Havenwyck Hospital

“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: 53399 Based on interview and record review, the facility failed to obtain guardian consent for 1(P-2) of 4 patients reviewed, resulting in the potential for the guardian making uninformed decisions regarding P-2’s care. Findings include: On 02/21/2026 P-2 was admitted to Facility A with a chief complaint of being “acutely psychotic, hyperverbal, and disorganized.” P-2 was determined to be a “Danger to self.” On 03/10/2026 Probate Court Judge Staff Y signed an order granting temporary guardianship for P-2 to Guardian Staff T effective on 03/10/2026 and expiring 11/10/2026. On 04/07/2026 at 2101 a medication consent form for a new “Antipsychotic” was signed and dated by P-2 however, the legal guardian Staff T, remained in place. On 05/12/2026 at 1215 Staff O, and Staff C were queried, with P-2 having a legal guardian in place, should P-2 have signed their own consent for treatment, “consent for psychotropic medications”, and “Transition of Care: Discharge Plan form”? Both parties acknowledged “P-2 should not have signed those consents with a guardian in place. The Policy “Consent to Treatment and Services” identifies that informed consent is required for “Treatment services in the inpatient, outpatient, or residential programs and Psychotropic medications.” The policy “Written Informed Consent for Psychotropic Medications” states, “Treating Practitioner has the legal responsibility for obtaining the Patient ’ s (or the Legal Representative ’ s) informed consent and approval to proceed with the proposed medication involving significant risk prior to administration, except in emergencies.”

“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: 50585 Based on interview and record review, the facility failed to designate assault precautions on patient observation rounding sheets according to the facility’s policy and procedure for 2 (P-1, P-12) of 4 patients reviewed with assault precautions resulting in the increased likelihood of negative outcomes for all patients. Findings include: On 5/12/2026 at 1215, P-1’s medical record was reviewed. On 3/30/2026 at 1000, P-1 had an order for assault precautions. A review of P-1’s patient observation rounding sheets revealed that the box for assault precautions was not checked on 4/2/2026 and 4/3/2026. On 5/13/2026 at 0930, P-12’s medical record was reviewed. On 3/18/2026 at 1900, P-12 had an order for assault precautions. A review of P-12’s patient observation rounding sheets revealed that the box for assault precautions was not checked from 3/18/2026 through 4/3/2026. On 5/13/2026 at 1230, Director of Quality Staff C confirmed the findings of the missing assault precaution documentation on the rounding sheets for P-1 and P-12. According to the facility’s policy and procedures: “Patient Observation Rounds,” dated 10/2025, “PCS/RCS: a. Review and update patient observation forms. Reflect changes in individual patient precautions levels, room or bed changes, new admissions and/or discharges as they occur. “Assault/Homicide precautions,” dated 4/2025, “Patients who are considered at risk for acting out with aggression or violence may be placed on Assault/Homicide Precautions (AP) by order of the physician. The physician will also indicate the level of monitoring required: 15 minute checks, 1:1.””

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 53399 Based on interview and record review, the facility failed to ensure a patient’s guardian was notified of the post-discharge care destination for 1 (P-2) of 4 patients reviewed, resulting in the potential for negative outcomes. Findings include: On 02/21/2026 P-2 was admitted to Facility A with a chief complaint of being “acutely psychotic, hyperverbal, and disorganized.” P-2 was determined to be a “Danger to self.” On 03/10/2026 Probate Court Judge Staff Y signed an order granting temporary guardianship for P-2 to Guardian Staff T effective on 03/10/2026 and expiring 11/10/2026. On 03/20/2026 (Time not documented) Physician Staff S, Social Worker Staff R, and Registered Nurse Staff Z completed a “Transition of Care: Discharge Plan Form” which contained a handwritten, incorrect physical address (provided by external community resource Facility D) for Facility C (The correct discharge destination) that accepted P-2 for residency. The transition of care document was presented to P-2 while under legal guardianship and was signed and dated by P-2. The legal guardian did not sign the document. On 03/23/2026 P-2 was transported from Facility A by a public ride share service to the incorrect address for Facility C (an abandoned house) resulting in P-2 being left unattended at the incorrect address. On 03/24/2026, Facility A was notified by Facility C that P-2 did not arrive at Facility C, and Facility A filed a missing person’s report with local and City Law enforcement. On 03/28/2026, (Law enforcement) P-2 was located and transported P-2 to Facility B, where P-2 was assessed. P-2 was transferred back to Facility A on 03/29/2026 where P-2 was readmitted for an additional 16 patient days. The following policy was reviewed with Risk Manager Staff O and Director of Regulatory, Performance Improvement and Quality Staff C: “Discharge Planning Protocol Policy.” On 05/12/2026 Staff O, and Staff C were queried, with P-2 having a legal guardian in place, in your respective roles, should P-2 have signed their own consent for “Transition of Care: Discharge Plan form”? Both parties acknowledged “P-2 should not have signed those consents with a guardian in place.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48772 Based on observation, interview, and record review, the facility failed to involve patient participation in the plan of care, failed to provide the right to be informed and ask questions, failed to provide care in a safe setting, and failed to ensure the right to be free from all forms of abuse or harassment, resulting in the potential for less than optimal outcomes for all pts served by the facility. See tags: A0130 - Participation in Care Planning A0131 - Right to make informed decisions A0144 - Right to care in a Safe Setting A0145 - Right to be free from Abuse/Harassment”

