #1 throwing ice at him. Patient #2 became upset that other kids in the unit knew about their alleged sexual activity and subsequently told the staff that Patient #1 raped him. Patient #1 - The patient observation status was Q15. The unit census was 13 (1 RN, 1 LPN, 2 BHA’s). Patient #2 - The patient observation status was Q15. The unit census was 13 (1 RN, 1 LPN, 2 BHA’s). Video Surveillance revealed in part: Video surveillance at incident site? Yes. Is Video recorded? Blank. If recorded, how long is recording maintained? 15 days. Has video been reviewed? Blank. If video was not reviewed, why not? N/A (Not Applicable). Names/titles/positions of ALL video reviewers: S3DRM. What was revealed on video? Blank. Comments Section: Blank. Investigation Results revealed in part: The investigation into the reported sexual allegation was unable to substantiate due to lack of evidence. On 12/08/2025, Patient #1 reported to S7RN, that he had engaged in oral sex with Patient #2 on 12/06/2025. Patient #2 denied any sexual activity with Patient #1 on 12/06/2025. On 12/08/2025, Patient #1 and Patient #2 were taken to the emergency room due to allegations of sexual intercourse. At Hospital ‘A’ Patient #2 reported to the physician that another patient from River Place Behavioral Health, named Patient #2, had attempted to pull his pants down on 12/06/2025, which he interpreted as an attempted sexual assault that he resisted. Patient #2 clarified that there was no actual penetration. No SANE examinations were conducted on Patient #2, as there had been no actual assault. Meanwhile, Patient #1 was sent to Hospital ‘B’ due to allegations of sexual intercourse. Patient #1 had a head-to-toe assessment completed, but not a full SANE exam. Guardians of both patients were notified and Sheriff’s department was informed. Sexually Acting Out precautions were added for both patients. Patient #2 was discharged on 12/08/2025, and returned home with his guardian, while Patient #1 remains inpatient at River Place Behavioral Health. In an interview on 01/20/2026 at 11:09 AM, S2DOQ confirmed that the Final Self-Report sections for “if video was reviewed” and “what video revealed” were left blank. S2DOQ confirmed that they did not have video available for the incident on 12/06/2025 saved for review. S2DOQ confirmed that S3DRM reviewed the video for the above-mentioned incident. S2DOQ brought the final report to S3DRM to inquire what the video revealed. In an interview on 01/20/2026 at 11:13 AM, S2DOQ returned to the surveyor with the following notes handwritten by S3DRM: Has video been reviewed? Yes was checked. What was revealed on video? Video footage reviewed. Rounds were not being completed to meet expectations. S2DOQ was asked to clarify what “rounds not being completed to meet expectations” meant. S2DOQ stated that staff were not rounding within the correct time frames. In an interview on 01/20/2026 at 12:38 PM, S3DRM was asked by surveyor what she viewed while reviewing video footage from 12/06/2025. S3DRM stated they could not view inside rooms due to patient rooms not having cameras. S3DRM stated video of hallway outside the room revealed the BHA’s were rounding, but there were gaps in their rounds. Surveyor asked S3DRM how long the gaps in rounding were. S3DRM was unable to give an exact time frame between gaps. S3DRM confirmed that on the night of 12/06/2025 staff were forcing their rounding entries and not visualizing Patient #1 and Patient #2 who were roommates. S3DRM clarified that forcing patient rounds meant that the BHA’s were not in proximity of the patients in order to visualize them while documenting their observation on the tablet. S3DRM further confirmed that a staff member was terminated as a result of the investigation. Review of Self-Report failed to reveal that Patient #1 had an order for Q 5 minute observations on date of incident, 12/06/2025. Self-Report failed to reveal Patient #1 punched Patient #2 in the face on 12/08/2025, after staff were made aware of incident. Further review of the Self-Report failed to reveal that staff were forcing their patient rounds, and not performing rounds per physician order. In an interview on 01/20/2026 at 3:46 PM, S1ICNO and S2DOQ confirmed that Patient #1 had orders for Q 5 minute observations on 12/06/2025 at the time of the incident involving Patient #1 and Patient #2. S1ICNO and S2DOQ further confirmed that Patient #1 was not being observed Q 5 minutes per physician orders.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50453 Based on record review and interview, failure of the nursing staff to update the care plan following an incident for 1 (#1) of 3 patient records reviewed. Findings: Review of hospital policy titled, “Precautions, Sexual Acting Out,” last approved 05/2025, revealed in part: POLICY: Provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior. Patients are educated upon admission that they have a responsibility to report any sexual verbal/physical abuse or threats of sexual abuse by others. If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place. PROCEDURE: 6. Risk of sexual acting out behaviors will be addressed in the Interdisciplinary Treatment Plan. Treatment plan will be updated as needed.” Review of the Hospital/Licensed Provider Abuse/Neglect Initial Report finalized on 12/22/2025 revealed in part that Patient #1 and Patient #2 were involved in an Alleged Sexual Abuse (Patient to Patient Sexual Assault) Incident on 12/06/2025. Review of Patient #1’s medical record revealed an admission date of 12/02/2025 and a discharge date of 12/22/2025. Patient #1’s nursing notes revealed in part the alleged sexual assault incident between Patient #1 and Patient #2 occurred on 12/06/2025. Further review of Patient #1’s medical record failed to reveal that Patient #1’s care plan was updated to include Sexual Acting Out precautions. In an interview on 01/21/2026 at 11:22 AM, S2DOQ confirmed that the plan of care for Patient #1 was not updated to include Sexually Acting Out precautions.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure the Registered Nurse (RN) assigned the nursing care of each patient. This deficient practice is evidenced by failing to ensure all patient care assignments were completed in accordance with hospital policy. Findings: Review of hospital policy titled “Assignment of Nursing Staff,” last approved 05/2025, revealed in part: “POLICY: To assure quality nursing care and a safe patient environment, nursing personnel staffing and assignments are based on at least the following: 1. A Registered Nurse assigned to each patient unit. 2. A Registered Nurse plans, supervises and evaluates the nursing care of each patient. 3. A Registered Nurse receives report before assigning appropriate aspects of nursing care to Nurses and Mental Health Associates. PROCEDURES: 1. Staffing assignments reflective of this policy will be completed at the beginning of each shift by the Charge Nurse. 2. Staffing assignments will be documented on the Staffing Assignment Sheet. 3. The name and title of the staff member to be assigned will be entered in the space provided. 4. The names of the patients assigned to the staff member will be entered in the space provided. 6. It is the responsibility of each staff member to review his/her assignment when it is completed. 7. The Assignment Sheet will be available to staff throughout the shift. 9. The Staffing Assignment Sheets will be reviewed and maintained by the CNO/DON.” Unit ‘A’ Patient Care Assignment Sheets for 12/04/2025 - 12/10/2025 were reviewed. Further review failed to reveal patient assignment/room numbers assigned to staff in the space provided for the following dates: 12/04/2025 day shift; 12/05/2025 day and night shift; 12/06/2025 day and night shift; 12/08/2025 day shift; 12/09/2025 day shift; and 12/10/2025 night shift. Review of Patient #1’s provider orders revealed the following order: One to One Psych Observation ordered on 12/08/2025 at 9:44 AM and discontinued on 12/09/2025 at 6:06 AM. Review of Patient Care Assignment Sheet dated 12/08/2025 night shift, failed to reveal that Patient #1 had an observation level of 1:1 with an assigned staff member. In an interview on 01/20/2026 at 3:02 PM, S1ICNO and S2DOQ confirmed that the above-mentioned patient care assignment sheets were not completed per hospital policy. S2ICNO and S2DOQ further confirmed that Patient #1 was not assigned 1:1 on the 12/08/2025 night shift Patient Care Assignment Sheet.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure that each patient’s medical record contained all documentation. This deficient practice is evidenced by failure of the nurse to document a disposition note on Patient #2. Findings: Review of hospital policy number LD-05, titled “Plan for Provision of Patient Care,” last revised: 01/2026, revealed in part: “III. DISCHARGE and POST-DISCHARGE PLANNING PROCESS: The physician and therapist, with the support of nursing, coordinate the discharge arrangements with the patient and family. The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, or discharged to include: reason for transfer, referral or discharge, patient’s physical and psychosocial status, summary of care provided and progress toward goals, and community resources and referrals provided to the patient. Transitions between levels of care are smooth and coordinated, involving communication to facilitate family support, social work, nursing care, consultations, and referrals.” Review of Patient #2’s medical record revealed Patient #2 was a 15 year old male with an admission date of 12/03/2025 for suicidal ideations. Patient #2 was discharged on 12/08/2025 at 7:30 PM, following an incident of alleged patient to patient sexual assault. Further review failed to reveal documentation by the nurse of the time the patient was discharged, documentation that the patient received discharge education/follow-up instructions, or documentation regarding who patient #2 was discharged into the care of. In an interview on 01/21/2026 at 12:02 PM, S2DOQ confirmed Patient #2’s medical record did not reveal documented evidence of the discharge instruction from the facility by the nurse. S2DOQ further confirmed that Patient #2’s medical record failed to reveal documented evidence that Patient #2 received education/follow-up instructions upon disposition.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 50453 Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. Findings: Observations during a tour of Unit A on 01/20/2025 from 9:02 AM - 9:40 AM revealed the following: Nurse Station: -Toilet paper stuck to top of wall inside nurse station. Room ‘a’: - Toilet paper stuck to ceiling. Room ‘b’: -Ceiling vent near window has brownish/red colored stains. Room ‘c’: -Ceiling vent covered in white/gray substance Room ‘d’: -Bathroom ceiling vent brown/gray fuzzy substance. Room ‘e’: -Bathroom overhead light missing 1 screw. -Toilet paper stuck to ceiling. -Bathroom ceiling vent brown fuzzy substance. Room ‘f’: -Room ceiling vent at entrance covered in white/gray substance. -Bathroom ceiling has multiple wads of toilet paper stuck to ceiling. -Bathroom ceiling vent brown/gray fuzzy substance. Room ‘g’: Bathroom vent has brownish/red colored stains. Room ‘h’: -2 holes in the wall with exposed sheet rock. Room ‘i’: -hole in wall of ante room behind door with exposed sheet rock. In an interview during the tour, S1ICNO confirmed the above-mentioned findings.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to inform 1 (#3) of 3 (#1-#3) patients, or when appropriate, the patient’s representative, of the patient’s rights, in advance of furnishing patient care. Findings: Review of hospital policy “Title: Patient Rights, No: RR-07, Date of Last Revision: 6/2023” revealed, in part: “Policy: The Hospital protects and promotes patient’s rights that are extended to all patients and prohibits discrimination. It is the policy of the Hospital to ensure that patient rights are communicated to all patients and their legal guardian and employees to avoid any misunderstanding of those rights, and to provide a list of patients’ rights to all patients or their legal guardian upon admission. Procedure: 1. The following rights shall be afforded to all patients and are not subject to modification: a. Patients have the right to be fully informed before or upon admission about their rights and responsibilities and about any limitation on these rights imposed by rules of the hospital.” Review of Patient #3’s medical record revealed an admission date of 08/28/2025. Further review failed to reveal evidence that Patient #3 or their representative was informed of their patient rights. In an interview on 09/03/2025 at 1:38 PM, S3Patient Advocate confirmed Patient #3’s medical record failed to reveal evidence they or their representative was notified of their patient rights.