Stonebridge Behavioral Hospital

“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: 44763 Based on record review and interview, the facility failed to ensure compliance with reporting of potential abuse and neglect. This deficient practice was evidenced by failure of the facility to submit an initial report to Louisiana Department of Health (LDH) within 24 hours of becoming aware of an event involving potential abuse or neglect. Findings: Review of the form “Self-Reporting Process for Hospitals - Abuse/Neglect,” revised 12/01/2021, revealed in part, “Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.” Further review of the document revealed, “The initial and final reports shall be emailed to hsshospitalself-reports@la.gov via an encrypted/secure email. As indicated above, the initial report must be submitted within 24 hours of awareness of the incident/allegation/suspicion. Since hospitals must operate 24 hours a day, seven days a week, no adjustment is made to accommodate weekends or holidays. In other words, if an event is noted to occur (or an allegation is received) on Friday at 10:30 p.m., the initial report shall be emailed no later than Saturday at 10:30 p.m. E-mails are automatically tagged with the date and time of receipt, providing proof that reports were submitted in a timely manner. The e-mail address listed below is relevant to hospitals only.” Review of the LDH Hospital / Licensed Provider Abuse / Neglect Initial Report form dated 06/26/2026 revealed in part, on 06/21/2026 night shift Patient #2 sustained a fall from wheelchair that resulted in a laceration to the forehead and Patient #2 was transferred to an acute care hospital. After being admitted to the acute care hospital, this hospital was notified that the DNR patient had expired. In an interview on 06/29/2026 at 3:09 PM, S1ADM stated the hospital became aware of Patient #2’s death on Tuesday (06/23/2026). S1ADM stated he and S4CPO started talking about self-reporting to LDH on Thursday (06/25/2026). S1ADM confirmed the hospital sent the self-report to LDH on Friday (06/26/2026).”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by: 1. failure of the nursing staff to perform fall risk assessments as per hospital policy for 1 (Patient #2) of 3 sampled patients; 2. failure to obtain an order for wound care for 1 (Patient #1) of 3 sampled patients; 3. failure to ensure EKG was performed as ordered for 1 (Patient #1) of 3 sampled patients; 4. failure to ensure admission labs were entered for 1 (Patient #1) of 3 sampled patients; and 5. failure to ensure labs were performed as ordered for 1 (Patient #3) of 3 sampled patients. Findings: 1. Failure of the nursing staff to perform fall risk assessments as per hospital policy for 1 (Patient #2) of 3 sampled patients. Review of the hospital’s policy titled “Admission Assessment Management - At Risk for Falls (ARF)”, effective date 12/2023, revealed in part, Charge RN/Primary RN: Re-assesses fall risk every 7 days and/or immediately after a fall. Review of Patient #2’s medical record revealed Patient #2 was admitted on 06/04/2026 and transferred to hospital ‘A’ on 06/21/2026 after a fall. Review of the (ARF) “At Risk for Falls Assessment - Admission” revealed the assessment was performed on 06/04/2026 at 8:20 PM. Further review of Patient #2’s medical record failed to reveal documentation of the At Risk for Falls Assessments performed weekly and immediately after a fall according to hospital policy. In an interview on 06/30/2026 at 10:23 AM, S3DON confirmed the fall risk assessment performed at admission was the only one documented in Patient #2’s medical record. S3DON further confirmed a fall risk assessment should have been documented every 7 days. S3DON confirmed a fall risk assessment was not documented after Patient #2’s fall. S3DON stated Patient #2 was transferred out. 2. Failure to obtain an order for wound care for 1 (Patient #1) of 3 sampled patients. Review of Patient #1’s clinical record revealed admission on 06/18/2026 and discharge on 06/19/2026. Patient #1 was readmitted on 06/23/2026 at 8:30 PM. Patient #1’s History and Physical dated 06/25/2026 at 10:44 AM revealed the following, in part: HPI: Patient readmitted after hospitalization for traumatic full thickness skin tear. Arm was dressed upon arrival here with the only instructions given to follow up with surgeon in 10 to 14 days. Assessment/Treatment Plan/Interventions: Right arm full thickness skin tear - get records from hospital. Do not touch dressing until we get this. In an interview on 06/29/2026 at 4:02 PM, S6MD revealed the hospital had not obtained records from the previous hospital. S6MD confirmed the hospital failed to obtain an order for wound care for Patient #1. 3. Failure to ensure EKG was performed as ordered for 1 (Patient #1) of 3 sampled patients. Review of the hospital’s policy titled “Diagnostic Management - Ordering Diagnostics” dated 12/2023 revealed the following, in part: Diagnostic Services ...are obtained via practitioner’s order upon admission and/or for patients in need. Nursing: Initiates and follows the vendor-specific process and submits the order for services. Review of Patient #1’s admission orders dated 06/18/2026 revealed an order for EKG. Further review of Patient #1’s clinical record failed to reveal EKG prior to discharge. In an interview on 06/30/2026 at 11:09 AM, S1ADM confirmed Patient #1 did not have an EKG as ordered. 