Freedom Behavioral Hospital of Ferriday

“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: 17450 Based on observation and interview, the psychiatric hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by the failure to maintain a patient care environment free of ligature risk in 20 patient bathrooms (Rooms a - t). Findings: Observations of the psychiatric hospital on 08/26/2025 at 1:30 PM with S1VP revealed the bathrooms of Rooms a - t had toilet seats that were not completely secured to the toilet bowl. This would create a ligature point, which would allow for the potential of self-injurious behaviors by a patient. In an interview on 08/26/2025 at 2:00 PM, S2VP confirmed the ligature points in the above patient bathrooms.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 17450 Based on observation, record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. This deficient practice was evidenced by the failure of the hospital to identify multiple environmental and housekeeping issues throughout the hospital. Findings: On 08/26/2025 at 1:30 PM, during tour of the psychiatric hospital with S1VP, multiple environmental and housekeeping issues were identified. These included 20 patient bathrooms (Rooms a - t) that had toilet seats that were not completely secured to the toilet bowl, creating a ligature point that a patient could utilize and 12 patient rooms with no working water faucet at the sink (Rooms a, e, g, h, m, n, o-s, u, v). Observations also revealed maintenance and housekeeping issues such as AC unit leaks, cleanliness in patient rooms and bathrooms, foul odors, and one patient’s door hanging off the hinges. Interview with S1VP during these above observations revealed that he was unaware of these issues. S1VP further stated that staff were supposed to conduct environmental rounds at least twice daily and submit any issues in writing to the administrative team be addressed. When asked if any of these issues had been brought to the administrative team to be addressed, S1VP stated no. When asked if the staff were actually performing rounds twice daily in order to recognize opportunities for improvement, S1VP stated “obviously not”.”

“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: 17450 Based on record review and interview, the hospital failed to ensure that the registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to perform routine and accurate skin assessments for 3 of 3 patients diagnosed with scabies (Patient #1, 2, 3). Findings: Patient #1 Review of a physician progress note dated 07/30/2025 revealed “scabies infestation”. The patient has moderate infestation to trunk and hands and itches. The physician ordered the first dose of Permethrin cream to treat the scabies. Review of a physician progress note dated 08/25/2025 revealed “itching all over”. Scabbed areas on abdomen. Review of the daily nursing assessments revealed the following: 07/30/2025 - no skin assessment documented 07/31/2025 - day shift assessment revealed skin “warm, dry and intact”. There was no skin assessment for the night shift documented. 08/01/2025 - no skin assessment documented 08/02/2025 - no skin assessment documented The patient was in an acute care hospital from 08/09/2025 and returned to the psychiatric hospital on 08/19/2025. Review of the re-admission nursing assessment dated 08/19/2025 revealed no documented evidence of a skin assessment. Review of nursing assessments from 08/19/2025 through 08/24/2025 revealed no documented skin assessments. The nursing assessment dated 08/25/2025 (day shift) revealed “red rash itching”. There were no further skin assessments in the medical record. On 08/27/2025 at 12:30 PM, interview with S2QA revealed that nurses should perform skin assessments twice daily, once per shift. S2QA confirmed that Patient #1 did not receive twice daily skin assessments on the above dates and the assessments that were performed were inaccurate or incomplete. Patient #2 Review of a physician progress note dated 07/31/2025 revealed bites to right upper arm, skin excoriated, scabies. The physician ordered the first dose of Permethrin cream. Review of a physician progress note dated 08/14/2025 revealed patient has crusted scabies bites to left shoulder and bilateral legs, also complains of itching. Review of a physician progress note dated 08/15/2025 revealed patient has numerous bite marks to left shoulder, left arm, abdomen and back. Skin is excoriated. Review of the daily nursing assessments revealed the following: 07/30/2025 - day shift nurse documented skin “warm, dry, intact”. There was no skin assessment for the night shift. 07/31/2025 - no skin assessment documented 08/01/2025 - no skin assessment documented 08/02/2025 - no skin assessment documented for day shift. The night shift documented “rashes on body and irritation” 08/03/2025 - no skin assessment documented for day shift. The night shift documented “rashes”. 