Universal Behavioral Health 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 observations and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by: 1) failure to document the correct level of observation being performed per provider order for 5 (#R1-#R5) of 12 (#R1-#R12) close observation check sheets reviewed; and 2) failure to ensure current glucometer control solutions met the safety needs of the patients. Findings: 1) Failure to document the correct level of observation being performed per provider order for 5 (#R1-#R5) of 12 (#R1-#R12) close observation check sheets reviewed. Review of hospital policy number BH1032, titled “Observation Precautions,” last revised 11/12/2024, revealed in part: “PURPOSE: To promote safety and ensure the patient is being treated in the least restrictive environment that is clinically permitted. POLICY: It is the policy of Universal Behavioral Health Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient’s status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner. PROCEDURE: The licensed independent practitioner (LIP) shall order the patient the appropriate observation status at time of admission. Any change in the patient’s observation status shall require a LIPs order. The Charge Registered Nurse is responsible for assigning the staff members to perform designated special observation status for each patient on his/her assigned unit. DOCUMENTATION: The LIP shall either verbally or in writing, issue an order for required observation status. The Charge Registered Nurse will be responsible for staff assignments on the MHT Unit Assignment Form. RN or LPN shall make rounds every 2 hours and sign the Observation Sheet to ensure that MHT’s are observing their assigned patient, filling the form out correctly and not charting ahead. Documentation shall be completed in a timely manner such that an employee does not document ahead of time, nor does the employee document in such a fashion as to “catch up” the MHT Observation Sheet. The safety of patients and accuracy of documentation requires strict adherence to this policy and procedure.” Observations during a tour of the hospital on 08/21/2025 from 9:14 AM - 9:40 AM revealed 12 patients on Unit B. Review of the Unit Assignments revealed that Unit B had 11 patients on Q 15 minute observations and 1 patient on one to one observations. Review of the Close Observation sheets for Patient’s #R1-#R5 revealed an observation of Level 1 (1:1 Observation) marked as their observation status. Further review failed to reveal the correct observation of Level II (Q 15 minutes) as being marked per provider order. In an interview on 08/21/2025 at 9:23 AM, S1DON confirmed that the Close Observation sheets for Patient’s #R1-#R5 were completed incorrectly, and verified that Level II should have been marked. S1DON further confirmed that Patient’s #R1-#R5 had orders for Q 15 minute observations and were not on 1:1 observations. 2) Failure to ensure current glucometer control solutions met the safety needs of the patients. Observations during a tour of the hospital on 08/21/2025 from 9:14 AM - 9:40 AM revealed Even Care Proview Glucose Control Solutions vials being opened and not properly labeled with an open date and beyond use date (expiration date). This would present a risk for harm or injury to a patient related to treatment being rendered based on the results of a capillary blood glucose reading via a glucometer that has not been properly quality control tested. The undocumented vials were as follows: Unit A: Even Care Proview Glucose Control Solution #1 vial and Even Care Proview Glucose Control Solution #2 vial had an open date of 07/27/2025. Further review of the Even Care Proview Glucose Control Solutions failed to reveal a beyond use date (expiration date) marked on either opened vial. In an interview on 08/21/2025 at 9:29 AM, S1DON confirmed the above mentioned findings.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50453 Based on observations, record reviews, and interviews, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by: 1) failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 4 (#R1-#R4) of 12 (#R1-#R12) Patient Observation Check Sheets reviewed; and 2) failure of the Registered Nurse to document an assessment each shift for 1 (#1) of 3 (#1-#3) patient medical records reviewed. Findings: 1) Failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 4 (#R1-#R4) of 12 (#R1-#R12) Patient Observation Check Sheets reviewed. Review of hospital policy number BH1032, titled “Observation Precautions,” last revised 11/12/2024, revealed in part: “PURPOSE: To promote safety and ensure the patient is being treated in the least restrictive environment that is clinically permitted. POLICY: It is the policy of Universal Behavioral Health Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient’s status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner. Status guidelines as follows: 2. Level II: Q15 Minute Observation: Patients shall be visualized every fifteen (15) minutes by a staff member. Visual observation every 15 minutes by assigned staff prior to documenting patient location and behavior. Assigned staff members visualize patients on observation every 15 minutes or more often as indicated by patient behavior. DOCUMENTATION: The LIP shall either verbally or in writing, issue an order for required observation status. The Charge Registered Nurse will be responsible for staff assignments on the MHT Unit Assignment Form. RN or LPN shall make rounds every 2 hours and sign the Observation Sheet to ensure that MHT’s are observing their assigned patient, filling the form out correctly and not charting ahead. Documentation shall be completed in a timely manner such that an employee does not document ahead of time, nor does the employee document in such a fashion as to “catch up” the MHT Observation Sheet. The safety of patients and accuracy of documentation requires strict adherence to this policy and procedure.” Observations during a walk-through on 08/21/2025 revealed the following on Unit B: Review of Patient #R1-#R4 Observation Sheets for Unit B revealed the last documented observation as performed was at 8:30 AM. Further review failed to reveal documented evidence that Q15 minute observations were performed at 8:45 AM, 9:00 AM, or 9:15 AM on Patient #R1-#R4. In an interview on 08/21/2025 at 9:23 AM, S1DON confirmed the above mentioned findings. 2) Failure of the Registered Nurse to document an assessment each shift for 1 (#1) of 3 (#1-#3) patient medical records reviewed. Patient #1 A review of Patient #1’s medical record revealed Patient #1 was admitted on 08/03/2025 at 4:45 AM and discharged on 08/13/2025 at 11:09 AM. Further review of the nursing assessments in Patient #1’s medical record failed to reveal documented evidence of a nursing assessment on 08/10/2025 for the 7 AM-7 PM shift. In an interview on 08/21/2025 at 2:55 PM, S2DRM confirmed that a nursing shift assessment is to be completed for each shift on each patient. S2DRM verified the 7 AM-7 PM nursing shift assessment was not documented on 08/10/2025 for Patient #1.”