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to ensure the patient right to make informed decisions regarding his or her care. This deficient practice was evidenced by failing to obtain informed consent for treatment form for 1 (#3) of 3 (#1-#3) sampled patients. Findings: Review of hospital policy “Title/Subject: Admission Procedure-Intake Office, Policy Number: IN-010, Revision Date: 1/23” revealed, in part: “II. Purpose. To ensure that the individual meeting criteria for hospitalization are informed, knowledgeable, and consent to Formal Voluntary Admission and treatment in a psychiatric setting, they also agree to abide by outlined rules and regulations and to follow the course of treatment prescribed by the attending physician. III. Procedure. The Intake Coordinator or intake designee will: H. Intake Coordinator or Designated unit staff will notify patient and family on the forms in the admission packet and obtain patient’s consent on the following: Formal Voluntary or Non-contested Admission, Conditions of Admission, Acknowledgment of Notification of Rights, Notice of Advanced Directives, Addendum to consent for Admission and Conditions of Admission Form Regarding Advance Directives.” Review of Patient #3’s medical record revealed an admission date of 08/28/2025. Further review failed to reveal evidence that Patient #3 or their representative signed an informed consent for treatment. In an interview on 09/03/2025 at 1:41 PM, S3Patient Advocate confirmed Patient #3’s medical record failed to reveal evidence they or their representative signed informed consent for treatment.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice was evidenced by failing to ensure all patient care staff (S4LPN) completed mandatory training after an event where a patient (#1) experienced a medical emergency for 1 (#1) of 3 (#1-#3) sampled patients. Findings: Review of the hospital’s LDH Self-Report dated 07/31/2025 revealed, in part, Patient #1 experienced altered mental status on 07/31/2025 at 12:18 PM that resulted in a Code Blue and Medical Send Out. Review of the hospital investigation revealed S4LPN was present during the event. The hospital substantiated the allegation and found that there was a delay of calling the code blue and getting additional assistance to the patient. Further review revealed, in part: “On August 12th and August 14th, the organization held a Town Hall Meeting that provided all 100% of staff training which covered the following: Mission and Vision of the Organization; Patient Safety; Shift-to-Shift Rounding; The ObservSMART Value; Zero Tolerance; Hospital Codes (Code Green, Blue, White Yellow, and etc.); Incident Reporting (Levels of Incident Reporting and Reductions); Compliance; Risk Management. The organization will complete additional staff training on utilizing the ROAR/Panic Button technology. 100% of staff will be trained. The organization will be also training the staff on the following policies and procedures: Code Blue; Early Response; Emergency Response.” Review of hospital 08/12/2025 and 08/14/2025 Town Hall Meeting and Educational Attendance Roster revealed no evidence S4LPN attended the training. Review of hospital nursing staff revealed S4LPN currently employed by the hospital. In an interview on 09/03/2025 at 8:33 AM, S2Interim CNO confirmed S4LPN still employed by hospital. S2Interim CNO confirmed that S4LPN did not complete the hospital staff training on 08/12/2025 or 08/14/2025.”

“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: 14442 Based on record review and interview, the hospital failed to ensure the Quality Assessment and Performance Improvement program measured, analyzed, and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure results of code blue evaluations were submitted to the performance improvement committee as stated in hospital code blue policy. Findings: Review of hospital policy “Title: Code Blue, No: POC-11, Date of Last Revision: 10/2023” revealed, in part: “Code Blue Drills. The CNO/designee will conduct Code Blue drills each shift, minimum quarterly. The Code Blue drill event will be documented on the Code Blue Record. The Code Blue drills will be evaluated through completion of the Code Blue Evaluation form by the Registered Nurse. The Code Blue Evaluation will be reviewed by the CNO to identify training needs, process issues, etc. Results of the evaluations will be submitted to the Performance Improvement Committee and Medical Executive Committee.” In an interview on 09/03/2025 at 10:50 AM, S2Interim CNO confirmed the hospital had no evidence results of code blue evaluations were submitted to the Performance Improvement Committee.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 14442 Based on record review and interview, the registered nurse failed to supervise the care provided to each patient. The deficient practice was evidenced by failure of the RN to conduct code blue drills each shift, minimum quarterly as stated in hospital code blue policy. Findings: Review of hospital policy “Title: Code Blue, No: POC-11, Date of Last Revision: 10/2023” revealed, in part: “Code Blue Drills. The CNO/designee will conduct Code Blue drills each shift, minimum quarterly. The Code Blue drill event will be documented on the Code Blue Record. The Code Blue drills will be evaluated through completion of the Code Blue Evaluation form by the Registered Nurse. The Code Blue Evaluation will be reviewed by the CNO to identify training needs, process issues, etc. Results of the evaluations will be submitted to the Performance Improvement Committee and Medical Executive Committee.” In an interview on 09/03/2025 at 8:33 AM, S2Interim CNO confirmed for year 2025, hospital had no evidence Code Blue drills conducted quarterly each shift as stated in hospital Code Blue policy.”

“Neurological Examination CFR(s): When indicated, a complete neurological examination must be recorded at the time of the admission physical examination. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to ensure a complete neurological examination was recorded at the time of the admission physical examination. This deficient practice was evidenced by failing to have a complete neurological assessment with examination of Cranial Nerves I-XII for 1 (#3) of 3 (#1-#3) sampled patients. Findings: Review of hospital policy “Title/Subject: Assessment/Reassessment, Policy Number: NSG 03, Revision Date: 3/2024” revealed, in part: “Policy: All patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the interdisciplinary team to prioritize identified problems within the Interdisciplinary Treatment Plan. Procedure: 3. History and Physical. a. Within the first twenty-four (24) hours of the patient’s admission, a practitioner will complete a history and physical examination and shall include a neurological examination. The following shall be included in the History and Physical documentation: xi. Cranial Nerves Examination I-XII-in detail and how tested for each.” Review of Patient #3’s medical record revealed an admission date of 08/28/2025. Further review of Patient #3’s history and physical and medical record revealed no evidence of complete neurological assessment with examination of Cranial Nerves I-XII. In an interview on 09/03/2025 at 11:54 AM, Interim CNO confirmed Patient #3’s medical record failed to reveal evidence of complete neurological assessment with examination of Cranial Nerves I-XII.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44495 Based on observation and interview, the facility failed to ensure care in a safe setting. The deficient practice is evidenced by the finding of items considered contraband on the unit. Findings: Tour of the facility, on 04/14/2025 between 9:50 AM and 10:05 AM, revealed a backpack and a lunch bag that belonged to staff stored on a shelf in a patient room, an Inspire remote with a battery in a patient room, and the plastic cover from the television remote in the day room. In interview at the time of discovery, S1Adm and S2CNO verified the objects had the potential for harm should not have been left unmonitored on the unit. S1Adm also verified the remote for the Inspire unit needed to be secured to prevent theft and ensure availability for the patient with the implant while sleeping.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to ensure compliance with reporting of potential abuse and neglect. The deficient practice is evidenced by failure of the facility to submit and initial report to Louisiana Department of Health within 24 hours of becoming aware of an event involving potential abuse or neglect. Findings: Review of the form “Self-Reporting Process for Hospitals - Abuse/Neglect,” revised 12/01/2024, revealed in part, “Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.” Further review of the document revealed, “The initial and final reports shall be emailed to hsshospitalself-reports@la.gov via an encrypted/secure email. As indicated above, the initial report must be submitted within 24 hours of awareness of the incident/allegation/suspicion. Since hospitals must operate 24 hours a day, seven days a week, no adjustment is made to accommodate weekends or holidays. In other words, if an event is noted to occur (or an allegation is received) on Friday at 10:30 p.m., the initial report shall be emailed no later than Saturday at 10:30 p.m. E-mails are automatically tagged with the date and time of receipt, providing proof that reports were submitted in a timely manner. The e-mail address listed below is relevant to hospitals only.” Review of an initial report submitted on 03/26/2026 to Louisiana Department of Health (LDH) revealed an incident that involved potential neglect by nursing staff and occurred on 03/23/2025 during the day shift. Further review revealed the date of discovery as 03/24/2025 and the initial report was submitted to LDH on 03/26/2025. In interview on 04/14/2025 at 3:51 PM, S4RMC verified the submission of the initial report was not within 24 hours of awareness of the event.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure restraints were documented according to hospital policy and standard of care. The deficient practice is evidenced by failure of the nursing staff to document an order for a therapeutic hold anddocument the use of a restraint in the patiet record for 1 (#R2) of 1 reviewed record with the use of a restraint. . Findings: Review of a self-reported incident that occurred 04/02/2025 at 10:35 AM revealed Patient #R2 was in an altercation with another patient. The two patients were separated and Patient #R2 “was placed in a short therapeutic hold and then brought to the seclusion room (door open) where he was given a PRN medication and allowed to self-calm.” Review of the medical record for #R2 failed to reveal an order or documentation of the restraint. In interview on 04/14/2025 at 12:39 PM, S2CNO verified a therapeutic hold was used and the nursing staff failed to document a verbal order and failed to fill out the documentation required after the use of a restraint.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to identify deviations from hospital policy affecting patient safety. The deficient practice is evidenced by failure the hospital to identify neglect when a patient with orders for one to one observation was left alone in her room. Findings: Review of the policy POC-28, “Observations, Patient,” revised 02/2025, revealed in part, “1:1 Observation- . . . .Staff are to remain within visual range and close proximity (easy reach) of patient at all times.” Review of an incident that occurred on 03/23/2025 at 1:15 PM and self-reported to the Louisiana Department of Health, revealed the reviewer of the incident verified the nurse providing ordered one to one care a patient for a patient left the patient alone in the room for 20 seconds while the nurse went to the nursing station. The reviewer of the incident concluded that the allegation of neglect could not be substantiated and staff followed the one to one policy. In interview on 04/14/2025 at 10:45 AM, S2CNO verified there was neglect when the nurse left the patient in the room alone.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 44495 Based on record review and interview, the registered nurse failed to supervise the care provided to each patient. The deficient practice is evidenced by failure of the RN to enter the precautions for 8(#2, #3, #R3, #R4, #R5, #R6, #R7, #R8) of 9 (#2, #3, #R3, #R4, #R5, #R6, #R7, #R8, #R9) patients with special precautions into the patient observation system to ensure the BHA knew the special precautions for monitoring each patient. Findings: During tour of the facility on 04/14/2025 between 9:50 AM and 10:05 AM, S5BHA was asked about the precautions ordered for Patient #3. S5BHA checked the tablet used for tracking the patients but the precautions for Patient #3 had not been entered into the system.S5BHA verified she did not know what precautions were ordered for Patient #3. Further review of the list of patients on the unit revealed precautions were not listed for 8 of 9 patients. Review of the daily census for the unit revealed the following precautions for each patient: Patient #2-Suicide, assault, and fall; Patient #3- Suicide precautions #R3- Suicide, seizure, and fall; #R4- Suicide #R5- Assault and suicide #R6- Assault and suicide #R7- Assault and suicide #R8- Suicide #R9- Suicide, seizure, and fall In interview on 04/14/2025 at 10:15 AM, S2CNO verified the nurse had not put the precautions in the system to assist the BHAs in their observations.”