08/04/2025 - no skin assessment documented Further review of the twice daily skin assessments revealed on 08/14/2025 (day shift), the nurse documented “reddened areas” and on 08/15/2025 (night shift), the nurse documented “skin rashes”. There were no further detailed assessments of these areas. On 08/27/2025 at 1:15 PM, interview with S2QA confirmed that Patient #2 did not receive twice daily skin assessments on the above dates. S1QA further confirmed when skin assessments were documented, they were not accurate or complete. Patient #3 Review of a physician progress note dated 07/30/2025 revealed patient has a history of itching. Moderate scabies infestation to hands, buttocks, abdomen and back. Areas of hands between fingers are crusted and patient complains of itching. The physician ordered the first dose of Permethrin cream. Review of a physician note dated 08/07/2025 revealed orders to give the second dose of Permethrin cream for continued scabies issues. Review of the daily nursing assessments revealed skin assessments were not conducted twice daily (per shift) on the following dates: 07/30/2025 - 08/03/2025. Review of the skin assessment performed on 08/04/2025 (day shift) revealed skin was “warm, dry and intact”. On 08/27/2025 at 1:45PM, interview with S2QA confirmed that Patient #3 did not receive the required twice daily skin assessments on the above dates.”

“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: 17450 Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well-being of the patients are assured. This was evidenced by 1) Failing to ensure that the water faucets in 12 patient rooms were working properly (Rooms a, e, g, h, m, n, o-s, u, v) and 2) Failing to ensure that adequate housekeeping/maintenance was provided throughout the hospital. Findings: 1. Failing to ensure that the water faucets in 12 patient rooms were working properly On 08/26/2025 at 1:30 PM, tour of the hospital with S1VP revealed patient Rooms a, e, g, h, m, n, o-s, u and v had no working water faucets in their rooms. When the faucet was turned on, no water came out of the faucet. During this time, interviews were made with random patients who resided in the rooms with no working water faucet. The patient in Room e stated “It has been like that for a while.” The patient in Room f stated that his water faucet has not worked “for a while”. The patient in Room g stated his water faucet in his room has not worked since he was admitted in March 2025. The patient in Room h stated his water faucet has not worked for the past month. The patient stated that he had reported this issue. The patient in Room o stated he has not had a working water faucet in his room for three weeks. The patient in Room p stated he has not had a working water faucet in his room “for a long time”. When asked how he washes his hands, he stated “I don’t”. Interview with S1VP on 08/26/2025 at 2:00 PM revealed that he was unaware that the water faucets in the above patient rooms were not functioning. 2. Failing to ensure that adequate housekeeping/maintenance was provided throughout the hospital On 08/26/2025 at 1:30 PM, tour of the hospital with S1VP revealed the following: - The shower room on Unit B had mold/mildew on the upper walls and ceiling. - Room c had towels at the bottom of the AC unit with visible water stains on the towels. The patient in this room stated that the unit has been leaking water. - The door on Room f was hanging off the frame. The patient in this room stated that the door had been hanging loose from the frame for a while. - The light switch in Room h did not work. When the patient was asked how he could see at night, he stated that he has to turn on his bathroom light to be able to see in his bedroom. The patient stated he had reported this a long time ago. - There was a “water sock” around the bottom of the AC unit in Room m. The patient in this room stated the unit had been leaking for about two weeks. - The shower walls in Room q had large amounts of rust that had dripped on all sides. There was grime and mildew in the floor of the shower. - Room t had a horrible urine odor. - The ante-room bathroom of the seclusion room had large amounts of an old dried brown substance dripping down all sides of the commode. - Room w had dried red substance on the front of the sink. The commode had large amounts of an old dried brown substance dripping down all sides of it. There was dirt and grime on the floor of the bathroom. Bugs were flying in the bathroom. - Room x had dirt, grime and debris on the floors in the bathroom. Bugs were flying around the commode. - Room y had a horrible odor in the room and the surveyor was unable to enter the room due to this odor. On 08/26/2025 at 3:15 PM, interview with S1VP confirmed the above housekeeping and maintenance issues. S1VP confirmed he was not aware of these issues and that they should have been picked up on the daily environmental rounds the staff is supposed to be performing.”