“Social Service Records CFR(s): The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure social service records included all interviews with patients, family members and others, assessment of home plans, family attitudes, and community resource contacts as well as a social history. This deficiency was evidenced by failing to ensure changes to discharge plan were updated for 1 (#1) of 3 (#1-#3) patient medical records reviewed. Findings: Review of hospital policy number BH6010, titled “Social Services,” last revised 02/24/2025, revealed in part: “POLICY: Social work contact with the patient, family and significant others shall occur during, or as soon as possible, after patient admission within 72 hours to be initiated. Continuity of care is an important social work principle and may be demonstrated through case management and a major role in discharge planning. Activities, in conjunction with the patient’s wishes, may include contact with patient’s family, identifying and assisting in referral of the patient to community-based agency(ies) at the time of discharge. Social service staff responsibilities shall include, but not limited to: Participating in discharge planning; arranging for follow-up care; developing mechanisms for exchange of appropriate information with sources outside the facility.” Review of hospital policy number BH1303, titled “Discharge of Patients,” last revised 03/25/2025, revealed in part: “PROCEDURE: Social Services shall notify the family or caretaker of the discharge order.” Review of hospital policy number BH1301, titled “Discharge and Transition of Care Planning of Patients with Social Services,” last revised 03/25/2025, revealed in part: “POLICY: Patients shall be advised of recommendations for programs and services in the community, and with the consent of the patient/family, appropriate referrals shall be made by the Social Worker/Discharge Planner. The Social Worker/Discharge Planner shall attempt to find adequate and appropriate living arrangements for all patients discharged from the behavioral health facility. Based on input from the patient, family/significant other, providers, and members of the multidisciplinary team, a discharge plan shall be developed. PROCEDURE: Information shall be obtained from the patient and/or family member, providers, medical records, and other information available to assist in transitioning the patient to the most relevant level of care. Information to form a plan may include: Patient’s optimal level of functioning outside of the facility. Patient’s current support system. Potential for out-of-home placement shall be assessed and appropriate level of care options for long-term care shall be explored with the patient and family. The patient/family shall be given an aftercare plan, which includes discharge referral information. DOCUMENTATION: The Social Worker/Discharge Planner shall document the discharge summary on the discharge summary form utilized by the multidisciplinary team. This summary shall report the patient’s: Patient/family involvement and response to treatment interventions if applicable.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 08/03/2025 at 4:45 AM with diagnoses of Schizophrenia, Bipolar 1 Disorder, Cannabis Use Disorder, and Psychosis. Patient #1 was discharged on 08/13/2025 at 11:09 AM. Review of Patient #1’s Psychosocial Assessment signed by S7SW on 08/05/2025 at 3:48 PM revealed in part the following: Admission Criteria: Altered Thought Process Violent/Homicidal Relationships: Describe current relationship with other family members: Patient states relationship with family is “good.” Housing: Resides with: Homeless (Patient was residing with sister. Patient refuses to return). Collateral Contact: See Initial Discharge Planning and Collateral Contact Note Summary: LMSW met with patient to complete PSA and obtain collateral information. Patient reports living with his sister. Patient states he wants to discharge to a group home. Patient gave brother’s information for collateral contact. Patient reports his brother will provide him transportation at discharge. Patient to be discharged once mood has stabilized, improved thought process, medication compliance, and improved insight and judgement. Review of Patient #1’s Discharge Planning Log signed by S8SW on 08/14/2025 at 1:44 PM revealed in part the following: 08/05/2025 at 12:39 PM Discharge location: Group Home Collateral contact/Support Identified: YES Collateral/support involved in discharge plan: YES 08/07/2025 at 1:49 PM - 3 Day Post Initial Discharge Plan Completion Any changes to initial discharge plan: NO Discussed barriers/recommendations with client/collateral contact: YES 08/13/2025 at 1:55 PM - Follow Up with Discharge Plan (if applicable) Any changes to initial discharge plan: NO Review of Patient #1’s Discharge Planner Note signed by S8SW on 08/13/2025 at 2:26 PM revealed in part the following: Chief Complaint: Psychosis 1) Client’s current presentation: Appropriate Mood and actively participating in discharge discussion. 4) Is identified collateral contact/support aware of discharge plan and in agreement: YES 7) Collateral/support contact verbalized understanding of current discharge plan/crisis safety plan: YES Discharge plan was discussed with client and/or collateral contact day of discharge. Confirmed discharge location and follow up care scheduled and/or recommended after discharge. Client/collateral contact will be provided a printed copy of discharge plans and aftercare appointments along with discharge medication list. Review of Patient #1’s medical records failed to reveal documentation that contact with Patient #1’s collateral was obtained. Further review of failed to reveal documented evidence that the collateral contact/support was notified and in agreement with the discharge plan for Patient #1. In an interview on 08/21/2025 at 1:20 PM, S3DSS confirmed that they were unable to make contact with the collateral contact/support for Patient #1 prior to discharging the patient. S2DRM and S3DSS verified that the above mentioned social worker documentation revealed that the collateral contact/support was contacted and aware of the discharge plan for Patient #1. S3DSS further stated that the collateral/support contact documentation was incorrect.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital failed to ensure patients (or their representatives) were informed of their patient rights. This is evidenced by failure to have documentation that 2 (#1 and #3) of 3 ( #1-#3) patients (or their representatives) reviewed for patient rights were informed of their patient rights. Findings: Review of psychiatric hospital’s policy #1.11 titled “Rights of All Patients”, dated 07/2021, revealed in part: “Procedure, in part: 2. Upon admission, the patient is provided with notification of their rights. 3. Documentation that the patient was given notification of their rights must be kept in the patient’s permanent medical record. Patient Rights, in part: 15. The right to be informed of your rights and responsibilities in advance of furnishing or discontinuing care.” Patient #1 Review of Patient #1’s medical record revealed an admission date of 01/02/2025 with diagnoses of Schizoaffective, bipolar type, and Urinary Tract Infection (UTI) with urinary catheter. Continued review failed to reveal documentation that Patient #1 was notified of their patient rights. In an interview on 02/18/2025 at 3:05 PM, S1DON confirmed Patient #1’s medical record failed to reveal evidence they were notified of their patient rights. Patient #3 Review of Patient #3’s medical record revealed an admission date of 11/20/2024 with diagnoses of Schizoaffective, bipolar type, and Psychosis. Continued review failed to reveal documentation that Patient #3 was notified of their patient rights. In an interview on 02/18/2025 at 4:20 PM, S1DON confirmed Patient #3’s medical record failed to reveal evidence they were notified of their patient rights.”

“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 facility failed to ensure patient care in a safe setting. This deficient practice is evidenced by failure to ensure 9 (#R1-#R9) patients on suicide precautions were not exposed to ligature risks in patient care area room B. Findings: Review of psychiatric hospital’s policy #BH1117 titled “General Facility Safety and Patient Management”, last revised 10/20/24, revealed in part: “Policy: Universal Behavioral Health Hospitals’ environment shall be maintained in a safe, clean and orderly manner and designed to optimize positive self-regard. The facility shall be routinely checked to protect patients, visitors, and staff from potential safety hazards.” Review of psychiatric hospital’s policy #BH1119 titled “Contraband and Restricted Articles” last revised 10/30/2024, revealed in part: “Policy, in part: It is the policy of Universal Behavioral Health Hospital to define as contraband those items that could pose potential safety risks to patients or threaten the integrity of the milieu. Procedure, in part: Items considered to be restricted shall include, but shall not be limited to: Bags, plastic bags.” Review of psychiatric hospital’s policy #1.11 titled “Rights of All Patients”, dated 07/2021, revealed in part: “Patient Rights, in part: 30. The right to receive care in a safe setting.” Review of psychiatric hospital’s census dated 02/18/2025 revealed Patients #R1-#R9 were on suicide precautions. On 02/18/2025 at 9:27 AM, Observation of room B revealed a 7-10 gallon trash receptacle lined with a plastic trash bag noted with a blue bag with fabric handles overflowing from the top of the receptacle. Over the trash receptacle was a blue sign that indicated use of paper bags only with an arrow pointing to the trash receptacle. In an interview on 02/18/2025 at 9:27 AM, S1DON and S2RM confirmed that the plastic garbage bag and the blue bag with fabric handles were a ligature risk and should not be accessible to new patients who were brought to room B on admission.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by failure of the Registered Nurse to document observations on 1 (#2) of 3 (#1-#3) patients every 2 hours per hospital policy. Findings: Review of psychiatric hospital’s policy #8.08, titled “Observation Precautions”, last updated 01/2024, revealed in part: “Documentation, in part: Charge nurse or designee will make rounds every 2 hours and sign the observation sheet to ensure that MHT’s are observing their assigned patient, filling the form out correctly and not charting ahead.” Review of Patient #2’s medical record revealed an admission date of 02/06/2025 with diagnoses of MDD, and Suicidal Ideations with a plan. Further review revealed precaution level “Suicide”. A review of Patient #2’s Close Observation sheets failed to reveal the registered nurse documented observations every 2 hours as required by hospital policy on the following dates and times: 02/07/2025 from 6:15 AM-5:45 PM 02/15/2025 from 6:15 AM-3:45 PM In an interview on 02/18/2025 at 1:57 PM, S1DON confirmed the Registered Nurse failed to document patient observations every 2 hours per hospital policy on Patient #2.”