“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: 48772 Based on interview and record review, the facility failed to involve patient participation in the plan of care for 1 (P-4) of 13 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-4: This 16-year-old male was admitted to the facility on 4/8/25 with brief psychotic disorder and homicidal ideation. He has a past medical history of diabetes mellitus type 2, with long term use of insulin. During record review, it was noted that the master treatment plan included acute psychosis, possible major depressive disorder, and depression with suicidal ideations. The plan failed to include diabetes, blood glucose monitoring, or insulin use. This finding was reviewed and acknowledged by the chief nursing officer (Staff D) during an interview on 9/23/25 at 1405. Policy -187673129, Interdisciplinary Treatment Plan for Inpatient Services (revised 08/25) states, “Any medical problems or diagnoses that are not receiving treatment will be listed on the Treatment Plan cover sheet/problem list as deferred with justification provided. If the medical problem requires active treatment, it will either be included in the plan as “chronic/stable” medical problem if only routine care is provided or on a separate problem sheet if more than routine care is indicated.””

“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: 48772 Based on interview and record review, the facility failed to provide the patient representative with the right to make informed decisions regarding care in 1 (P-3) of 13 records reviewed, resulting in the potential for unmet care needs. Findings include: P-3: This 14-year-old male was voluntarily admitted to the facility on 8/9/25 for suicidal ideation, disruptive mood regulation disorder, auditory hallucinations, and insomnia. P-3 has a history of autism spectrum disorder and attention deficit hyperactivity disorder. Record review indicates the guardian was contacted by the physician assistant (Staff N) on 8/10/25 to discuss treatment plan and to obtain consent for medication, and on 8/13/25 and 8/15/25 by social work to discuss treatment plan, family therapy session, and to review discharge safety plan. The adolescent unit charge nurse (Staff G) was interviewed on 9/23/25 at 1410. Staff G was queried on communication and stated communication can be documented on the guardian communication log, in nursing progress notes, or in additional progress notes added to the medical record. The medical record also contained a “guardian communication log,” which was blank. Nursing progress notes were reviewed and there was no documentation of communication with the guardian. The facility failed to document communication with the guardian. This finding was reviewed and acknowledged by the chief nursing officer (Staff D) during an interview on 9/23/25 at 1405. In addition, it was noted that the “transition of care: discharge plan - part II” contained handwritten information regarding follow-up appointments and that education was provided on healthcare disparities. The handwriting was not legible. The limited licensed professional counselor (Staff L) was interviewed on 9/23/25 at 0849. Staff L confirmed that she had completed the discharge plan. Staff L acknowledged that her handwriting can be difficult to read and stated that she will provide families with her contact information if they have questions or have difficulty reading her writing.”

“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: 48772 Based on observation and interview, the facility failed to provide care in a safe setting, resulting in the potential for injury or harm for all patients served by the facility. Findings include: During a tour of the Adult B-Female unit on 9/22/25 at 1335, a patient (P-13) was observed pacing the halls, throwing a stress ball against the wall. The census on this unit at that time was 39 with 28 patients documented with assault precautions, and 19 patients documented with suicide precautions. An interview was conducted with the chief executive officer (Staff A) on 9/22/25 at 1612. Staff A was queried on screening process for appropriate use of stress ball. Staff A stated there is not a specific screening tool, the patient is assessed on what helps them calm down. Staff A stated that stress balls are provided throughout the facility. The nurse manager of C-Unit (Staff O) was interviewed on 9/25/25 at 1300. Staff O stated stress balls are on every unit in the facility. Staff O stated that patients may request a stress ball or staff can offer one. Staff O stated that it is not documented who on the unit may have a stress ball in their possession and there are no restrictions relating to use in patient rooms or if a staff member must be present while in use. Staff O was queried on when a stress ball would be considered a risk and replied if the patient has a history of attempting to choke or asphyxiate themselves. The recreational therapist (Staff P) was interviewed on 9/25/25 at 1310. Staff P states she will provide a patient with a stress ball if they ask for one. Staff P stated, she was “told they are considered safe.” The original packaging and order information was requested and provided by the facility. A box of stress balls was provided, which were observed in a cardboard box without individual packaging. A stress ball was inspected and torn in half. The core of the ball appeared to contain foam, which was easily manipulated and the piece re-expanded. The order for the stress ball was placed online and the description failed to include choking hazard information.”