“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: 17450 Based on record review and interview, the hospital failed to ensure that patients or his or her representative has the right to make informed decisions regarding care as evidenced by failing to obtain consent for psychoactive medications for 3 of 3 sampled adolescent patients (Patient #1, 2, 3). Findings: Review of the hospital policy, titled Use of Psychotropic Medication Without Patient Consent (dated 03/21/2028), revealed in part that the hospital permits the administration of psychotropic meds without patient consent under one of the following circumstances: The patient is experiencing a psychiatric emergency and medication must be administered to prevent imminent harm OR The treating physician has made contact or has attempted to contact the patient’s primary care physician or a prior treating physician AND A second physician documents clinical justification for administration of psychotropic medication, without the patients consent after making an appropriate assessment OR The second physician that was the patient’s treating physician prior to this hospitalization, consults with the treating psychiatrist and indicates support of medicating the patient without his/her consent. In this case, the treating psychiatrist shall document the date, time, and content of the verbal consultation. 1. Review of the medical record for Patient #1, who was 14 years old, revealed an admit date of 08/24/2024 with diagnoses including major depressive disorder and generalized anxiety disorder. The patient was admitted on a PEC, and the patient’s mother signed a formal voluntary admission consent on 08/26/2024. Review of physician orders dated 08/25/2024 revealed an order for Zoloft (psychoactive medication used for depression) 25mg every night for two nights, then 50mg every night. Review of the patient’s MAR revealed the patient received the Zoloft on 08/26/2024 and 08/27/2024. Further review of the medical record revealed there was no consent obtained prior to administering the psychoactive medication, Zoloft, to the patient. There was also no documented evidence that two physicians were involved in the approval of administering the medication, per hospital policy. On 09/17/2024 at 10:00 a.m., interview with S1CEO confirmed that the hospital policy states to obtain consent from the parents prior to administering psychoactive medication to the child/adolescent patients of the hospital. S1CEO confirmed consent was not obtained prior to administering psychoactive medication to Patient #1. 2. Review of the medical record for Patient #2, who was 16 years old, revealed an admission date of 08/25/2024 with a diagnosis of major depression. Review of the following physician orders revealed orders for psychoactive medication: 08/27/2024- Methylphenidate ER 27mg daily 09/02/2024- Risperdal 1mg four times daily 09/02/2024- Zoloft 100mg every night 09/06/2024- Methylphenidate ER 36mg daily 09/07/2024- Methylphenidate 5mg daily 09/07/2024- Prazosin 1mg every night Further review of the medical record revealed the patient was administered the above psychoactive medications without first getting consent by the patient’s parent/guardian or by getting the approval of two physicians (per policy). On 09/16/2024 at 2:45 p.m., S2QA reviewed the patient’s medical record with the surveyor and confirmed there was no documented evidence that consent was obtained prior to administering the above psychoactive medications to the patient. S2QA further confirmed there was no documented evidence that two physicians approved the administration of the medication. S2QA confirmed that psychoactive medications should not be administered prior to obtaining consent. 3. Review of the medical record for Patient #3, who was 9 years old, revealed an admission date of 09/06/2024 with a diagnosis of disruptive mood dysregulation disorder. Review of the following physician orders revealed orders for psychoactive medication: 09/09/2024- Zoloft 50mg daily 09/09/2024- Abilify 10mg daily Further review of the medical record revealed the patient was administered the above psychoactive medications without first getting consent by the patient’s parent/guardian or by getting the approval of two physicians (per policy). On 09/16/2024 at 2:20 p.m., S2QA reviewed the patient’s medical record with the surveyor and confirmed there was no documented evidence that consent was obtained prior to administering the above psychoactive medications to the patient. S2QA further confirmed there was no documented evidence that two physicians approved the administration of the medication.”