“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: 44495 Based on record review and interview, the hospital failed to ensure the Registered Nurse (RN) assigned patients to the BHAs on each shift. The deficient practice is evidenced by and incompletely filled out assignment sheet for one of three days reviewed. Findings: Review of the requested “Unit Assignment” sheets revealed the sheets were organized in a binder for each day of the current month. Review of the second sheet in the binder revealed the charge nurse on 04/01/2025 for the day shift revealed there were 25 patients on the unit. Further review revealed the listed staffing included the charge nurse, 1 LPN, and 1 BHA assigned to a one to one. The assignment sheet did not list the other BHA’s working that day or which patients each was assigned to observe. There was only a note that read, “See attached Census dated 04/01/2025.” In interview on 04/14/2025 at 2:02 PM, S3NS verified that the nurse should have listed all working staff on the sheet and indicated which BHAs were assigned to each patient on the census if she did not have time to list all 25 patients on the assignment sheet.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 44495 Based on record review an interview, the registered nursed failed to ensure the nursing staff followed all hospital policies for patient care. The deficient practice is evidenced by failure to perform neurological checks after a patient was kicked in the head during an altercation. Findings: Review of the policy, POC-06, “Assessment, Neurological,” last revised 02/2024, revealed in part, “POLICY- Neurological assessment will be initiated when a patient has sustained a head injury, had a change in level of consciousness, un-witnessed fall or per practitioner order.” Further review of the policy revealed the assessment was to include a documentation of level of consciousness, pupillary size and reaction, vital signs, handgrip, speech and responsiveness. Evaluations were to be performed every 15 minutes for one hour, the every thirty minutes for 1 hour, then every hour for 4 hours, then every 4 hours for 4 checks, and the every eight hours for 6 checks. Review of an incident self-reported to the Louisiana Department of Health revealed on 04/08/2025 at 9:15 AM a patient grabbed Patient #R1 by the hair, struck her in the head and then kicked her in the head. Patient #R1 denied any injury after the incident. Review of documentation by the nurse on 04/08/2025 at 1:04 PM revealed Patient #R1 complained of mild head pain but no injuries were noted. The physician was notified. Review of the progress note by the licensed practitioner on 04/08/2025 at 3:02 PM revealed the patient was evaluated and acetaminophen was ordered for the headache. In interview on 04/14/2025 at 12:15 PM, S3NS verified the nursing staff did not perform neurological checks on Patient #R1 who was hit and kicked in the head and there was no documentation that the licensed practitioner had given orders that the assessments were not needed.”

“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 registered nurse failed to administer medications according to hospital policy. The deficient practice is evidenced by failure to reassess the patient in 2 (#2, #3) of 3 (#1, #2, #3) reviewed records after a PRN (as needed) medication was administered. Findings: Review of policy POC-07, “Assessment/Reassessment,” last revised 02/2023, revealed in part, “Additionally, reassessments of patient response to PRN medications shall be documented post intervention. Documentation shall include the patient’s response to the intervention as well as presence of negative side effects (or lack thereof).” Review of the medical record for Patient #2 revealed an order for Melatonin tablet; 6 milligrams; Oral; Nightly PRN for insomnia. Further review revealed the melatonin was administered on 04/13/2024 at 8:42 PM and the nurse failed to document a follow-up assessment for effectiveness. Review of the medical record for Patient #3 revealed an order for Melatonin tablet; 6 milligrams; Oral; Nightly PRN for insomnia. Further review revealed the melatonin was administered on 04/11/2024 at 8:14 PM and the nurse failed to document a follow-up assessment for effectiveness. In interview during the record review on 04/14/2025 at 11:59 AM, S3NS verified the nurse failed to reassess Patient #2 after the administration of the PRN melatonin. At 1:43 PM S3NS verified the nurse failed to reassess Patient #3 after the administration of PRN melatonin.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by failure of the hospital staff to perform timely observation rounds for 2 (#1, #2) of 3 (#1-#3) patients sampled resulting in the 2 (#1, #2) patients to have sexual intercourse. Findings: Review of the hospital policy and procedure titled, “Observations, Patient, No: POC-28” last revised in November 2023, revealed, in part: “In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse. Procedure: The physician will order one of three levels of observation at time of admission and as the patient’s condition warrants a change: 15 minute check (Q15), 5 (Q5) minute check, One-to-one. Q15 Minute Rounds: All patients are monitored at minimum once in every 15 minute block of time. Q5 Minute Rounds: All patients are monitored at minimum once in every 5 minute block of time.” Review of Patient #1’s medical record revealed Patient #1 was admitted to Unit “a” on 02/24/2025 under a Physician’s Emergency Certificate and the diagnosis of unspecified psychotic disorder. Patient #1 had a physician level of observation order for Q5 minute check. Review of Patient #2’s medical record revealed Patient #2 was admitted to Unit “a” on 02/22/2025 under a Physician’s Emergency Certificate and the diagnoses of bipolar disorder, severe with psychotic features. Patient #2 had a physician level of observation order for Q15 minute check. Review of the “Hospital/Licensed Provider Abuse/Neglect” form revealed, in part, on 02/25/2025 at 8:15 PM Patient #1 and Patient #2 were found by staff engaging in sexual intercourse. In an interview on 03/24/2025 at 11:24 AM, S2Director of Risk Management confirmed Patient #1 and Patient #2 were found by staff engaging in sexual intercourse on 02/25/2025. S2Director of Risk Management confirmed Patient #1 had an order for Q5 minutes observation rounds and Patient #2 had an order for Q15 minutes observation rounds. S2Director of Risk Management confirmed hospital staff missed three observation rounds for Patient #1 and one observation round for Patient #2. S2Director of Risk Management confirmed the incident on 02/25/2025 between Patient #1 and Patient #2 occurred during the time of missed observation rounds.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to ensure a registered nurse (RN) supervised the care for each patient. This deficient practice was evidenced by failure of the registered nurse to supervise staff to ensure timely observation rounds performed for 2 (#1, #2) of 3 (#1-#3) patients sampled resulting in the 2 (#1, #2) patients to have sexual intercourse. Findings: Review of the hospital policy and procedure titled, “Assignment of Nursing Staff, No: NSG-01”” last revised in February 2023, revealed, in part: “To assure quality nursing care and a safe patient care environment, nursing personnel staffing and assignments are based on at least the following: A registered nurse plans, supervises and evaluates the nursing care of each patient.” Review of the hospital policy and procedure titled, “Observations, Patient, No: POC-28” last revised in November 2023, revealed, in part: “In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse. Procedure: The physician will order one of three levels of observation at time of admission and as the patient’s condition warrants a change: 15 minute check (Q15), 5 (Q5) minute check, One-to-one. Q15 Minute Rounds: All patients are monitored at minimum once in every 15 minute block of time. Q5 Minute Rounds: All patients are monitored at minimum once in every 5 minute block of time.” Review of Patient #1’s medical record revealed Patient #1 was admitted to Unit “a” on 02/24/2025 under a Physician’s Emergency Certificate and the diagnosis of unspecified psychotic disorder. Patient #1 had a physician level of observation order for Q5 minute check. Review of Patient #2’s medical record revealed Patient #2 was admitted to Unit “a” on 02/22/2025 under a Physician’s Emergency Certificate and the diagnoses of bipolar disorder, severe with psychotic features. Patient #2 had a physician level of observation order for Q15 minute check. Review of the “Hospital/Licensed Provider Abuse/Neglect” form revealed, in part, on 02/25/2025 at 8:15 PM Patient #1 and Patient #2 were found by staff engaging in sexual intercourse. In an interview on 03/24/2025 at 1:02 PM, S2Director of Risk Management confirmed that the RN was responsible for ensuring observation rounds were conducted as ordered. S2Director of Risk Management confirmed Patient #1 and Patient #2 were found by staff engaging in sexual intercourse on 02/25/2025. S2Director of Risk Management confirmed hospital staff missed three observation rounds for Patient #1 and one observation round for Patient #2. S2Director of Risk Management confirmed the incident on 02/25/2025 between Patient #1 and Patient #2 occurred during the time of missed observation rounds. S2Director of Risk Management confirmed the RN did not effectively supervise staff to ensure timely observation rounds were performed.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure patients were kept free of all forms of abuse or harassment. This deficient practice is evidenced by the hospital failing to report potential allegations of abuse/neglect related to 2 (#3, #4) of 2 (#3, #4) patients reviewed for elopement to LDH-HSS (Louisiana Department of Health - Health Standards Section) within 24 hours of the awareness of this potential allegation. Findings: Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed “Department” shall mean the Department of Health and Hospitals. “Unit” means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, “Abuse” is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report. Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. A review of incident logs from 01/01/2024 to 07/01/2024 revealed Patient #3 eloped on 06/24/2024 and Patient #4 eloped on 06/24/2024. A review of the hospital’s self-reports to LDH-HSS did not reveal the elopements being self-reported. In an interview on 07/01/2024 at 3:15 p.m. S3DQRM confirmed the above mentioned findings.”