4. Failure to ensure admission labs were entered for 1 (Patient #1) of 3 sampled patients. Review of the hospital’s policy titled “Diagnostic Management - Ordering Diagnostics” dated 12/2023 revealed the following, in part: Diagnostic Services ...are obtained via practitioner’s order upon admission and/or for patients in need. Nursing: Initiates and follows the vendor-specific process and submits the order for services. Review of Patient #1’s admission orders dated 06/18/2026 failed to reveal orders for labs. Further review failed to reveal any lab results from the month prior to admission. In an interview on 06/30/2026 at 3:15 PM, S5MD revealed patients were to have labs ordered upon admission, or lab results from the month prior to admission available for review. S5MD revealed the following labs were ordered upon admission if results were not available for review: - CBC; - CMP; - Lipid; - UA; - RPR; - B12; - Folate; - Vitamin D; and - Thyroid Panel. S5MD confirmed labs were not ordered for Patient #1 upon admission, but should have been. When asked if labs not being entered or performed has been an ongoing issue, S5MD replied “Yes, it has fallen through the cracks.” 5. Failure to ensure labs were performed as ordered for 1 (Patient #3) of 3 sampled patients. Review of the hospital’s policy titled “Diagnostic Management - Ordering Diagnostics” dated 12/2023 revealed the following, in part: Diagnostic Services ...are obtained via practitioner’s order upon admission and/or for patients in need. Nursing: Initiates and follows the vendor-specific process and submits the order for services. Review of Patient #3’s admission orders revealed an order for HgbA1c, RPR, TSH, and Vitamin B12. Further review failed to reveal results of HgbA1c, RPR, TSH, or Vitamin B12. In an interview on 06/30/2026 at 5:04 PM, S1ADM confirmed Patient #3’s labs were not performed as ordered, but should have been. 51596”

“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: 51596 Based on record review and interview, the hospital failed to ensure a care plan was initiated within eight (8) hours of admission for 1 (Patient #1) of 3 sampled patients. Findings: Review of the hospital’s policy titled “Provision of Care - Care Planning & Special Procedures” dated 12/2023 revealed the following: (C) Admitting Nurse/Charge Nurse: Opens initial care plans for nursing services ...within eight hours of admission. Review of Patient #1’s clinical record revealed an admission date of 06/18/2026 at 3:45 PM. Patient #1’s Master Treatment Plan of Care was created on 06/19/2026 at 6:02 AM. Further review of Patient #1’s clinical record revealed Patient #1 was readmitted on 06/23/2026 at 8:30 PM. Patient #1’s Master Treatment Plan of Care for her readmission was created on 06/25/2026 at 3:12 PM. In an interview on 06/30/2026 at 10:02 AM, S4CPO confirmed Patient #1’s care plans were not initiated within eight hours of her admissions, but should have been.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 51596 Based on record review and interview, the nursing staff failed to ensure medications were administered in accordance with Federal regulations. This deficient practice was evidenced by: 1. Failure to administer scheduled medications as ordered for 1 (Patient #1) of 3 sampled patients; 2. Failure to ensure documentation of the reason a scheduled medication was not administered as ordered for 1 (Patient #1) of 3 sampled patients; 3. Failure to ensure documentation of pain assessment before and after administering a medication ordered PRN for pain for 1 (Patient #1) of 3 sampled patients; and 4. Failure to develop a policy which addressed the actions to be taken when scheduled doses of medications are not administered. Findings: 1. Failure to administer scheduled medications as ordered Review of Patient #1’s clinical record revealed she was admitted on 06/18/2026 and discharged on 06/19/2026. Patient #1 was readmitted on 06/23/2026. Review of Patient #1’s Medication Administration Record (MAR) dated 06/18/2026 - 06/19/2026 revealed the following scheduled medications were not administered as ordered on 06/18/2026 at 9:00 PM: Donepezil 5mg; Mirtazapine 15mg; Quetiapine Fumarate 50mg; Lorazepam 0.5mg; and Gabapentin 100mg. In an interview on 06/30/2026 at 9:51 AM, S4CPO confirmed Patient #1 was not administered the medication as ordered. 2. Failure to ensure documentation of the reason a scheduled medication was not administered as ordered Review of Patient #1’s MAR dated 06/24/2026 - 06/29/2026 revealed the following: - Scheduled medications were not administered as ordered on 06/24/2026 at 9:00 PM: Quetiapine Fumarate 75mg; and Donepezil 10mg. - Scheduled medications were not administered as ordered on 06/25/2026 at 9:00 AM: Sertraline 50mg; and Quetiapine Fumarate 25mg. - Scheduled medications were not administered as ordered on 06/27/2026 at 1:00 PM: Lorazepam 0.5mg. - Scheduled medications were not administered as ordered on 06/28/2026 at 9:00 AM: Aspirin 81mg; Gabapentin 100mg; Lorazepam 0.5mg; Memantine 10mg; Sertraline 50mg; and Quetiapine Fumarate 25mg. - Scheduled medications were not administered as ordered on 06/28/2026 at 1:00 PM: Lorazepam 0.5mg. - Scheduled medications were not administered as ordered on 06/28/2026 at 9:00 PM: Quetiapine Fumarate 75mg; and Donepezil 10mg. Further review of the MAR and Patient #1’s clinical record failed to reveal documentation regarding why the scheduled medications were not administered as ordered. In an interview on 06/30/2026 at 10:40 AM, S4CPO confirmed the above-mentioned findings. 