“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: 17450 Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program’s performance improvement program implemented preventive actions. This deficient practice is evidenced by the lack of an implemented preventive action plan following an incident with an adolescent patient involving failure to obtain consent for psychoactive medications. Findings: Review of a written grievance, dated 08/28/2024, completed by the parents of Patient #1 revealed before meds were administered, parents explicitly demanded that the child was not given meds without parental consent. We were told that consent was absolutely needed before meds would be given. Upon visit on 8/28/24, we were informed by our daughter that she was given two separate doses of a green pill. The hospital’s written response to the grievance, dated 08/28/2024, and sent to the parents of Patient #1 was reviewed. The response revealed in part that the corporate team was reviewing current policy on administering medication to minors and that staff would undergo education now and annually on proper handoff communication and obtaining medication consents. Review of the LDH Abuse/Neglect initial report dated 08/29/2024 revealed that Patient #1’s parents visited on 08/24/2024 and informed staff they did not want to start the patient on medications. Parents made another visit on 08/28/2024 and the patient reported she had started a new medication. The report further stated that the chart was audited and Zoloft (psychoactive medication) was administered to the patient on 08/27/2024 and 08/28/2024. There was no consent for the medication on the chart or any documentation from conversation with the mother about not wanting her daughter to be on any medications. The report further stated that the investigation showed a lack of communication in handoff between nurses concerning new medication orders. On 09/17/2024 at 10:00 a.m., interview with S1CEO revealed that since this incident with Patient #1, the hospital is reviewing policies related to obtaining consent for psychoactive medication. S1CEO confirmed the current policy states to obtain consent prior to administering psychoactive medications to patients. S1CEO confirmed consent was not obtained prior to administering Zoloft to Patient #1. Review of the medical record for currently admitted Patient #2 revealed the patient had been administered the following psychoactive medications without documentation of consent from the parent/responsible party or the approval of two physicians (per policy): Methylphenidate ER 27mg daily (ordered 08/27/2024) Risperdal 1mg four times daily (ordered 09/02/2024) Zoloft 100mg every night (ordered 09/02/2024) Methylphenidate ER 36mg daily (ordered 09/06/2024) Methylphenidate 5mg daily (ordered 09/07/2024) Prazosin 1mg every night (ordered 09/07/2024) Review of the medical record for currently admitted Patient #3 revealed the patient had been administered the following psychoactive medications without documentation of consent from the parent/responsible party or the approval of two physicians (per policy): Zoloft 50mg daily (ordered 09/09/2024) Abilify 10mg daily (ordered 09/09/2024) On 09/17/2024 at 10:30 a.m., interview with S2QA revealed that after identifying the problem with communication and the failure to obtain consent for the psychoactive medication involving Patient #1 on 08/28/2024, all staff were inserviced on proper communication and obtaining consents for psychoactive medications. Review of the sign in sheets for the inservice training on proper communication and obtaining consents revealed only 7 of 32 current staff had been inserviced. On 09/17/2024 at 11:00 a.m., interview with S2QA revealed that she had not gotten to all staff yet, although it had been three weeks since the incident and identification of the problem. On 09/17/2024 at 11:20 a.m., when S2QA was asked if there had been any QA/monitoring put into place after the incident with Patient #1 to ensure consents are being obtained, she stated no. On 09/17/2024 at 11:25 a.m., interview with S1CEO confirmed that monitoring should have been put in place to ensure consents were being obtained for psychoactive medications. Informed S1CEO that upon review of current patients (Patient #2 and Patient #3) medical records, consents for psychoactive medications were still not being obtained. S1CEO stated the system was still broken.”