“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, policy review and interview, the hospital failed to follow hospital policy and standard of care for medication administration. The deficient practice was evidenced by nursing personnel failing to follow up on the effectiveness of as needed (PRN) medication administration in 1 (#2) of 3 (#1-#3) reviewed medical records. Findings: A review of facility policy, “Assessment/Reassessment,” Policy NO: POC-07 with an Original Date of Issue: 09/2017 and Date of Last Revision: 02/2023, revealed in part, Policy: All patients admitted to the hospital will receive a thorough assessment and evaluation. Reassessments: “ ...each patient is reassessed as necessary based on the patient’s plan for care or change in their condition, including change in the patient’s level of paint. Reassessment are also to be based on the patient’s diagnosis; desire for care, treatment and services, response to previous care, treatment and services. In addition, the reassessment and reassessment information includes the patient’s perception of the effectiveness of, and any side effects related to their medication.” A review of facility policy, “Medication Administration and Records,” Policy Number: PHR-159, with an Origination Date: 09/2017 and no revisions, revealed in part, 2.0 Statement of Policy: 2.1 Guidelines for proper documentation of administered medications, omitted medications, and response to as needed (PRN) medications will be outlined. 4.2 Medication Administration Procedure: 4.2.3 Analgesic Therapy and As Needed Medication Monitoring: All medications that have been administered PRN must also have documentation of the result and effectiveness. A review of Patient #2’s electronic medical record (EMR) revealed a nursing note from 06/30/2024 at 4:15 p.m. with S5RN documenting, “ ... pt (patient) having chills. T 101.9. Will notify MD.” A nursing note created on 07/01/2024 at 7:07 p.m. and signed on 07/01/2024 at 7:08 p.m. was entered for 06/30/2024 for 4:24 p.m. and documented by S5RN, “This nurse sent message to S6NP, re: pt symptoms. Waiting on response.” A review of medications revealed the administration of acetaminophen 650mg tablet on 06/30/2024 at 4:27 p.m. for a temperature of 101.9º F (38.8º C). The View Flowsheet revealed a documented temperature of 101.9º F on 06/30/2024 at 4:15 p.m. There was no documentation related to a follow up of the effectiveness of the administration of the acetaminophen or contact being made with the provider. The next documented temperature of 103.1º F (39.5º C) was on 06/30/2024 at 9:31 p.m. and this was the first documentation related provider acknowledgement of the patient having an elevated temperature. This was over 5 hours from the time of initial elevated temperature and the acetaminophen administration. In an interview on 07/02/2024 at 1:00 p.m. S3DQRM 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 hospital environment in such a manner to ensure the safety and well-being of patients. This deficient practice was evidenced by the discoloration and liquid staining of ceiling tiles of Room #i. Findings: Observations during a tour of the hospital on 07/01/2024 from 10:30 a.m. to 11:45 a.m. revealed the medication room of Room #i having 4 ceiling tiles surround a ventilation duct being discolored and liquid stained. In an interview during the tour, S2CNO confirmed the 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: 48051 Based on observation, policy review, and interview, the hospital failed to maintain all equipment in a manner to ensure an acceptable level of safety and/or quality. This deficient practice was evidenced by the hospital failing to ensure glucometer control testing was performed on 1 (Room #l) of 3 (Rooms #i, #l, #m) glucometers reviewed for quality control testing. Findings: A review of the FreeStyle Precision Pro Operator’s Manual revealed Item 4-1 Operating Guidelines for Control Solution Testing: When To Test with Control Solutions: As required by your facility’s quality policy. A review of hospital policy, “Waived Testing,” no policy number, with an Original Date of Approval: 04/2023 and Date of Last Revision: 07/03/2023 revealed in part, Policy: The hospital performed quality control checks for waived testing on each procedure. The hospital maintains records for waived testing. The following waived tests are performed at this hospital: 6. Blood Glucose Monitoring. Procedure: c. If manufacturers’ manuals or package inserts are used as the policies or procedures for each waived test, they are enhanced to include specific operational policies (that is, detailed quality control protocols and any other institution specific procedures regarding the test or instrument). The hospital did not provide written information regarding the frequency of performing the quality control testing. The above mentioned policy and operator’s manual referred to one another as to the frequency. A review of the Room #l’s Glucometer Log for 06/2024 revealed 10 (06/13 - 06/17/2024, 06/22 - 06/23/2024, 06/28 - 06/30/2024) of 30 (06/01 - 06/30/2024) days missing documentation of a quality control performance. In an interview on 07/01/2024 at 10:35 a.m. S2CNO confirmed the above mentioned findings. Further S2CNO confirmed the quality controls should be performed daily.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to ensure the hospital environment was maintained in a clean and sanitary condition to avoid sources and transmission of infection. This deficient practice was evidenced by: 1) Failing to ensure the hospital was maintained in a clean and sanitary condition; and 2) Failing to ensure all equipment was maintained in a clean and sanitary condition. Findings: 1) Failing to ensure the hospital was maintained in a clean and sanitary condition Observations during a tour of the hospital on 07/01/2024 from 10:30 a.m. to 11:45 a.m. revealed the following conditions that would prohibit the proper sanitary cleaning in patient care areas: A. Cracked and peeling mattress coverings located in Rooms #a, #b, #f, #j, and #k; B. Black substances in the grove between the shower pan and wall coverings of the showers located in Rooms #d, #f, and #g; C. The top surface of 2 nightstands were swollen, bubbled/blistered, and cracked in Room #j; D. The metal coverings surrounding the packaged thermal air conditioners (PTAC) contained a brown substance that resembled rust in Rooms #b, #c, #d, #e, #f, #j, and #k; and E. Peeling and chipped paint and wall damage exposing the underlying dry wall in Room #b to the left the entry door, Room #h to the right of phone #1 and phone #2, and Room #j to the right of the bathroom mirror. In an interview during the tour, S2CNO confirmed the above mentioned findings. 2) Failed to ensure all equipment was maintained in a clean and sanitary condition Observations during a tour of the hospital on 07/01/2024 from 10:30 a.m. to 11:45 a.m. revealed a FreeStyle Precision Pro Glucose Meter in Room #l nursing station with tape and sticky substance on the outside covering. This would prohibit the proper sanitary cleaning of this glucose meter. In an interview during the tour, S2CNO confirmed the above mentioned finding.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 14442 Based on record reviews and interview, the hospital failed to ensure the registered nurse supervised the care of each patient. This deficient practice was evidenced by failure of the registered nurse to ensure correct documentation of level of observation for sexual acting out precautions for 1 (#1) of 4 (#1 - #4) sampled patients. Findings: Review of the Hospital policy titled Observations, Patient, dated 11/2023, revealed in part: Policy: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse. Procedure: The physician will order one of three levels of observation at time of admission and as the patient’s condition warrants a change: 15 minute check; 5 minute check; one-to-one. The physician may also order a precaution level of observation for: Sexual Acting Out. Documentation of Observations: Staff documents all levels of observation in the medical record. Each entry is to include the following ...Level of observation, Precautions, Location, Behavior, and Activity. Patient #1 Review of Patient #1’s medical record revealed an admit date of 01/13/2024. On 01/19/2024, Patient #1’s level of observation increased from Q (every) 15 minute check to Q 5 minute check and then one-to-one for sexual acting out behaviors. On 01/20/2024, Patient #1’s level of observation changed to Q 5 minute check for sexual acting out behaviors and remained at that level until discharge 02/01/2024. Further review for Patient #1 revealed an incident dated 01/27/2023 at 19:00. Review of this incident revealed Patient #1 and Patient #2 reported to staff that they had engaged in consensual sexual intercourse on 01/24/2024. Review of Patient #1’s Observations Sheets dated 01/26/2024, 01/28/2024, 01/29/2024, 01/30/2024, and 02/01/2024 revealed level of observation check every 5 minutes. Further review of these Observations Sheets revealed the box for monitoring sexual acting out precautions was not checked. In an interview on 02/27/2024 at 9:33 a.m., S2Director of Risk Management confirmed the registered nurse was responsible for ensuring the correct precautions were checked on patient Observation Sheets. S2Director of Risk Management confirmed Patient #1 had sexual acting out behaviors and sexual acting out precautions should be checked on the observation sheets. S2Director of Risk Management confirmed this was not done for Patient #1 on the above dates.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 14442 Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to address sexual acting out behaviors on the care plan for 2 (#1, #4) of 4 (#1 - #4) sampled patients. Findings: Review of the hospital policy titled Treatment Planning, dated 10/2023 revealed in part: Policy: Each patient’s treatment shall be guided by the interdisciplinary treatment plan. The treatment plan is the tool used by the physician and interdisciplinary treatment team to implement the physician ordered services and move the patient toward the expected outcomes and goals. Procedure: 3.0 Guidelines of Treatment Plans: 3.1 The treatment plan shall be an accurate and functional representation of the patient’s treatment experience. Patient #1: Review of Patient #1’s medical record revealed an admit date of 01/13/2024. On 01/20/2024, Patient #1’s level of observation changed to Q 5 minute check for sexual acting out behaviors and remained at that level until discharge 02/01/2024. Further review for Patient #1 revealed an incident dated 01/27/2023 at 19:00. Review of this incident revealed Patient #1 and Patient #2 reported to staff that they had engaged in consensual sexual intercourse on 01/24/2024. Review of Patient #1’s treatment plan revealed the plan did not address sexual acting out precautions and behaviors. In an interview on 02/27/2024 at 9:48 a.m., S2Director of Risk Management confirmed Patient #1 had sexual acting out behaviors that started soon after admit. S2Director of Risk Management confirmed Patient #1’s treatment plan did not address sexual acting out precautions and behaviors. Patient #4 Review of Patient #4’s medical record revealed an admit date of 02/21/2024. Patient #4 had precautions for sexual acting out behaviors. Review of Patient #4’s treatment plan revealed the plan did not address sexual acting out precautions and behaviors. In an interview on 02/28/2024 at 12:49 p.m., S2Director of Risk Management confirmed Patient #4 had sexual acting out behaviors since admit. S2Director of Risk Management confirmed Patient #4’s treatment plan did not address sexual acting out precautions and behaviors.