“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: 47397 Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to include medical diagnoses in the plan of care for 1 (#2) of 3 (#1-#3) patient care plans reviewed. Findings: Review of psychiatric hospital’s policy #1.11 titled “Rights of All Patients”, dated 07/2021, revealed in part: 43. The right to a treatment plan that is set up to meet your individual needs.” Review of psychiatric hospital’s policy #1.10 titled “Rights of Involuntary Patients”, last reviewed 09/2018, revealed in part: “Procedure, in part: 2. All patients receiving mental health services pursuant to the provisions of the Louisiana Mental Health Code have the following rights, in part: c. to individualized treatment plans.” Review of Patient #2’s medical record revealed an admission date of 02/06/2025 with diagnoses of Human Immunodeficiency Virus (HIV) (on Biktarvy), obesity, substance abuse, MDD, anemia , gunshot wound (history of), nicotine dependence and Suicidal Ideations with a plan. Review of Patient #2’s Multidisciplinary Integrated Treatment Plan failed to reveal active problems pertaining to HIV, a medical problem requiring intervention. In an interview on 02/18/2025 at 2:15 PM, S1DON confirmed Patient #2’s treatment plan was not set up up meet his individual needs as required by hospital policy.”

“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 psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This deficient practice is evidenced by failure to ensure an RN made all patient care assignments. Findings: Review of psychiatric hospital’s policy #3.14, titled “Assignment of Patient Care”, dated 01/2021, revealed in part: “Procedure, in part: 2. The RN on each shift will assess each patient’s needs before making assignments to other nursing staff. Completion of the “Unit Assignment Sheet” will be accomplished by the Charge RN in collaboration with the lead MHT”. Observations on 02/18/2025 at 9:15 AM revealed S6MHT sitting at a table in the milieu filling out a document titled “Unit Assignments” dated 02/18/2025 for the psychiatric hospital census of 24. In an interview on 02/18/2025 at 9:15 AM S6MHT stated she was trying to finish making the assignments for the day. In an interview on 02/18/2025 at 9:21 AM, S1DON confirmed S6MHT was not a Registered Nurse and completed the assignment sheet dated 02/18/2025. S1DON stated the Registered Nurse should assign the nursing care of each patient but on this day the Registered Nurse was PRN (as needed) will look at assignments made by MHT and sign the sheet.”

“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: 47397 Based on observation and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failing to have a clean and sanitary environment. Findings: Review of psychiatric hospital’s policy #1.11 titled “Rights of All Patients”, dated 07/2021, revealed in part: Rights which May Not Be Limited in part: 5. Safe and sanitary housing.” On 02/18/2025 at 9:23 AM, observation of room A revealed a half opened Styrofoam-like box of old-appearing food on the floor near the wall by the door with trash strewn around it. In an interview on 02/18/2025 at 9:23 AM, S1DON confirmed the old food and trash on the floor was unsanitary and should not be in room A.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 47397 Based on observation, record review and interview the hospital failed to provide re-evaluation of the patient’s condition to identify changes that required modification of the discharge plan. This deficiency is evidenced by failure of the hospital to identify changes that required modification of the discharge plan in 2 (#1 and #2) of 3 (#1-#3) patients reviewed. Findings: Review of psychiatric hospital’s policy #2.12 titled, “Discharge Criteria/Discharge Planning Standards”, dated 01/2021, revealed in part: “Procedure in part: 1. Individualized criteria for discharge are determined by the attending psychiatrist in charge of the patient’s treatment and the interdisciplinary treatment team. The following criteria must be met in order to discharge a patient in part: c. There is no longer need for skilled observation and treatment. d. there is no longer an indication of impaired mental and/or physical function or mood alteration which is sufficient to interfere substantially with the patient’s capacity to meet the demands of the family, educational, occupational, and social environment. e. patient has achieved maximum benefit as an inpatient and the care and treatment required by the patient can be effectively rendered on an outpatient basis or in a less restrictive seitting. f. Patient is returning to stable family and/or living situation. Review of psychiatric hospital’s policy #3.11 titled, “Discharge Planning”, last updated 01/2024, revealed in part: “Procedure, in part: 3. The discharge plan will address the individual needs of the patient, be realistic and achievable, and include, but not be limited to, the following: a. Aftercare. b. Disposition. c. Education/Teaching Needs.” Review of psychiatric hospital’s policy #5.24 titled, “Social Work Plan and Services”, last updated 01/2024, revealed in part: “Procedure in part: Goals in part: 3. To ensure that treatment and discharge planning takes into account the patient’s family and community resources. Review of psychiatric hospital document titled, “Social Worker Job Description”, last revised 07/2022, revealed in part: “Once they have determined the mental health status and treatment history of their patients, psychiatric social workers are responsible for overall case management. This can include ensuring their Patients receive the mental health support they need by, in part: Coordinating safe and effective discharges when the time comes for patients to transition to a different treatment facility or back home.” Review of psychiatric hospital document titled, “Discharge Planner Job Description”, undated, revealed in part: Regularly re-evaluate a patient’s condition to identify necessary modification of the discharge plan, and complete the discharge planning process in a timely manner prior to discharge. Prepare patients and their caregivers to be active partners/participants in post-discharge care. Provide discharge instructions to patient upon discharge. Conduct safety planning with patient upon discharge.” Patient #1 Review of Patient #1’s medical record revealed an admission date of 01/02/2025 with diagnoses of Schizoaffective, bipolar type, and Urinary Tract Infection (UTI) with urinary catheter. Hospital Insurance was Medicare and Medicaid. Review of Patient #1’s Psychosocial Assessment dated 01/03/2025 at 11:30 AM revealed a recent discharge from another psychiatric facility on 12/31/2024 after a stay of several days. Patient’s sister expressed frustration that she was not included in the discharge planning and that the patient was returned to her care without proper follow-up. Patient was unable to provide any relevant information due being disorganized. Patient was unable to authorize whether his sister could be called. Review of Patient #1’s discharge plan dated 01/03/2025 revealed patient had a catheter placement. Further review revealed decreased oral intake and risk for falls requiring assistance with bathing and ADLs daily/PRN. In an interview on 02/19/2025 at 11:08 AM, S1DON verified Patient #1’s medical record failed to reveal the urinary catheter was removed before discharge. Review of Patient #1’s Initial Discharge Planning and Collateral Contact dated 01/10/2025 revealed documentation that the patient’s sister reported he was unable to care for himself and his house was in bad shape. Sister reported that he is unable to perform ADLs and stated she would rather the patient not discharge back to her house. Documentation of current outpatient services revealed a psychiatrist. No PCP or specialists listed, only N/A. Listed under Barriers to a successful discharge plan: “Unable to identify at this time.” Other recommended follow-up revealed N/A. Review of Patient #1’s Discharge Follow up dated 01/17/2025 at 12:09 PM revealed in part: Discharge medications included clonazepam (benzodiazepine) 0.5 mg oral tablet twice daily. Divalproex sodium (mood stabilizer that requires blood level monitoring) 250 mg oral tablet delayed release twice daily. Paliperidone (antipsychotic) 3 mg oral tablet extended release at bedtime. Suicide Prevention, in part: Patient calm, compliant with discharge. Patient denies SI, HI, AVH. Patient understands the importance of crisis planning. Patient understands that all follow-up appointments are recommended 5-7 days following discharge. Patient discharging home with sister with home health referral. Patient transporting via Medicaid. Further review revealed documentation the patient was self-ambulatory and required no assistive devices. In an interview on 02/19/2025 at 11:08 AM, S1DON confirmed Patient #1 discharged home without a wheelchair even though he required the use of a wheelchair during his admission. Review of Psychiatric Progress note dated 01/16/2025 (the day before discharge) revealed Patient #1 presented with significant psychiatric deterioration characterized by marked thought disorder and behavioral disorganization. The clinical presentation was notable for bizarre behaviors and significant impairment in cognitive functioning. Patient demonstrated marked difficulty with basic activities of daily living (ADLs), requiring staff assistance for basic self-care needs. There was evidence of severe thought disorder manifesting as thought blocking and notably delayed speech patterns. The patient’s cognitive status showed significant impairment, with disorientation to time, place, and situation. Review of Patient #1’s medical record failed to reveal a Psychiatric Progress note for 01/17/2025. Review of Patient #1’s Daily Nursing Note dated 01/17/2025 (day of discharge) revealed he appeared disheveled and unkempt. Sensorium clouded. Speech mumbled and delayed. Mood anxious. Affect anxious sullen and flat. Thought processes blocked and slowed. Thought content blocked and slowed. Perceptual disturbance was auditory. Further review revealed Patient #1’s gait/balance was jerking/unstable when walking or standing. Required use of assistive devices. Patient needed assistance with bed/wheel chair and toilet transfers. Continued review revealed patient was anxious, flat and sullen. Patient was responding to internal stimuli. Patient was mumbling with slow delayed responses. Foley catheter was in place and patient was on 1:1 observations. In an interview on 02/19/2025 at 2:45 PM, S1DON confirmed Patient #1’s Discharge Follow-up dated 01/17/2025, Nursing Note dated 01/17/2025 and the Psychiatric Progress note dated 01/16/2025. Review of Patient #1’s Social Worker Progress Note dated 01/14/2025 at 3:23 PM revealed the discharge planner spoke with his outpatient psychiatrist who was concerned about his discharge. The discharge planner informed the psychiatrist of the discharge plan to go home with hospice care. The psychiatrist requested to speak with Patient #1. The discharge planner brought the phone into patient’s room and he proceeded to blame the psychiatrist for his admission and stated his medications were messed up because of the psychiatrist. Patient #1 stated he was stuck in a psychological war and that he was being toured by his mind. Patient agreed to go to a rehab swing bed. Review of Patient #1’s Psychiatric Progress Notes dated 01/09/2025, 01/11/2025, 01/12/2025, 01/15/2025, and 01/16/2025 failed to reveal provider discussed discharge plans with patient or family. Review of Patient #1’s discharge follow-up, social worker progress notes, and discharge planning notes failed to reveal modifications to the discharge plan regarding the following: - significant psychiatric deterioration characterized by marked thought disorder and behavioral disorganization the day before discharge, -required urinary catheter care, -marked difficulty with basic activities of daily living, -need for ambulatory assistive devices, -cognitive status that showed significant impairment, with disorientation to time, place, and situation, -patient was responding to internal stimuli on the day of discharge. In an interview on 02/18/2025 at 12:32 PM, S9DSS reported social services had been short staffed until the end of January. Patient #2 Observation of hospital entrance on 02/18/2025 at 11:30 AM revealed Patient #2 returning after having been discharged on the same day at 10:15 AM. Patient #2 was expressing concern regarding the incorrect address provided to his transportation driver. In an interview on 02/18/2025 at 11:35 AM, Patient #2 stated the social worker gave the driver the wrong address. She gave the driver the address of Shelter D instead of his brother’s home. Patient #2 explained he had told the social worker yesterday afternoon that he wanted to go to his brother’s home and that he did not want to go to the shelter. When he left at 10:15 AM he thought he was going to his brother’s home until the driver told him the address he was being transported to was Shelter D. Patient #2 reported he did not speak to a social worker before he was discharged at 10:15 AM. Observation of hospital entrance on 02/18/2025 at 11:40 AM revealed Patient #2 still waiting with driver for social worker too obtain correct address of his brother. Observation of hospital entrance on 02/18/2025 at 11:45 AM revealed S5DP spoke with Patient #2 and stated she would not send him to his brother’s home without speaking to his brother. S5DP stated he had to go to Shelter D where he could call his brother to get a ride. Patient #2 stated he did not want to go to the Shelter D. S5DP stated if he chose not to go to Shelter D and to wait for her to call his brother, she would have to redo all the paper work and and that would take a while. Patient #2 decided to go the shelter after social worker said she had to redo all of the paper work, which would take a while. In an interview on 02/18/2025 at 11:50 AM, S5DP stated the discharge paper work included discharge planning and documents pertaining to Shelter D. She did not call the brother today because he was going to Shelter D. S5DP reported she was not aware Patient #2 did not want to go to shelter because she did not speak to Patient #2 before he left the hospital on 02/18/2024. Review of Patient #2’s medical record revealed an admission date of 02/06/2025 with diagnoses of HIV, substance abuse, MDD, and Suicidal Ideations with a plan. Review of Patient #2’s physician orders dated 02/17/2025 at 3:58 PM revealed the following: Discharge home 02/18/2025 with current medications and follow-up care. Review of Patient #2’s Discharge Follow-up dated 02/18/2025 and signed by nurse at 9:30 AM revealed discharge destination was “Shelter”. Further review failed to reveal evidence S5DP spoke with Patient #2 on 02/18/2025. In an interview on 02/18/2025 at 12:32 PM, S9DSS verified the discharge planner should always speak with patients before they leave the hospital. S9DSS confirmed the discharge plan should have been modified. S9DSS reported that when Patient #2 asked S5DP to call his brother on 02/18/2025 she should have called the brother to confirm his agreement with Patient #2’s discharge to his home. In an interview on 02/19/2025 at 10:38 AM, S1DON verified Patient #2’s physician orders indicated Patient #2 was to discharge home 02/18/2025 with current medications and follow-up care.”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 47397 Based on record review and interview the psychiatric hospital failed to assess its discharge planning process on a regular basis as evidenced by failure to complete an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs. Findings: Review of psychiatric hospital’s policy #2.12 titled, “Discharge Criteria/Discharge Planning Standards”, dated 01/2021, revealed in part: “Policy, in part: It is the policy of the hospital to define Discharge Planning Standards and responsibilities of the interdisciplinary staff for maintaining those standards. Purpose, in part: To ensure the continuity of care and effective utilization of resources.” Review of psychiatric hospital’s documents provided by S1DON and S2RM failed to reveal evidence of an ongoing, periodic review of a representative sample of discharge plans including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. During an interview on 02/19/2025 AT 10:42 AM, S1DON confirmed the psychiatric hospital has never implemented an ongoing, periodic review of a representative sample of discharge plans to assess its discharge planning process.”