3. Failure to ensure documentation of pain assessment before and after administering a medication ordered PRN for pain Review of Patient #1’s MAR dated 06/24/2026 - 06/29/2026 revealed Hydrocodone-APAP 5-325mg was administered on 06/24/2026 at 12:00 AM. Further review failed to reveal documentation of pain assessment before or after medication was administered. In an interview on 06/30/2026 at 10:40 AM, S4CPO confirmed nursing staff should have documented Patient #1’s pain assessment before and after prn medication for pain was administered, but had not. 4. Failure to develop a policy which addressed the actions to be taken when scheduled doses of medications are not administered In an interview on 06/30/2026 at 10:40 AM, S3DON revealed staff should document a reason when a scheduled medication is not administered as ordered. In an interview on 06/30/2026 at 11:04 AM, S4CPO revealed the facility does not have a policy which addresses the actions to be taken when scheduled doses of medications are not administered as ordered.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the patient’s right to participate in the development and implementation of his or her plan of care as evidenced in 2 (#1, #2) of 3 medical records review. Findings: A review of medical records revealed: Patient #1: A review of Patient #1’s medical record revealed the hospital document titled, “Treatment Plans COVER PAGE - MASTER TREATMENT PLAN OF CARE.” This document included a subsection related to patient participation in the development of the treatment plan. The subsection contained the following options to be completed: a signature of authentication by the patient, the power of attorney (POA), the legal guardian, and/or next of kin; an area to be completed if the patient was unable to participate in the development of this treatment plan and an indication as to this reason of non-participation; and an area with options to be selected if the patient were disoriented. This master treatment plan failed to reveal the documentation of the patient, POA, legal guardian or next of kin’s participation in the development and implementation of her plan of care or a reason as to why they previously mentioned parties did not participate. Patient #2: A review of Patient #2’s medical record revealed the hospital document titled, “Treatment Plans COVER PAGE - MASTER TREATMENT PLAN OF CARE.” This document included a subsection related to patient participation in the development of the treatment plan. The subsection contained the following options to be completed: a signature of authentication by the patient, the power of attorney (POA), the legal guardian, and/or next of kin; an area to be completed if the patient was unable to participate in the development of this treatment plan and an indication as to this reason of non-participation; and an area with options to be selected if the patient were disoriented. This master treatment plan failed to reveal the documentation of the patient, POA, legal guardian or next of kin’s participation in the development and implementation of her plan of care or a reason as to why they previously mentioned parties did not participate. In an interview on 05/21/2026 at 12:30 p.m., S1IADM confirmed the above-mentioned findings.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient as evidenced by the failure to document the performance of weekly weight assessments per provider order in 1 (#1) of 3 medical records reviewed. Findings: A review of Patient #1’s medical record revealed an admission 03/03/2026 and a discharge on 04/01/2026. A review of provider orders revealed a verbal order initiated by S2RN on 03/03/2026 at 9:35 p.m. for, “Weight on admission and weekly.” This order was signed by S3MD on 03/18/2026 at 1:18 p.m. The medical record revealed an admission weight on 03/03/2026 at 5:15 p.m. of 173 [units of measurement not identified]. The medical record failed to reveal the documentation of another weight measurement during the patient’s admissions. In an interview on 05/21/2026 at 12:30 p.m., S1IADM confirmed the above-mentioned findings.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the electronic medical record was easily retrievable, readily accessible, and electronic medical record maintenance ensured the security of all record entries in 1 (#2) of 3 electronic medical records reviewed. Findings: A review of Patient #2’s electronic medical records revealed the provider orders were not retrievable and unavailable for surveyor review. A request was initiated with S1ADM on 05/22/2026 at approximately 10:00 a.m. for the potential retrieval of this portion of the medical records by the hospital’s Health Information System. As of exiting the facility on 05/21/2026 at approximately 4:30 p.m., the hospital was unable to provide this portion of the medical record to this surveyor. In an interview on 05/21/2026 at approximately 4:30 p.m., S1IADM confirmed the above-mentioned findings.”