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47397 Based on observation, record review, and interview the facility failed to meet the requirements for the Condition of Participation (CoP) for Patients’ Rights. This deficient practice is evidenced by: 1) failure to provide appropriate staffing to ensure care in a safe setting(see findings under Tag A0144); 2) failure to ensure patients admitted into hospital did not have potentially harmful contraband in their possession(see findings under Tag A0144); 3) failure to ensure nursing staff recognized ligature risks in a patient with suicidal ideations (see findings under Tag A0144); 4) failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients with safety risks (see findings under Tag A0144); 5) failure to provide medical attention in a timely manner(see findings under Tag A0145) and 6) failure to monitor and thereby prevent Patient #2, who was on “assault” and “sexual acting out” precautions, from attacking Patient #1 which likely led to Patient #1’s fractured shoulder (see findings under Tag A0145).”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47397 Based on record review, observation, and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by: 1) Failure of nursing services to meet the staffing ratios required to provide a safe environment for patients (See findings under Tag A0392), and 2) Failure of nursing services to ensure a Registered Nurse completed all patient care assignments at the beginning of each shift (See findings under Tag A0397).”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure every patient, or his/her designated representative, shall whenever possible, make informed decisions regarding his or her care. This deficiency is evidenced by failure to have Patient #1 or her representative sign a written consent form prior to transfer to another facility. Findings: Review of Hosptial policy titled, “EMTALA”, dated 09/2017, revealed, in part: Policy, in part: It is the policy of this Hospital to assess, stabilize and transfer persons who present with an emergency medical condition relative to their presenting clinical condition. Purpose: To provide guidelines which meet the requirements and associated responsibilities for the treatment and transfer of individuals ....Forms, in part: Consent for Transfer. Procedure, in part: 1. any person who presents to the Hospital will be evaluated to determine whether the person has an emergency medical condition. If so, the patient must be stabilized, and/or appropriately transferred. 2. Emergency Medical Condition, in part: The following criteria shall be used to determine whether such an emergency exists: a. ...an acute medical condition that without immediate medical attention, could reasonably be expected to result in serious jeopardy of the health of an individual ...or serous impairment or dysfunction of any bodily organ or part. 12. Notice to Patient. a. The individual or the individual’s representative if any is present, must be notified of the transfer and of the reasons for such transfer. The individual’s acknowledgment of such notification should be reflected in an appropriate “Request/Consent for Transfer” form. Review of Patient #1’s Medical record revealed an admit date of 01/26/2024. Further review revealed an incident report dated 01/30/2024 detailing an incident that occurred on 01/30/2024 at 11:15 a.m. At approximately 11:15 a.m. on 01/30/2024, a sudden outburst was heard from hallway, upon further observation patient was seen on floor being repeatedly hit by a peer who was on top of her yelling and cursing. Altercation was broken up by the maintenance staff. The patient complained of hitting her right shoulder on the floor when she was attacked. Redness and limited range of motion was noted to the site. Medical provider ordered a mobile xray of the right shoulder at 11:30 a.m. Review of Patient #1’s mobile xray findings signed by radiologist at 01/30/2024 at 5:04 p.m. and received by hospital at 6:05 p.m., revealed suspected nondisplaced fracture of greater tuberosity. Review of January 2024’s Hospital Transfer list revealed Patient #1 was transferred to an Emergency Department on 01/30/2024 at 7:15 p.m. Review of Patient #1’s Medical Record revealed an Authorization to Disclose Healthcare Information dated 01/27/2024. Continued review revealed signed permission to disclose treatment information to a specific individual with the contact’s phone number documented. Review of Patient #1’s Medical Record failed to reveal evidence of a signed consent for transfer. Continued review failed to reveal Patient #1’s contact was notified of the transfer and of the reasons for such transfer. In an interview on 02/20/2024 at 1:25 p.m., S4RM confirmed Patient #1’s medical record failed to reveal a signed consent for transfer. S4RM verified Patient #1’s medical record failed to reveal her contact was notified of the transfer and of the reasons for such transfer.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by: 1) failure to provide appropriate staffing to ensure care in a safe setting; 2) failure to ensure patients admitted into hospital did not have potentially harmful contraband in their possession; 3) failure to ensure nursing staff recognized ligature risks in a patient with suicidal ideations; 4) failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients with safety risks; 5) failure to ensure that ordered levels of observations were implemented per Hospital policy for 5 (#R1-#R5) of 5 (#R1-#R5) patients reviewed for observation levels. Findings: 1) Failure to provide appropriate staffing to ensure care in a safe setting. Review of hospital policy titled “Assignment of Nursing Staff”, dated 02/2023, revealed, in part: Policy, in part: To assure quality nursing care and a safe patient environment ... Review of Hospital incident reports dated 01/28/2024-02/19/2024 revealed 12 falls unobserved by staff and 10 incidents regarding patient-to-patient attacks. Review of Hospital Grievance Communication Form completed by Patient R8 on 11/27/2023 revealed the following: Patient R8 was located on Unit D and admitted for less than 48 hours and had seen 3 fights all with males. Patient R8 reported that there were only female workers on the unit and the place was not safe for the female workers or female patients. Patient R8 wrote that she would be looking for someone on a higher level to address this issue. Patient R8 planned to follow up on this matter. Patient R8 reported she would like to be transferred to a different hospital or home because the place was not safe. Patient R8 would be reaching out to the news outlets about this situation because it was a major issue. Review of Hospital response to Patient R8’s complaint revealed, in part: ....We were unable to substantiate this allegation. When compared to other psychiatric hospitals in this region, this hospital has low incidents. Review of incident reports revealed two incidents involving patient attack and patient injury that occurred on 11/27/2024 on Unit D. In an interview on 02/20/2024 at 10:50 a.m., S4RM confirmed the incidents and stated that she recognizes there is an increased trend of unobserved falls and patient-to-patient attacks. In an interview on 02/20/2024 at 10:53 a.m. S4RM stated that she and S1CNO asked for increased staffing in December of 2023 due to increasing trends related to patient safety and staffing. S4RM and S1CNO reported they have created action plans to measure staffing ratio versus acuity levels with plans to present results to upper management. 2) Failure to ensure patients admitted into hospital did not have potentially harmful contraband in their possession. Review of Hospital Incident Report Form dated 12/12/2024 revealed 5 sewing needles (labeled as Contraband/Weapons) were found in Patient R9’s room. Review of grievance/complaint/Self-Report log failed to reveal documentation that an investigation as to how/why Patient R9 was admitted into the hospital with 5 sewing needles that could potentially be used as weapons. In an interview on 02/20/2024 at 11:00 a.m., S4RM stated she did not know how Patient R9 was able to bring in the 5 sewing needles since the intake department has metal detector wands. S4RM verified the self-report log failed to reveal a self-report for this incident. 3) Failure to ensure nursing staff recognized ligature risks in a patient with suicidal ideations. Review of Hospital Policy titled, “Precautions, Suicide” revealed, in part: Policy ...The psychiatric practitioner shall order observation and precautions consistent with the assessed level of risk. Procedure, in part: 3 ...Suicide precautions may also trigger a combination of the following actions, in part: Increased observation level based on risk ...Limit linens and belongings. Observations of Unit B on 02/19/2024 at 10:40 a.m. guided by S1CNO revealed Patient #R4 in Room a on telephone with a towel wrapped around her head. Further Observation revealed S1CNO realized Patient #R4 had a towel wrapped around her head and explained to S8BHA that Patient #R4 should not have a towel wrapped around her head because she was a suicide risk on Suicide Precautions. In an interview on 02/19/2024 at 10:41 a.m., S8BHA reported Patient #R4 had taken a shower about 45 minutes prior and must have wrapped the towel around her head after her shower before going into Room a to use the telephone. S8BHA stated the patient was on Q 15 minute observations. S1CNO reviewed Patient #R4’s observation sheet and pointed out to S8BHA that Patient #R4 was actually on Q 5 minute observations. S1CNO and S8BHA went into Room a and retrieved the towel wrapped around Patient #R4’s head. In an interview on 02/19/2024 at 1:20 p.m., S8BHA reported she did not realize Patient #R4 having a towel wrapped around her head was a ligature risk. S8BHA was not sure how long Patient #R4 had the towel in Room a. S1CNO reported that the hospital collects the towels after showering so that they cannot be used as ligature risk. S1CNO stated that S8BHA probably missed collecting the towel wrapped around R4’s head. S1CNO confirmed the linens should be limited in a patient on Suicide Precautions and observation level of Q 5 minutes. 4) Failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients with safety risks. Observation of Unit C on 02/19/2024 at 10:50 a.m. guided by S1CNO, revealed an exit to area E used for patient outdoor recreation. Upon exit, observation of outside patient area revealed a plastic bag among other trash lying on sidewalk that led to area E. In an interview on 02/19/2024 at 10:55 a.m., S1CNO confirmed the plastic bag was an asphyxiation risk and should not be lying on sidewalk with other trash in patient recreation area. 5) Failure to ensure that ordered levels of observations were implemented per Hospital policy for 5 (#R1-#R5) of 5 (#R1-#R5) Patients reviewed for observation levels. Review of Hospital policy titled, “Patient Rights”, dated 06/2023, revealed, in part: Procedure, in part: 1. The following rights shall be afforded to all patients and are not subject to modification, in part: g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse ... Review of Hospital policy titled, “Observations, Patient”, revealed in part: Policy, in part: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse. Documentation of Observations: Staff documents all levels of observation in the medical record. Each entry is to include the following ...Level of observation, Precautions, Location, Behavior, and Activity. Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and/or to back fill time frames that were not completed in a timely manner. Q 5 minute rounds, in part: All patients are monitored at minimum once in every 5-minute block of time ...During rounds staff are to, in part: Make direct visual contact; look for signs of danger or distress. Review of Patient #R1’s Observation Sheet dated 02/19/2024 on 02/19/2024 at 10:20 a.m. revealed observation level Q 5 minutes and Suicide Precautions. Further review failed to reveal documentation that the patient was observed from 10:05-10:20 a.m. Review of Patient #R2’s Observation Sheet dated 02/19/2024 on 02/19/2024 at 10:20 a.m. revealed observation levels Q 5 minutes and Suicide, Seizure and Fall Precautions. Further review failed to reveal documentation that the patient was observed from 10:10-10:20 a.m. Review of Patient #R3’s Observation Sheet dated 02/19/2024 on 02/19/2024 at 10:20 a.m. revealed observation levels Q 5 minutes and Suicide Precautions. Further review failed to reveal documentation that the patient was observed from 10:10-10:20 a.m. In an interview on 02/19/2024 at 10:25 a.m., S1CNO verified that Observation Sheet for Patient #R1, #R2, #R3 and #R5 failed to reveal documentation these patients were observed per policy. Review of Patient # R4’s Observation Sheet 02/19/2024 on 02/19/2024 at 1:20 p.m. revealed R4 was on Q 5 minute observations and Suicide and Fall precautions. Continued review failed to reveal documentation R4 was observed from 12:55 p.m. through 1:20 p.m. In an interview on 02/19/2024 at 1:20 p.m., S1CNO verified that Observation Sheet for Patient #R4 failed to reveal documentation that Patient #R4 was observed from 12:55 p.m. through 1:20 p.m. Review of Patient #R5’s Medical Record revealed an admit date of 02/19/2024 at 9:00 a.m. Review of Patient #R5’s Observation Sheet on 02/19/2024 at 10:18 a.m. revealed patient was on Q 5 minute observations and Suicide, Seizure and Fall Precautions. Further review failed to reveal documentation that Patient #R5 was observed from 9:30 a.m.-10:20 a.m. In an interview on 02/19/2024 at 10:20 a.m., S17BHA reported that there were issues going on with other patients that distracted her from documenting observations on Patient #R5. In an interview on 02/19/2024 at 12:10 p.m., S4RM confirmed the observation sheets failed to reveal documentation that the patients was observed per policy. S4RM reported that the number of patients for 1 BHA to observe has been an issue for the units in the past.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on record review and interview, the facility failed to ensure each patient was free from abuse, neglect and harassment. The deficient practice is evidenced by: 1) failure to provide medical attention in a timely manner; 2) failure to monitor Patients #1 and #2 per policy, potentially causing Patient #1 to obtain a fractured shoulder; 3) failure to investigate fully, reports of Abuse or Neglect; 4) failure to notify Patient #1’s designated contact of Patient #1’s abuse. Findings: 1) Failure to provide medical attention in a timely manner. Review of Hospital policy titled, “Patient Rights”, dated 06/2023, revealed, in part: Procedure, in part: 1. The following rights shall be afforded to all patients and are not subject to modification, in part: g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse ... Review of Patient #1’s Medical record revealed an admit date of 01/26/2024. Further review revealed an incident report dated 01/30/2024 detailing an incident that occurred on 01/30/2024. At approximately 11:15 a.m. a sudden outburst was heard from hallway, upon further observation, Patient #1 was seen on floor being repeatedly hit by Patient #2 who was on top of her yelling and cursing. Altercation was broken up by the maintenance staff. Patient #1 complained of hitting her right shoulder on the floor when she was attacked. Redness was noted to the site with limited range of motion also noted. Medical provider ordered a mobile xray of the right shoulder at 11:30 a.m. Review of nursing note dated 01/30/2024 revealed the mobile xray was ordered at 12:40 p.m. Review of nursing note dated 01/30/2024 at approximately 4:00 p.m., revealed Patient #1 was screaming that she was in severe pain. Review of observation sheet for 01/30/2024 revealed Patient #1 was crying at 6:30 p.m. Review of Patient #1’s mobile xray revealed findings of a suspected nondisplaced fracture of greater tuberosity were signed by radiologist on 01/30/2024 at 5:04 p.m. The results were received by hospital at 6:05 p.m., almost 7 hours after the injury occurred. Review of nurses note revealed orders to transfer to Emergency Department were dated 01/30/2024 at 6:38 p.m. Review of January 2024’s Hospital Transfer list revealed Patient #1 was finally transferred to an Emergency Department on 01/30/2024 at 7:15 p.m., 8 hours following the injury. In an interview on 02/20/2024 at 1:15 p.m., S4RM verified that it took approximately 8 hours after Patient #1’s injury to be transferred to Emergency Room. S4RM was not able to determine why there was a delay in treatment. 2) Failure to monitor Patients #1 and #2 per policy, potentially causing Patient #1 to obtain a fractured shoulder. Review of Hospital policy titled, “Precautions, Assault”, revealed, in part: Policy ...implement appropriate treatment at the onset of increased patient agitation. Procedure, in part: Upon admission, all patients will be evaluated for level of assaultive crisis ...During hospitalization, all patients will be assessed and observed for ...behaviors which may increase the potential for assaultive behavior ...Any changes in behavior or events which may impact on a patient’s Potential for assaultive behavior are to be reported to the Charge Nurse. Review of Hospital policy titled, “Observations, Patient”, revealed in part: Policy, in part: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse. Documentation of Observations: Staff documents all levels of observation in the medical record. Each entry is to include the following ...Level of observation, Precautions, Location, Behavior, and Activity. Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and/or to back fill time frames that were not completed in a timely manner. Q 5 minute rounds, in part: All patients are monitored at minimum once in every 5-minute block of time ...During rounds staff are to, in part: Make direct visual contact; look for signs of danger or distress. Review of Hospital Job Description titled, “Behavioral Health Associate I”, dated 01/01/2020, revealed, in part: Essential Functions, in part: Responsible for conducting safety checks and ensuring that supervision is conducted at 15 minute intervals, as noted in special precautions, or in accordance with individualized supervision guidelines as needed. Document timely, accurate and appropriate clinical information in patient’s medical record. Review of Hospital self-report #69871 dated 01/31/2024 revealed the incident involving the attack by Patient #2 on Patient #1 occurred at 11:15 a.m. in the hallway. Review of Patient #1’s observation report, mistakenly dated 01/29/2024, confirmed by S4RM to have the incorrect date. S4RM verified the correct date for the observation report reviewed was 01/30/2024. Continued review revealed Patient #1 was on Q 15 minute observations and suicide precautions. Additional review revealed documentation that Patient #1 was located in her room, calm and sitting/lying from 10:45 a.m. until 12:00 p.m. In an interview on 02/20/2024 at 1:22 p.m., S4RM verified that the documentation on Patient #1’s observation sheet was incorrect. Review of Patient #2’s observation report dated 01/30/2024 revealed Q 5 minute observations. Further review revealed Patient #2 was on Elopement, Suicide, Assault and Sexual Acting Out precautions. Continued review revealed documentation that Patient #2 was located in the activity room, calm and watching television from 11:10 a.m. until 12:10 p.m. In an interview on 02/20/2024 at 1:22 p.m., S4RM verified that the documentation on Patient #2’s observation sheet was incorrect. In an interview on 02/20/2024 at 1:25 p.m., S4RM stated Patient #2 had walked out of the treatment team room around 11:15 a.m., angry and aggressive because she was on elopement precautions and could not go into the dining area. When she came out of the treatment team room angry, she went down hallway and jumped on Patient #1. It was the maintenance man who separated the patients. S4RM confirmed the acuity level to staff ratio was inefficient and may have contributed to this incident especially because staff were not near the treatment room. 3) Failure to investigate fully, reports of Abuse or Neglect. Review of Hospital policy titled, “Abuse and Neglect”, revealed, in part: Procedure, in part: 8. Investigation, in part: a. Reports of Abuse or Neglect, which occur while the patient is hospitalized, will be thoroughly investigated by the Risk Manager or other staff as assigned by the Chief Executive Officer. Review of self-report #69871 dated 01/31/2023, provided by the facility to the Louisiana Department of Health, failed to reveal a final report indicating the incident was fully investigated. In an interview on 02/20/2024 at 1:20 p.m., S4RM verified that she had not completed the investigation of the Abuse/Neglect incident occurring on 01/30/2024 involving the abuse of Patient #1 by Patient #2. 4) Failure to notify Patient #1’s designated contact of Patient #1’s abuse. Review of Hospital policy titled, “Abuse and Neglect”, revealed, in part: Procedure, in part: 3. Patient-to-Patient Abuse, in part: c. The registered nurse will notify the designated family contact and/or legal representative of the patient who was abused. Review of Patient #1’s Medical Record revealed an Authorization to Disclose Healthcare Information dated 01/27/2024. Continued review revealed signed permission to disclose treatment information to a specific individual with the contact’s phone number documented. Review of Patient #1’s Medical Record failed to reveal evidence that Patient #1’s contact was notified she was the victim of Patient-to-Patient Abuse. In an interview on 02/20/2024 at 2:05 p.m., S4RM verified Patient #1’s Medical Record failed to reveal evidence that Patient #1’s contact was notified she was the victim of Patient-to-Patient Abuse.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the use of restraint was in accordance with safe and appropriate restraint and seclusion techniques as per hospital policies and procedures for 1 (#2) of 1 (#2) patient records reviewed for use of restraints. Findings: Review of Hospital policy titled, “Seclusion, Restraint, and Therapeutic Time Out” dated 10/2023, revealed, in part: IV. Procedure, in part: 10. The registered nurse will complete required documentation of seclusion and restraint episodes in [Hospital] Seclusion and Restraint Packet. 13. A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion and/or restraint to assess physical and psychological status. The in-person evaluation includes the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. The evaluation must be completed even if the seclusion and/or restraint has been discontinued prior to the in person evaluation. Documentation of the one-hour face-to-face assessment occurs in [Hospital] Seclusion and Restraint Packet. 