“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 hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: 1) failure to ensure 1 (#5) of 3 (#2, #3 and #5) patients on suicide precautions sampled were observed per physician orders (See findings under A0145). 2) failure to ensure contraband was not accessible to patients (See findings under A0144); 3) failure to identify an environmental safety risk as evidenced by allowing an unstable patient in the nurses’ station for PRN injection (See findings under A0144); 4) failure to ensure patients with a diagnosis of homicidal ideations received a Violence Risk Assessment per policy in 1 (#5) of 3 (#1, #4, and #5) patients reviewed for Violence Risk Assessment (See findings under A0144); 5) failure to ensure staff criminal background checks did not include convictions that bar employment in 1 (#S4DPA) of 4 (S2MHT, S4DPA, S9MHT, and S10MHT) non-licensed personnel files reviewed (See findings under A0145); 6) failure to ensure nursing staff observed patients’ #R11-#R17 every 2 hours as per hospital policy (See findings under A0145); 7) failure to ensure the hospital’s direct care staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S7LPN) of 9 (S1LPN, S2MHT, S4DPA, S5RN, S6LPN, S7LPN, S8RN, S9MHT, and S10MHT) direct care staff sampled having an expired certification in Management of Aggressive Behavior. (See findings under A0200).”

“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 each patient received care in a safe setting as evidenced by: 1) failure to ensure contraband was not accessible to patients; 2) failure to identify an environmental safety risk as evidenced by allowing an unstable patient in the nurses’ station for PRN injection; 3) failure to ensure patients with a diagnosis of homicidal ideations received a Violence Risk Assessment per policy in 1 (#5) of 3 (#1, #4, and #5) patients reviewed for Violence Risk Assessment. Findings: 1) Failure to ensure contraband was not accessible to patients. Review of hospital policy titled “Rights of All Patients”, dated 07/2021, revealed in part: The right to receive care in a safe setting. Review of hospital policy titled “General Facility Safety and Patient Management”, dated 01/2021, revealed in part: Policy, in part: The behavioral Health services environment shall be maintained in a safe, clean and orderly manner at all times. The facility shall be routinely checked to protect patients, visitors, and staff from potential safety hazards. Review of hospital policy titled “Contraband”, dated 12/26/23, revealed, in part: Policy: It is the policy of the hospital to define contraband as those items that could poise potential safety risks to patients or threaten the integrity of the milieu. Purpose: to define items considered contraband and to establish controls for maintaining the safety and security of the milieu. Procedure: In part: 1. Contraband (Harmful Material) is defined as, in part: c. Medication and drugs: prescribed, illicit, and over-the-counter. h.Grooming products... i....plastic bags. f ...cell phones. g....lighters. Review of hospital policy titled, “Patient Room Safety”, dated 01/2021, revealed in part: Policy, in part: Patient rooms will be checked every shift. Contraband will be removed if found and charge nurse is notified. Review of hospital policy titled. “Admission Process”, dated 01/2021, revealed in part: Procedure, in part: 4 ....The patient will be wanded for metal detection and safety before entering the unit. 5. The MHT/nurse will conduct a patient search and complete the patient belongings inventory in the intake room ...Prior to securing patient clothing and valuables, the staff will ensure all items are present and verified by admitting RN. 6. All valuables will be placed in a security envelope labeled with the patient’s name. A copy of the inventory form will be attached to the outside of the envelope with the original placed in the chart. The receipt from the security envelope will be attached to the original inventory form in the chart. The original inventory list is signed by the patient, the nurse, and the MHT. The original inventory list is maintained in the medical record. Observations Review of hospital census dated 07/15/2024 revealed 10 (#3, #R1, #R3-#R10) patients on suicide precautions. Observation on 07/15/2024 at 10:00 a.m. revealed plastic garbage bag in trashcan in dayroom c. In an interview on 07/15/2024 at 10:00 a.m., S3DON confirmed that the plastic garbage bag is considered contraband and should not be in dayroom c where it is accessible to patients. Observation on 07/15/2024 at 10:04 a.m. revealed room a contained a bottle of deodorant on bedside table. Further observation revealed room b contained a bottle of deodorant on bedside table. Review of Unit A’s census dated 07/15/2024 revealed #R1 was assigned to room a. Further review revealed #R1 was on suicide precautions. Review of Unit A’s census dated 07/15/2024 revealed #R2 was assigned to room b. Further review revealed #R2 was on behavioral precautions. In an interview on 07/15/2024 at 10:05 a.m., S3DON verified rooms a and b each contained a bottle of deodorant on bedside table. In an interview on 07/15/2024 at 10:15 a.m., S3DON #R1 was in room a and was on suicide precautions and should not have contraband in her room. S3DON verified #R2 was in room b and was on behavioral precautions and should not have contraband in her room. In an interview on 07/15/2024 at 1:10 p.m., S3DON and S11RM confirmed all grooming products, including deodorant, are considered contraband. S3DON reported that although the policy for contraband was updated in March, it should be further updated to include “Deodorant” as a grooming product. S3DON stated a contraband search of all rooms should be done and the bottles of deodorant removed immediately. Patient #4 Review of incident log dated 02/09/2024 at 3:07 p.m. revealed Patient #4 was found smoking drugs in his room. There were no actions listed on the incident log. The log indicated a self-report was not submitted. Review of incident log dated 02/09/2024 at 9:00 p.m. revealed Patient #4 was found with a lighter. Patient #4 appeared to be fidgety and acting suspicious. It was discovered that Patient #4 was hiding something between the wall and the handrail in the hallway. A search revealed a lighter. Action was to search Patient #4 and everything removed from room to be searched. The log indicated a self-report was not submitted. Review of incident report dated 02/09/2024 at 3:07 p.m. revealed Patient #4 was found smoking drugs in his room. Further review failed to reveal details of the incident. Continued review failed to reveal a supervisor or a physician was notified. Review of incident report dated 02/09/2024 at 9:00 p.m. revealed Patient #4 was found with a lighter. The incident report indicates this was the second lighter, the first lighter was found in his room. Measures to put in place were to do better searches during intake process. In an interview on 07/16/2024 at 11:10 a.m., S11RM confirmed the incidents that occurred on 02/09/2024 at 3:07 p.m. and 9:00 p.m. S11RM reported the hospital observed video and did not see where Patient #4 picked up the lighters or the drugs. The hospital interviewed staff and Patient #4 and could not determine where the lighters came from, what drugs he was smoking or how he obtained the lighters or the drugs. S11RM believed the drugs were flushed after found but could not verify. S3DON and S11RM do not know how or where Patient #4 obtained the contraband. S3DON and S11RM confirmed Patient #4 should not have had lighters or drugs per hospital policy. Patient #5 Review of incident log dated 04/15/2024 at 11:55 a.m. revealed Patient #5 was found with a cellphone and lighter in his room while cleaning it out upon discharge. Action was to educate staff on the importance of contraband rounds. The log indicated a self-report was not submitted. Review of incident report dated 04/15/2024 at 11:55 p.m. revealed Patient #5 was found to have a lighter and a cell phone on his person. The report indicated that Patient #5 