“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: 48051 Based on record review and interview, the hospital failed to ensure psychosocial assessment was fully completed in 1 (#2) of 3 medical records reviewed. Findings: A review of the hospital policy, “ADMISSION ASSESSMENT MANAGEMENT - PSYCHOSOCIAL ASSESSMENT,” Policy ID: AS-1003, effective date: 12/2023, revealed in part: “POLICY A patient psychosocial interview and assessment will be completed within seventy-two (72) hours of the admission. PROCEDURE -Part III of the Multidisciplinary Integrated Assessment (MIA): The Licensed Clinical Therapist provides a psychosocial assessment and interventions based on individualized needs during the psychiatric patient’s hospitalization. -The assessment will include, but not limited to demographic profile, presenting problems, social history, family history, family attitudes, an assessment of home plans, community resource contacts, financial resources, medical and psychiatric history, social supports, and functional status/capacity for activities of daily living and instrumental activities of daily living. -Obtain adequate data to identify and understand events and circumstances that led to this hospitalization. -Identify support systems and resources available to the patient. -Explore patient’s functional level and deficits in mental and physical competency. -Develop a plan of care, which addresses the patient’s immediate and long-term care needs.” A review of Patient #2’s medical record revealed the hospital document titled, “Multidisciplinary Integrated Assessment Part 3: Psychosocial Assessment,” created by S4LMSW on 03/31/2026 at 10:56 a.m. Some sections of this assessment indicated the information was unreliable and some sections were not marked or answered with a selection or information. The assessment failed to indicate if a family member, power of attorney, legal guardian and/or next of kin were contacted or attempted to be contacted to assist with the completion of this assessment. The sections of the assessment that failed to have any information selected included: Vocational, Academic, Military History; Legal Issues; Strengths, Assets, Resources, Limitations/Barriers; Family/Patient Learning Needs/Participation in Treatment; Family Member/LRP Participation in Care Treatment Services; Level of Participation Needed with Patient Consent; Patient Preferences, Attitudes, Expectations for Treatment; Family/LRP Preferences, Attitudes, Expectations for Treatment; Treatment Goals; Discharge Planning/Home Plans/Recommendations; Living Situation; Patient Preference of D/C Need; Master Treatment List and Treatment Plans Reviewed and Updated; and Problems Identified but Deferred with Rationale. This assessment failed to be fully completed and failed to be authenticated by a therapist. In an interview on 05/21/2026 at 12:30 p.m., S1IADM confirmed the above-mentioned findings.”

“Treatment Plan - Goals CFR(s): [The written plan must include] Short-term and long range goals; This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the treatment plan included short-term and long-range goals in 1 (#2) of 3 medical records reviewed. Findings: A review of the hospital policy, “PROVISIONS OF CARE-MASTER TREATMENT PLAN (MTP),” Policy ID: PC-13001, effective date: 12/2023, revealed in part: “POLICY Each patient must have an individualized ongoing comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities that is named in the Master Treatment Plan (MTP). A MTP will be developed for every patient within seventy-two (72) hours of admission, under the directive and supervision of the attending provider, involvement of the interdisciplinary team, and participation of the patient and/or authorized representative. PROCEDURE The Master Treatment Plan (MTP) The patient’s Master Treatment Plan is a comprehensive multidisciplinary plan designed to meet the individual treatment needs of the patient. The Master Treatment Plan must be: -Based on an inventory of the patient’s strengths and disabilities; -Must include a substantiated diagnosis; -Include short-term and long-range goals; -List the specific treatment modalities utilized; -Identify the responsibilities of each member of the treatment team; and -Include adequate documentation to justify the diagnosis, treatment and rehabilitation activities to carry out.” A review of Patient #2’s medical record revealed the hospital document titled, “Treatment Plans COVER PAGE - MASTER TREATMENT PLAN OF CARE.” This document failed to identify short-term and long-range goals. In an interview on 05/21/2026 at 12:30 p.m., S1IADM confirmed the above-mentioned findings.”