18. The patient is debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for seclusion and/or restraint. Debriefing occurs in order to develop a plan that actively involves the patient to prevent future episodes from occurring. 19. The legal representative or an immediate family member as requested by the patient shall be promptly notified of the seclusion and /or restraint. A review of Patient #2’s Medical Record revealed and admit date of 01/25/2024. Further review revealed on 01/30/2024 at approximately 11:15 a.m. Patient #2 was restrained by staff in a physical hold after attacking Patient #1. Continued review revealed 20 mg of Zyprexa administered intramuscularly as a onetime dose following the incident. Additional review failed to reveal the required Seclusion and Restraint Packet that would have included documentation of the following: 1) An in-person evaluation of the patient within one hour of initiation of seclusion and/or restraint to assess physical and psychological status, the patient’s immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the intervention. 2) Documentation of the one-hour face-to-face assessment. 3) Patient debriefing by a staff person to determine the sequence of events or circumstances that precipitated the need for seclusion and/or restraint. In an interview on 02/20/2024 at 1:47 p.m., S4RM verified that Patient #2 was restrained during the attack on Patient #1. S4RM confirmed that Patient #2 received a onetime dose 20 mg of Zyprexa intramuscularly after the incident. S4RM further verified that Patient #2’s medical record did not contain a restraint packet and stated that policy required documentation per the restraint packet.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the nursing services department of the hospital failed to provide adequate numbers of support personnel to provide nursing care to all patients as needed. This deficient practice was identified for 16 of 33 daily nurse staffing sheets reviewed and had the potential to affect any of the 71 inpatients receiving care and services during the time of the survey. Findings: Review of hospital document titled “Job Description, Director-Nursing Acute”, dated 01/01/2020, revealed, in part: Purpose Statement, in part: ...Recognize that patient safety is a top priority. Essential Functions, in part: Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed. Evaluate service needs and staffing requirements to ensure needs of patients are met. Review of Hospital Document titled “[Behavioral Health Associate] BHA Task Responsibility List” revealed, in part: - Q15 and Q 5 minutes checks (know where your patients are and what they are doing at all times) - Vital signs-to be done at shift start and at the discretion of the nursing staff - Provider Rounds-ensure patients see the providers timely when requested - Meal times and escort-ensure the nursing staff know who did not eat, or who is refusing to eat/drink - Admissions-ensure that all patients that are received on the unit from intake have a contraband search once on the unit. Ensure belongings brought are appropriately accounted for and documentd. - Declutter and organize the unit for the oncoming shift. - Patient phone-time duty-Patients are to be observed while on the phone. - Once per shift, use the linen ‘cans on wheels’ to collect used linen from your patient’s rooms and hallways, then transpose the linen collected to blue plastic bags once off the unit and place in the proper linen receptacle. - Laundry-When doing patient laundry duty be sure all laundry, on all of your assigned patients, are collected cleaned, folded, and put away. Be sure clothes are given to the correct patient. - Ensure the laundry room is tidy. - Biohazard room is neat and organized (no dirty bags on floor). - Ensure all logs (refrigerator logs) are checked and signed every day - ADL’s (Be sure that the patients are dressed appropriately, are well groomed, their beds made, and their allowed belongings are stored neatly In their assigned spaces. Rounds should be completed at least twice a shift - ADL baskets are stocked and all personal items are labeled. - Showers (offer a shower to the patients each day, and ensure that the nursing staff know th last time a patient showered). - Safety and Environmental checks on your assigned patients (check rooms, storage area and bathroom) for contraband at least 1 time every shift. Ensure doors are locked per the schedule. Review of hospital “Nursing Staffing Grid” approved by Medical Executive Committee revealed, in part: Procedure, in part: AM Shift Census: 01-13 1RN 1BHA Census: 14-16 1RN 1Nurse 1BHA Census: 17-18 1RN 1Nurse 2BHA Census: 19-26 1RN 1Nurse 2 BHA PM Shift Census: 01-13 1RN 1BHA Census: 14-16 1RN 1Nurse 1BHA Census: 17-18 1RN 1Nurse 1BHA Census: 19-26 1RN 1Nurse 2 BHA Review of 33 daily nursing staffing sheets for day and night shifts revealed on the following 16 shifts, nursing services failed to meet the staffing ratios required to provide a safe environment for patients: Review of Unit Assignments dated 01/26/24 AM shift for Unit A revealed a census of 18. Further review revealed 1 patient on 1:1 observation and 8 patients on Q 5 observations. Review of assigned staff revealed 1 RN and 1 Nurse. Based on the Nursing Staffing Grid, staff assignments should include 2 BHAs. In an interview on 02/20/2024 at 2:21 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 01/26/24 AM shift for Unit B revealed a census of 14. Further review revealed 1 patient on 1:1 observation and 7 patients on Q 5 observations. Further review of assigned staff revealed 1 RN, 1 BHA on 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff assignments should include another nurse. In an interview on 02/20/2024 at 2:23 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 01/26/24 PM shift for Unit B revealed a census of 14. Further review revealed 3 patients on 1:1 observation and 6 patients on Q 5 observations. Further review of assigned staff revealed 1 RN, 1 BHA assigned to each 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another nurse. In an interview on 02/20/2024 at 2:26 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/01/24 AM shift for Unit A revealed a census of 18. Further review revealed 1 patient on 1:1 observation and 4 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 1 LPN, 1 BHA assigned to 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another BHA. In an interview on 02/20/2024 at 2:28 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/03/24 AM shift for Unit D revealed a census of 17. Further review revealed 2 patients on 1:1 observation. Review of assigned staff revealed 1 RN, 1 LPN, 1 BHA assigned to 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another BHA. In an interview on 02/20/2024 at 2:33 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/04/24 PM shift for Unit B revealed a census of 14. Further review revealed 1 patient on 1:1 observation and 8 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 1 BHA assigned to 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another nurse. In an interview on 02/20/2024 at 2:35 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/05/24 AM shift for Unit B revealed a census of 14. Further review revealed 1 patient on 1:1 observation and 8 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 1 BHA assigned to 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another nurse. In an interview on 02/20/2024 at 2:38 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/12/24 undocumented shift for Unit D revealed a census of 22. Review revealed 2 patients on 1:1 observation and 10 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 2 BHAs assigned 1 to each 1:1 and 2 BHAs assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another nurse. In an interview on 02/20/2024 at 2:41 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/13/24 undocumented shift for Unit D revealed a census of 21. Review revealed 2 patients on 1:1 observation and 7 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 2 BHAs assigned 1 to each 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another BHA. In an interview on 02/20/2024 at 2:42 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/13/24 AM shift for Unit A revealed a census of 18. Review of assigned staff revealed 1 RN, 1 LPN and 1 BHA assigned to patients. Based on the Nursing Staffing Grid, staff should include another BHA. In an interview on 02/20/2024 at 2:44 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/13/24 PM shift for Unit A revealed a census of 18. Review of assigned staff revealed 1 RN and 2 BHAs assigned to patients. Based on the Nursing Staffing Grid, staff should include another nurse. In an interview on 02/20/2024 at 2:47 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/14/24 AM shift for Unit A revealed a census of 18. Review of assigned staff revealed 1 RN, 1 LPN and 1 BHA assigned to patients. Based on the Nursing Staffing Grid, staff should include another BHA. In an interview on 02/20/2024 at 2:48 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/16/24 PM shift for Unit A revealed a census of 16. Review of assigned staff revealed 1 RN and 2 BHAs assigned to patients. Based on the Nursing Staffing Grid, staff should include another nurse. In an interview on 02/20/2024 at 2:49 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/17/24 AM shift for Unit A revealed a census of 17. Review of assigned staff revealed 1 RN, 1 LPN and 1 BHA assigned to patients. Based on the Nursing Staffing Grid, staff should include another BHA. In an interview on 02/20/2024 at 2:52 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/17/24 PM shift for Unit A revealed a census of 16 with 5 patients on Q 5 observations. Review of assigned staff revealed 1 RN, and 2 BHAs assigned to patients. Based on the Nursing Staffing Grid, staff should include another nurse. In an interview on 02/20/2024 at 2:51 p.m., S4RM verified deficient staffing. Review of Unit Assignments dated 02/19/24 AM shift for Unit B revealed a census of 12 with 5 patients on Q 5 observations. Review of assigned staff revealed 1 RN, and 1 BHA assigned to patients. Observation on 02/19/2024 at 1:18 p.m. of Unit B revealed 1 nurse (S18RN) on the unit. S18RN was observed in medication room pulling medications and administering medications through the medication window. Continued observation failed to reveal nursing staff on the unit while S18RN was in the medication room. In an interview on 02/19/2024 at 1:30 p.m., S18RN reported S8BHA left the unit around noon. S18RN stated it was difficult to observe the patients on suicide precautions with Q 5 observation levels while distributing and administering medications on her own. In an interview on 02/19/2024 at 1:20 p.m., S1CNO confirmed that between 11:50 a.m. and 1:20 p.m., staffing was deficient.