walked up and asked if he could have a charger for his phone. He had tried charging his phone with the hand dryer. When asked how he had possession of a phone, Patient #5 stated he had the phone since he came in. Patient #5 was also found to have a black lighter when he was smoking with another patient. A review of Patient #5’s medical record revealed admission on 04/08/24 at 10:50 p.m. and discharge on 04/15/2024 at 12:45 p.m. In an interview on 07/16/2024 at 12:35 p.m., S11RM reported Patient #5 was to be discharged on 04/15/2024. S11RM stated staff had him sign for his belongings and he grabbed the phone and lighter from the belonging bag at that time. A review of Patient #5’s “Personal Items Inventory Form”, dated 04/08/2024 at 10:50 p.m. failed to reveal a lighter and a cell phone were included on the list of Patient #5’s personal items. Further review revealed Patient #5 signed the form on 04/08/2024 at 10:50 p.m. Continued review revealed the section labeled, “Discharge Signatures and Return of Property”, contained Patient #5’s signature dated 04/15/2024 at 12:45 p.m., which was 50 minutes after the incident occurred. In an interview on 07/16/2024 at 12:45 p.m., S11RM confirmed Patient #5’s “Personal Items Inventory Form”, dated 04/08/2024 at 11:00 p.m. failed to reveal a lighter and a cell phone were included on the list of Patient #5’s personal items. S3DON and S11RM verified Patient #5 signed the form on 04/08/2024 at 10:50 p.m. and at discharge on 04/15/2024 at 12:45 p.m., which was 50 minutes after the incident occurred. S11RM did not know why the incident report and the incident log did not correlate. S11RM and S3DON confirmed patient should not have had a lighter or a phone per hospital policy. 2) Failure to identify an environmental safety risk as evidenced by allowing an unstable patient in the nurses’ station for a PRN injection. Review of incident log dated 06/02/2024 at 5:20 p.m., revealed Patient #1 was located in a locked and enclosed nurses’ station, yelling and screaming. Patient #1 was in the nurses’ station in order to receive a PRN medication. Patient #1 proceeded to pull a nurse’s wig from her head and a fight broke out. Actions taken: the patient removed from nurses’ station. The incident log indicated the incident was self-reported due to workplace violence. Review of Incident Report dated 06/02/2024 at 5:20 p.m. revealed Patient #1 was cursing, threatening and yelling at another patient. She was brought into the nurses’ station to receive a PRN medication. While administering the injection, Patient #1 jumped up and attacked an employee. She hit her in the back of the head and pulled her hair. Staff intervened. Patient #1 was removed from the nursing station. No injuries noted. Review of Hospital Abuse/Neglect Initial Report dated 06/04/2024 at 8:30 a.m. revealed that on 06/02/2024, Patient #1 was brought into the Unit A nurses’ station to receive a PRN medication. S1LPN was sitting at the nurses’ station desk. Patient #1 stood up and pulled S1LPN’s wig off head. S1LPN attempted to punch Patient #1 however, ended up hitting S2MHT. Patient #1 was removed from nurses’ station and escorted to room c with an MHT to keep her away from other patients. She was on Q 15 minute observations and discharged on 06/04/2024. S2MHT denied pain or injuries. S1LPN was sent to Unit B for the rest of shift. After hospital reviewed video, S1LPN was suspended for 3 shifts and required to complete crisis prevention training and anger management training before returning to work. In an interview on 07/15/2024 at 10:15 a.m., S3DON stated that PRN injections should be given in the patient rooms unless staff are unable to bring patient to their room. In an interview on 07/15/2024 at 12:59 p.m., S3DON confirmed patients are not allowed in the nurses’ station due to the risk of compromising patient and staff safety. S3DON reported that they are currently revising a policy regarding patient entrance into the nurses’ station. Patients are not allowed in nurse’s station. Any interaction should be in patient room, or exam room, or other room where a camera is located. In an interview on 07/16/2024 at 11:17 a.m, S2MHT stated Patient #1 was brought into the nurses’ station in order to contain her. S2MHT reported Patient #1 was in a chair in nurses’ station to get PRN injection. Two techs and three nurses were also in nurses’ station. S1LPN was working on the computer while Patient #1 was getting the injection. Patient #1 started acting out during injection, 3 techs tried to contain her. S1LPN’s back was to Patient #1 when Patient #1 reached out and snatched her wig off. S2MHT was hit in the middle of the nose while S1LPN was flailing her arms about. S2MHT stated she did not tell anyone she was hit until 06/04/2024. 3) Failure to ensure patients with diagnosis of homicidal ideation received a Violence Risk Assessment per policy in 1 (#5) of 3 (#1, #4, and #5) patients reviewed for Violence Risk Assessment. Review of hospital policy titled, “Homicide/Violence Precautions, Serious Threats of Physical Harm Including Tarasoff Warning”, revised 01/2024, revealed in part: Level II: Homicidal Precautions, in part: 1. Patient assessed to have a history of homicidal behavior or intent. 2. Patient behavior: a. possibility of the presence of homicidal ideation. Review of Patient #5’s medical record revealed an admission date of 04/08/24 at 10:50 p.m. with diagnosis of homicidal ideation, suicidal ideation, depressive disorder, substance use. Patient was admitted after fighting with his uncle. Review of Patient #5’s Psychiatric Evaluation dated 04/09/2024 at 1:47 p.m. revealed in part: Danger to others/Aggressive behavior. Behaviors that create a risk to self or others: Homicidal Ideations. Criteria for discharge, in part: No homicidal ideations for three days. Problem list for treatment plan: homicidal ideations, mood lability and substance abuse. Review of Patient #5’s Nursing Admission Assessment dated 04/08/2024 at 10:50 p.m. revealed Section VI: Violent Risk Assessment. Further review failed to reveal the assessment had been completed. In an interview on 07/16/2024 at 12:15 p.m., S11RM verified patient #5 was diagnosed with homicidal ideation and the level of homicidal/violence precaution could not be determined because the Violent Risk Assessment was not completed.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on observation, record review and interview the hospital failed to ensure all patients were free from all forms of abuse, harassment or neglect as evidenced by: 1) failure to ensure 1 (#5) of 3 (#2, #3 and #5) patients on suicide precautions sampled were observed per physician orders. 2) failure to ensure staff criminal background checks did not include convictions that bar employment in 1 (#S4DPA) of 4 (S2MHT, S4DPA, S9MHT, and S10MHT) non-licensed personnel files reviewed; 3) failure to ensure nursing staff observed patients’ #R11-#R17 every 2 hours as per hospital policy; Findings: 1) Failure to ensure 1 (#5) of 3 (#2, #3 and #5) patients on suicide precautions sampled were observed per physician orders. Review of hospital policy titled “Assessment of the Patient at Risk for Suicide”, dated 01/2021, revealed in part: Procedure, in part: 1. Suicide Precautions with appropriate monitoring will be initiated once suicide assessment completed and when a Physician’s Order is given to initiate suicide precautions as follows, in part: 7. Ongoing documentation by the nursing staff is required to verify that suicide precautions are maintained during each shift ...9. The charge nurse or nurse designee is responsible for ensuring that the appropriate level of observation is maintained and documented. 12. Employees who monitor a patient placed on Suicide Precautions must be trained in at least the following areas in part: Proper completion of the Observation Sheet. Review of hospital policy titled, “Observation Precautions”, dated 01/2021, revealed in part: Policy, in part: ...Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner. Procedure, in part: Documentation, in part: ...Charge nurse or designee will make rounds every 2 hours and sign the observation sheet to ensure that MHT’s are ...filling the form out correctly ... Review of Patient #5 electronic medical record, guided by S11RM, revealed an admission date of 04/08/24 at 10:50 p.m. with diagnosis of suicidal ideation, homicidal ideation, and major depressive disorder. Continued review revealed Patient #5’s Psychiatric Evaluation dated 04/09/2024 at 1:47 p.m.. The review revealed in part: 3. Attempt, threat or danger of Suicide. History of suicidal thoughts. Behaviors that create a risk to self or others: Suicidal Ideations ... Criteria for discharge, in part: No suicidal ideations for three days. Problem list for treatment plan: suicidal Ideations, homicidal ideations, mood lability and substance abuse. Additional review revealed provider orders dated 04/08/2024 at 11:49 p.m. included Suicide Precautions. Further review of Patient #5’s electronic medical record revealed a scanned observation sheet dated 04/09/2024 signed by the day and night nurse but failed to include Patient #5 was on suicide precautions. In an interview on 07/16/2024 at 12:30 p.m., S11RM verified that the scanned observation sheet in the electronic medical record dated 04/09/2024 failed to reveal Patient #5 was on Suicide Precautions. S11RM presented a paper copy of the observation sheet that was located in the closed chart also dated 04/09/2024, with an upside down check mark next to Suicide Precautions. S11RM indicated she was not sure if the paper version of the observation sheet had been altered. 2) Failure to ensure staff criminal background checks did not include convictions that bar employment in 1 (#S4DPA) of 4 (S2MHT, S4DPA, S9MHT, and S10MHT) non-licensed personnel files reviewed. Review of hospital policy titled “Patient Abuse and /or Neglect, dated 01/2021, revealed in part: Policy: It is the policy [hospital] to provide for a safe environment free from all forms of abuse or harassment. The intent of this requirement is to prohibit all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors. Goals, in part: 2. Screening of Employees: persons with a record of abuse or neglect will not be hired or retained employees. Review of hospital policy titled, “Personnel/New Hire policy”, revised, 01/2024, revealed in part: Procedure, in part: 3. The department Program Director does the interviews and when they have decided who to hire, HR submits background check ...4. When background check comes back clear, HR will notify Program Director. HR gives the PA to CEO for approval. HR then contacts the potential employee to come in to complete paperwork, receive identification badge, HR will schedule the new employee to complete mandatory ...trainings/orientations at this time. Review of incident log dated 05/31/2024 at 9:16 a.m. revealed Patient #1 was yelling and screaming. Patient #1 approached S4DPA and hit her, and S4DPA hit back. Once staff intervened and separated both parties, S4DPA went back and again attacked Patient #1. Action: Patient #1 was discharged per provider order. S4DPA was terminated. The incident log indicated the incident was self-reported. Review of Incident Report dated 05/31/2024 at 9:16 a.m. revealed Patient #1 was administered a PRN medication prior to incident. Patient yelling and cursing and ran up to staff member and punched her in the face. Staff members intervened and separated both parties. The incident report failed to indicate a follow up assessment was completed for Patient #1. Review of Hospital Abuse/Neglect Initial Report dated 05/31/2024 at 9:16 a.m. revealed video footage that on 05/31/2024, Patient #1 was walking in hallway when S4DPA walked out of office. Patient #1 appeared to be exchanging word. Patient #1 then swung at S4DPA and S4DPA swung back. Staff intervened immediately. S4DPA attempted to hit Patient #1 again. Patient #1 was brought to her room. Actions: Patient #1 was placed in her room and a discharge order was obtained from provider. Patient #1 unable to be discharged due to group home refusing to accept patient back and family not willing to accept patient back due to psychosis. S4DPA was terminated. The allegation was substantiated due to S4DPA hitting Patient #1. Review of terminations list revealed #S4DPA was terminated on 05/31/2024. Review of #S4DPA’s personnel file revealed date of hire 12/15/2023. Review of #S4DPA’s criminal background check, updated on 12/12/2023, revealed the following: 02/15/2020-CCRP 202 warrant. Continued review failed to reveal a disposition for the arrest warrant. In an interview on 07/16/24 at 1:30 p.m., S11RM confirmed the hospital does not have the disposition for #S4DPA’s arrest warrant and further stated the exact reason for the warrant was unknown. 3) Failure to ensure nursing staff observed patients’ #R11-#R17 every 2 hours as per hospital policy. Review of hospital policy titled, “Observation Precautions”, dated 01/2021, revealed in part: Policy, in part: ...Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner. Procedure, in part: Documentation, in part: ...Charge nurse or designee will make rounds every 2 hours and sign the observation sheet to ensure that MHT’s are observing their assigned patient, filling the form out correctly and not charting ahead. Review of Job Description titled, “Registered Nurse, Inpatient”, N.D. , revealed in part: Essential Job Functions, in part: 1. Responsible for supervision of ...MHTs. 19. Completes and signs ...required documentation within guidelines mandated by law and applicable hospital policies and procedures. Review of observation sheets dated 07/15/2024 for patients’ #R11-#R17 on Unit B failed to reveal the nurse made rounds every 2 hours and signed the observation sheet ensuring that MHT’s observed their assigned patients, filled the form out correctly and did not chart ahead. In an interview on 07/15/2024 at 1:40 p.m., S3DON confirmed nurse did not document rounds per hospital policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(ii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (ii) The use of nonphysical intervention skills. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the hospital’s direct care staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S7LPN) of 9 (S1LPN, S2MHT, S4DPA, S5RN, S6LPN, S7LPN, S8RN, S9MHT, and S10MHT) direct care staff sampled having an expired certification in Management of Aggressive Behavior. Findings: Review of hospital policy titled, “Workplace Violence Plan”, dated 06/15/2021, revealed in part: Purpose: ...to minimize the risk of violence occurring in the workplace, establish and maintain a safe, secure environment and comply with law and regulation. Annual Continuing Education, in part: All employees are required to participate in annual education and training activities related to workplace violence prevention ... Review of S7LPN’s personnel record revealed a certificate titled, “Management of Aggressive Behavior”, dated 06/10/2022 with an expiration date of 06/10/2024. Review of unit assignments dated 07/15/2024 revealed S7LPN was on the schedule for the day shift. In an interview on 07/15/2024 at 4:02 p.m., S3DON verified S7LPN is currently on the schedule and her crisis prevention training expired 06/10/24.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47397 Based on record review and interview the hospital failed to ensure nursing staff followed the policies and procedures of the hospital. This deficiency is evidenced by failure of the nursing staff to monitor fetal heart tones for Patient #1 per provider order. Findings: Review of hospital policy titled, “Fetal Heart Tones, Monitoring”, revised 01/2024, revealed in part: purpose: 1. To monitor the status of the fetus. 