“Treatment Plan - Modalities CFR(s): [The written plan must include] The specific treatment modalities utilized; This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the treatment plan included specific treatment modalities to be utilized in 1 (#2) of 3 medical records reviewed. Findings: A review of the hospital policy, “PROVISIONS OF CARE-MASTER TREATMENT PLAN (MTP),” Policy ID: PC-13001, effective date: 12/2023, revealed in part: “POLICY Each patient must have an individualized ongoing comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities that is named in the Master Treatment Plan (MTP). A MTP will be developed for every patient within seventy-two (72) hours of admission, under the directive and supervision of the attending provider, involvement of the interdisciplinary team, and participation of the patient and/or authorized representative. PROCEDURE The Master Treatment Plan (MTP) The patient’s Master Treatment Plan is a comprehensive multidisciplinary plan designed to meet the individual treatment needs of the patient. The Master Treatment Plan must be: -Based on an inventory of the patient’s strengths and disabilities; -Must include a substantiated diagnosis; -Include short-term and long-range goals; -List the specific treatment modalities utilized; -Identify the responsibilities of each member of the treatment team; and -Include adequate documentation to justify the diagnosis, treatment and rehabilitation activities to carry out.” A review of Patient #2’s medical record revealed the hospital document titled, “Treatment Plans COVER PAGE - MASTER TREATMENT PLAN OF CARE.” This document failed to identify specific treatment modalities utilized. In an interview on 05/21/2026 at 12:30 p.m., S1IADM confirmed the above-mentioned findings.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the treatment plan identified and assigned the responsibilities of treatment team members in 1 (#2) of 3 medical records reviewed. Findings: A review of the hospital policy, “PROVISIONS OF CARE-MASTER TREATMENT PLAN (MTP),” Policy ID: PC-13001, effective date: 12/2023, revealed in part: “POLICY Each patient must have an individualized ongoing comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities that is named in the Master Treatment Plan (MTP). A MTP will be developed for every patient within seventy-two (72) hours of admission, under the directive and supervision of the attending provider, involvement of the interdisciplinary team, and participation of the patient and/or authorized representative. PROCEDURE The Master Treatment Plan (MTP) The patient’s Master Treatment Plan is a comprehensive multidisciplinary plan designed to meet the individual treatment needs of the patient. The Master Treatment Plan must be: -Based on an inventory of the patient’s strengths and disabilities; -Must include a substantiated diagnosis; -Include short-term and long-range goals; -List the specific treatment modalities utilized; -Identify the responsibilities of each member of the treatment team; and -Include adequate documentation to justify the diagnosis, treatment and rehabilitation activities to carry out. There shall be an established collaborative relationship between the multidisciplinary team members, along with other services of the hospital, in the provision of patient care and the development of the Master Treatment Plan.” A review of the hospital policy, “PROVISIONS OF CARE-CARE PLANNING & SPECIAL PROCEDURES,” Policy ID: PC-13002, effective date: 12/2023, revealed in part: “POLICY To develop an interdisciplinary comprehensive plan for care that provides for goals, objectives, and interventions that meet all the identified treatment needs of the patient. PROCEDURE B. Multidisciplinary Team: -Consist of: o Provider of care o Charge Nurse o Social Worker or Licensed Counselor o Activity Therapist o Utilization Review/Case Manager o Patient and/or Authorized Representative o Other Team Members, as applicable.” A review of Patient #2’s medical record revealed the hospital document titled, “Treatment Plans COVER PAGE - MASTER TREATMENT PLAN OF CARE.” This document failed to identify specific problems related to Patient #2 and failed to identify the following team members being associated with the master treatment plan of care: the provider of care, nursing, social worker/licensed counselor, or utilization review/case manager. In an interview on 05/21/2026 at 12:30 p.m., S1IADM confirmed the above-mentioned findings.”