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with Hospital policy and the patient’s needs. This deficiency is evidenced by failing to ensure a Registered Nurse completed all patient care assignments at the beginning of each shift. Findings: Review of hospital policy titled “Assignment of Nursing Staff”, dated 02/2023, revealed, in part: Policy, in part: To assure quality nursing care and a safe patient environment ...Procedure, in part: Staffing assignments reflective of this policy will be completed at the beginning of each shift by the Charge Nurse. Staffing assignments will be documented on the Staffing Assignment Sheet. The name and title of the staff member to be assigned will be entered in the space provided. The names of the patients assigned to the staff member will be entered in the space provided. Non-direct care assignments are to be included on the assignment sheet. It is the responsibility of each staff member to review his/her assignment when it is completed. The Assignment Sheet will be available to staff throughout the shift. The Staffing Assignment Sheets will be reviewed and maintained by the Chief Nursing Officer, or designee. Review of Unit Assignment Sheet dated 01/27/2024 for AM shift of Unit A failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review failed to reveal the observation levels of each patient. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/20/2024 at 2:27 p.m., S4RM verified the Unit Assignment Sheet dated 01/27/2024 for AM shift of Unit A was not completed per policy. Review of Unit Assignment Sheet dated 02/05/2024 for AM shift of Unit A failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/20/2024 at 2:36 p.m., S4RM verified the Unit Assignment Sheet dated 02/05/2024 for AM shift of Unit A was not completed per policy. Review of Unit Assignment Sheet dated 02/08/2024 for PM shift of undocumented unit, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/20/2024 at 2:39 p.m., S4RM verified the Unit Assignment Sheet dated 02/08/2024 for PM shift of undocumented unit was not completed per policy. Review of Unit Assignment Sheet dated 02/11/2024 for undocumented shift of undocumented unit, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/20/2024 at 2:40 p.m., S4RM verified the Unit Assignment Sheet dated 02/11/2024 for undocumented shift of undocumented unit was not completed per policy. Review of Unit Assignment Sheet dated 02/12/2024 for undocumented shift of undocumented unit, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/20/2024 at 2:42 p.m., S4RM verified the Unit Assignment Sheet dated 02/12/2024 for undocumented shift of undocumented unit was not completed per policy. Review of Unit Assignment Sheet dated 02/12/2024 for undocumented shift of Unit B, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/20/2024 at 2:42 p.m., S4RM verified the Unit Assignment Sheet dated 02/12/2024 for undocumented shift of Unit B was not completed per policy. Review of Unit Assignment Sheet dated 02/15/2024 for undocumented shift of undocumented unit, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review revealed documentation the nurse in orientation completed Unit Assignment Sheet. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/20/2024 at 2:48 p.m., S4RM verified the Unit Assignment Sheet dated 02/15/2024 for undocumented shift of undocumented unit was not completed per policy. Review of Unit Assignment Sheet dated 02/16/2024 for undocumented shift of undocumented unit, failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/20/2024 at 2:49 p.m., S4RM verified the Unit Assignment Sheet dated 02/16/2024 for undocumented shift of undocumented unit was not completed per policy. Review of Unit Assignment Sheet dated 02/17/2024 for undocumented shift of undocumented unit, failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/20/2024 at 2:51 p.m., S4RM verified the Unit Assignment Sheet dated 02/17/2024 for undocumented shift of undocumented unit was not completed per policy. Review of Unit Assignment Sheet on 02/19/2024 at 10:07 a.m. for Unit A revealed the assignment sheet was completely blank. In an interview on 02/19/2024 at 10:07 a.m., S1CNO verified the Unit Assignment Sheet on 02/19/2024 for Unit A was not completed per policy. In an interview on 02/19/2024 at 10:08 a.m., S22RN reported she did not have time to fill out the assignment sheet. Review of Unit Assignment Sheet on 02/19/2024 at 10:50 a.m. for Unit C failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet. In an interview on 02/19/2024 at 10:50 a.m., S1CNO verified the Unit Assignment Sheet on 02/19/2024 for Unit C was not completed per policy. Review of Unit Assignment Sheet on 02/19/2024 at 11:12 a.m. for Unit D revealed the assignment sheet was completely blank. In an interview on 02/19/2024 at 11:12 a.m., S21RN reported that she did not have time to complete the assignment sheet. In an interview on 02/19/2024 at 11:12 a.m., S1CNO verified the Unit Assignment Sheet on 02/19/2024 for Unit D was not completed per policy.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 14442 Based on record reviews and interview, the hospital failed to ensure patients were free from abuse or harassment. This deficient practice was evidenced by failing to ensure an alleged patient-to-patient sexual assault was reported immediately for 1 (#1) of 3 (#1, #2, #3) sampled patients. Findings: Review of the hospital Abuse and Neglect policy and procedure revealed, in part: Policy: It is the policy of the Hospital that any staff who witnesses or suspect a patient has been abused either physically or verbally will report such abuse to the appropriate authority IMMEDIATELY. This includes patient-to-patient. This suspicion may be based upon verbal report. Procedure: 1. Staff who witness or suspect the patient has been abused either physically or verbally will report such abuse to the Administrator on Call IMMEDIATELY after notifying the appropriate authorities. This includes patient-to-patient abuse or neglect. Review of the hospital Required Reporting - State of Louisiana policy and procedure revealed, in part: Procedure: I. Allegations of Abuse/Neglect. a. Any allegations of abuse/neglect must be reported immediately to the Risk Manager or Administrator on Call (if afterhours or on weekends). Review of Patient #1’ Progress Note Psychiatry dated 11/10/2023 at 11:05 a.m. revealed, in part: Patient moved to A unit as other patient on 1:1 was paranoid towards her and (Patient #1) is history risk of violent behavior. However on A unit patient reports that male patient touched her chest while she was showering in her room and later came back into her room and was standing over her and touching her. Patient is currently on 1:1, nursing unable to explain how this could have occurred with patient on 1:1 but did state that male patient was psychotic and was entering other patient’s rooms. The male patient had been placed on 1:1, in room with tech by door monitoring closely. Review of Patient #1’s medical record revealed no evidence the 11/10/2023 alleged patient-to-patient sexual assault was immediately reported to the appropriate authority, Administrator, and Risk Manager as stated in the hospital’s policies and procedures. Further review revealed the Administrator and Risk Manager were notified 11/13/2023 at approximately 10:20 a.m. after Patient #1 called the local police department. In an interview on 11/20/2023 at 8:32 a.m., S3Director of Risk Management confirmed Patient #1’s alleged patient-to-patient sexual assault on 11/10/2023 was not immediately reported on 11/10/2023 to the appropriate authority, Administrator, and Risk Manager as stated in the hospital’s policies and procedures. S3Director of Risk Management confirmed that the hospital was notified on 11/13/2023 at approximately 10:20 a.m. after Patient #1 called the local police department.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. This deficient practice is evidenced by the failure to update the nursing care plans on 3 (#1, #2, #3) of 3 (#1-#3) sampled patients reviewed for completed and updated nursing care plans. Findings: A review of facility policy number POC-43 titled, “Treatment Planning,” revealed in part, under the section Guidelines of Treatment Plans, Item 3.1 The treatment plan shall be an accurate and functional representation of the patient’s treatment experience. 3.4 The treatment plan shall identify interventions developed to assist the patient in achieving goals. 6.0 A review of the patient’s Treatment Plan following any major clinical change shall be conducted, and appropriate modifications made. A medical record review on 11/06/2023 at 2:53 p.m. revealed Patient #1 had pedal edema identified on the history and physical completed on 11/03/2023 at 5:53 p.m. by the provider. There was no documentation indicating patient #1’s nursing care plan had been updated to include this medical diagnosis or treatment interventions. In an interview on 11/06/2023 at 3:00 p.m. S1DR confirmed there had been no update to Patient #1’s nursing care plan. A medical record review on 11/06/2023 at 1:00 p.m. revealed Patient #2 had pain and infected wound identified in the provider’s progress notes. There was no documentation indicating patient #2’s nursing care plan had been updated to include this medical diagnosis or treatment interventions. In an interview on 11/06/2023 at 2:00 p.m. S1DR confirmed there had been no update to Patient #2’s nursing care plan. A medical record review on 11/06/2023 at 3:45 p.m. revealed Patient #3 had pain to back and lower extremities identified on the provider’s progress notes. There was no documentation indicating patient #3’s nursing care plan had been updated to include this medical diagnosis or treatment interventions. In an interview on 11/06/2023 at 4:15 p.m. S1DR confirmed there had been no update to Patient #3’s nursing care plan.”

“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: 48050 Based on record review and interview, the hospital failed to ensure medications were administered as ordered. The deficient practice is evidenced by failure to administer pain medication as ordered in 3 (#1, #2, #3) of 3 (#1-#3) reviewed patient records. Findings: Review of the medical record for Patient #1 revealed Motrin 800mg every 6 hours as needed for pain 1-3/10 was administered on 11/03/2023 at 8:54 a.m. for pain 8/10; on 11/04/2023 2:23 p.m. for pain 10/10; on 11/05/2023 at 9:22 a.m. for pain 8/10; on 11/05/2023 at 6:25 p.m. for pain 8/10. Furthermore documentation was not in the medical record that the provider was notified that Patient #1’s pain level was greater than 3 when Motrin was administered. In an interview on 11/06/2023 at 2:30 p.m. S1DR verified that the nurse didn’t follow the PRN parameters to administer Motrin or notified the provider that Patient #1’s pain was greater than 3 on a pain scale of 1-10. Review of the medical record for Patient #2 revealed an order for Motrin 800mg every 6 hours as needed for pain 1-3/10. Motrin was administered 08/26/2023 11:09 p.m. for pain 10/10, 08/27/2023 2:47 p.m. for pain 10/10; 08/28/2023 8:24 a.m. for pain 10/10, 08/28/2023 5:32 p.m. for pain 10/10; 0 and on 8/29/2023 8:10 p.m. for pain 6/10. Furthermore documentation was not in the medical record that the provider was notified that Patient #2’s pain level was greater than 3 when Motrin was administered. In an interview on 11/06/2023 at 3:30 p.m. S1DR verified that the nurse didn’t follow the PRN parameters to administer Motrin or notified the provider that Patient #2’s pain was greater than 3 on a pain scale of 1-10. Review of the medical record for Patient #3 revealed an order for Motrin 800mg every 6 hours as needed for pain 1-3/10. Motrin was administered on 11/03/2023 12:17 p.m. for pain 4/10. Furthermore documentation was not in the medical record that the provider was notified that Patient #3’s pain level was greater than 3 when Motrin was administered. In an interview on 11/06/2023 at 4:15 p.m. S1DR verified that the nurse didn’t follow the PRN parameters to administer Motrin or notified the provider that Patient #3’s pain was greater than 3 on a pain scale of 1-10.”