2. To detect fetal distress and provide appropriate nursing intervention. Policy in part: All pregnant females admitted [to hospital] will be monitored. Procedure in part: 8. Check the fetal heart tones (FHT) every shift. Follow physician orders for perimeters and instructions. Review of Patient #1’s electronic medical record, guided by S11RM, revealed Patient #1 was admitted on 05/24/2024 at 5:30 p.m. and discharged on 06/04/2024 at 5:20 p.m. Continued review revealed Patient #1’s History and Physical completed on 05/25/2024 at 5:17 p.m. indicated Patient #1 was 18 weeks pregnant. Further review of Patient #1’s History and Physical revealed the provider’s Assessment and Plan. The Assessment and Plan revealed in part: 8. Pregnancy (18 weeks)-Fetal heart tones every shift. Monitor. Review of provider order dated 05/25/2024 at 5:21 p.m. revealed close observation-Staff to monitor Fetal Heat Tones every shift. Call if FHR <110 or >180. Review of Patient #1’s nursing notes revealed the following: 05/26/2024 at 10:00 p.m. Patient #1 refused FHT and was in seclusion. No indication medical provider was notified. 05/27/2024 day shift and night shift with no FHTs recorded. No documentation as to why. 05/28/2024 day shift and night shift with no FHTs recorded. No documentation as to why. 05/30/2024 night shift. Patient #1 refused FHTs and was in seclusion. No indication medical provider was notified. 05/31/2024 day shift or night shift with no FHTs recorded. No documentation as to why. 06/01/2024 day shift or night shift with no FHTs recorded. No documentation as to why. 06/02/2024 day shift or night shift with no FHTs recorded. No documentation as to why. 06/04/2024 day shift with no FHTs recorded. No documentation as to reason why. In an interview on 07/16/2024 at 11:10 a.m., S11RM verified that the FHTs were not recorded as above and the provider orders were not implemented per policy.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to provide care in a safe setting. The deficient practice is evidenced by the hospital failing to properly observe 1 (#1) of 3 (#1-#3) patients according to ordered observation levels. (see Tag A0144). Findings: A review of facility policy titled, “Observation Precautions” Policy 8.08, revealed in part, each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient’s status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Procedure A. Level I: One to One Observation (staff must be within arms-length of patient at all times). Item 1. Definition; This a strict one-to-one (1:1) observation with staff constantly monitoring the patient at all time, i.e. bathroom, shower, walking out of group, etc. The assigned staff member must be within arms-length of the patient at all times. The patient’s face and hands must be seen by the staff member at all times. Item 4. Used for: Extremely disturbed patients who are in imminent risk of harming themselves or others. A review of facility policy titled, “Rights of All Patients” Policy 1.11, revealed in part, it is the policy of the Hospital to maintain and protect the individual’s fundamental human, civil, constitutional, and statutory rights in accordance with Federal and State laws. Patient Rights, section: Basic Rights, item 30: The right to receive care in a safe setting. Section: Rights Which May Not Be Limited, item 4: To the extent that facilities, equipment, and personnel are available, the right to medical care and treatment in accordance with the highest standards accepted in medical practice. A medical record review of Patient #1 revealed the patient inserted a foreign object into his rectum on three different occasions. The facility did not follow proper policy and procedures while monitoring the patient during the second and third instance of Patient #1 placing a deodorant bottle into his rectum. All instances require the patient to be transferred to the emergency room with subsequent interventions for foreign body removal from the rectum under general anesthesia. The patient was originally admitted on 01/13/2024 at 11:00 a.m. for suicide ideations. He was placed on an every 15 minute observation level. The patient was allowed to take a shower around 8:00 p.m. and he placed a deodorant bottle in his rectum. The patient was sent to the emergency room and returned to this facility on 01/14/2024. His observation level was changed to one to one observation upon his return. On 01/14/2024 at approximately 9:55 a.m. while the patient was showering, the patient obtained a deodorant bottle and inserted the object into his rectum. The patient was sent to the emergency room and return around 4:30 p.m. On 01/15/2024 at approximately 8:00 a.m. while in his restroom grooming, he obtained a deodorant bottle and inserted the object into his rectum. The patient was sent to the emergency room and did not return to this facility. In an interview on 01/23/2024 at 11:45, S5MHT confirmed she was on 1:1 observation with Patient #1 on 01/14/2024. S5MHT indicated she began monitoring the patient approximately 1 hour prior to the incident, she was aware of the patient placing an object in his rectum on the preceding day and she stated, “But I was unaware of the full extent.” S5MHT handed the patient off to S6MHT for shower time and she went to perform other job duties. S5MHT also indicated she left the patient with a wash cloth, towel and a plastic medicine cup size of soap. S5MHT returned to the doorway of the shower room as the Patient #1 was complete with shower. Patient #1 informed her that he had inserted a deodorant bottle into his rectum. S5MHT asked him where the bottle had come, Patient #1 told her he had stuck his head out of the shower, did not see anyone and this is when he inserted the deodorant bottle into his rectum. S5MHT also indicated Patient #1 stated had found the deodorant bottle in the shower room. In an interview on 01/23/2024 at 1:00 p.m. S6MHT confirmed she was observing Patient #1 on 01/14/2023 during his shower. S6MHT confirmed she had left the patient to retrieve larger patient gown. S6MHT confirmed Patient #1 had completed his shower and that is when he informed the MHTs that he had inserted a deodorant bottle in his rectum. S6MHT indicated Patient#1 had to have found the deodorant bottle in the shower room because his shower supplies did not include deodorant. In an interview on 01/23/2024 at 11:30 a.m. and on 01/24/2023 at 12:05 p.m. S7MHT confirmed he was the MHT on 1:1 with Patient #1 on 01/15/2024. S7MHT described the incident as the patient was using his toiletries at the time, Patient #1 used his toothbrush and toothpaste, then handed it back to S7MHT. Patient #1 asked for his deodorant, the patient used the deodorant and immediately moved from using the deodorant to shoving the deodorant up his rectum. S7MHT indicated the patient was partially clothed and was not wearing any clothing on his bottom.”

“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: 1) Failure to report allegations of self-harm to LDH-HSS on 1 (#1) of 3 (#1 -#3) patients; and 2) Failure to timely report allegation of self-harm to LDH-HSS on 1 (#1) of 3 (#1 -#3) patients. 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. 1) Failure to report allegations of self-harm to LDH-HSS on 1 (#1) of 3 (#1 -#3) patients A medical record review of Patient #1 had 2 (01/13/2024 and 01/14/2024) prior incidents of placing foreign objects into his rectum and having to be transferred to Emergency Department for further treatment and removal. Both of these incidents were not reported to LDH-HSS. The only reported incident was the incident occurring on 01/15/2024. In an interview on 01/24/2023 at 4:00 p.m. S1CEO, S2DON and S3QA confirmed the facility did not report incident #1 and #2 mentioned above. DON and S3QA were unaware instances of self- harm were reportable and also considered this to be a behavior of Patient #1 and not self-harm. 2) Failure to timely report allegation of self-harm to LDH-HSS on 1 (#1) of 3 (#1 -#3) patients A review of the facility initial report sent to LDH-HSS revealed the incident occurring 01/15/2024 at 8:20 a.m. This initial report was received by LDH-HSS on 01/17/2024. The submitted initial report was not properly submitted to LDH-HSS within 24 hours of the facility becoming aware of the incident. In an interview on 01/24/2023 at 4:00 p.m. S1CEO, S2DON and S3QA confirmed they considered the 24 hour reporting time frame to be from the time administration was made aware of a reportable incident.”