“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: 50223 Based on observation, interview, and record review the facility failed to prevent peer to peer abuse for three patients (P-2, P-3 and P-12) out of 13 patients reviewed resulting in harm. Findings include: P2 A record review on 9/22/25 revealed that P-2 was a 16-year-old patient admitted to the facility on 8/11/25 with a diagnosis of Oppositional Defiance Disorder, Depression, and suicidal ideation. A review of the facility’s event log revealed events involving P-2 as follows: 8/17/25 “aggression by another patient” and 8/18/25 “physical confrontation with another patient”. A review of psychiatry progress note dated 8/15/25 revealed “patient was seen, she was overheard arguing with a peer, screaming in the hallway. Patient reports that a peer was bullying another friend of hers and she stepped in to defend her friend ...patient appears to become easily agitated by minor events around her. Discussed with patient that each interaction and even encounter is usually after she has had a major emotional outburst on the unit.” A review of a guardian communication log dated 8/18/25 0700 revealed “another patient made contact by slap.” A review of a document titled “seclusion restraint order” dated 8/18/25 0900 revealed “imminent danger to others. Going after and trying to attack peer.” A review of daily nurse progress note dated 8/18/25 0900 revealed “pt (patient) observed to be yelling cussing at staff. pt started argument with peer then was attacked by peer. Pt ended up having hair ripped out. Pt examined by dr. (doctor). Pt given IM (intramuscular medication). Guardian notified.” A review of psychiatry progress note dated 8/18/25 at 0930 revealed “she states she is extremely agitated on the unit. ‘I got my hair pulled out this morning’ she states she needed a few medications to help calm down. ‘I do not feel safe here, get me out of here’ patient became tearful with writer.” Psychiatry progress note dated 8/19/25 revealed “patient is extremely focused on discharge. Patient is tearful. ‘I’ve already lost my hair here. I don’t feel safe here.” P12 A review of P-12’s record revealed they were a 14-year-old patient admitted to the facility on 8/7/25 with a diagnosis of psychosis, and disruptive mood dysregulation disorder. P-12 was also having suicidal ideations. A review of a seclusion restraint order dated 8/9/25 revealed “imminent danger to others. throwing food, disrupting milieu, trying to attack peers and fight.” A line on the document with the directive, “describe actions taken to lessen physical and/or psychological risk is indicated” is left blank. A psychiatric progress note dated 8/11/25 revealed “She has positive anger issues, poor impulse control, decreased impulse awareness; delusional in nature; threatening physical harm to others; potential risk of injury to self and to others due to her aggression, anger, and lack of impulse control. She will continue to be on suicidal precautions, also on homicidal precautions due to her violent behavior.” Psychiatry progress note dated 8/15/25 revealed “other risk assessment formulations: homicidal/violence.” Psychiatry progress note dated 8/18/25 revealed “(P-12) got into an altercation with one of her peers and she admits to pulling the peers hair. She claims that the peer was mean and making her mad. (P-12) has been having increased physical altercations with her peers, and it has been difficult to redirect her” On 9/22/25 at 1048 Nurse Manager, Staff E, explained that if there is an altercation between patients, they de-escalate then separate them. If the patients are roommates they would switch their rooms, then notify the Dr (physician), notify the parents, and an incident report is filled out. On 9/22/25 at 1200 Chief Executive Officer, Staff A, explained that they put precautions in place for violent patients including blocking beds, separating patients, and increasing monitoring. On 9/22/25 at 1316 Patient Care Specialist, Staff J, was observed sitting in the hall on a rolling office chair. They explained that if there is fighting between patients they deescalate and try to intervene early, so it doesn’t escalate, they get the nurse involved and try to get to the root cause of the argument. Staff J explained that if it does escalate to a physical altercation they call “dr white” (an overhead page indicating more help is needed), they keep the patients separated and they may remove a patient from the unit. Staff J explained that the nurse will notify them ahead of time if a patient has a potential for violence so they can be watched more closely. On 9/22/25 at 1330 a group of 4 patients in the adult female unit were observed sitting on the floor in the hallway and sought surveyors’ attention to report a concern. They explained that there are patients on the unit that have frequent violent outbursts. The patients explained that they had been feeling better and making progress in their treatment but now are having more anxiety and are feeling “triggered” and unsafe with the violent patients on the unit and have needed additional medication as a result. They explained that some of the violent patients throw things, tv remotes for example, and that one of them got hit in the head with a thrown object. They explained that when they report the violence to the staff they are told that since the staff did not witness it occur there was nothing they could do. The patient exhibiting violent behaviors continue to remain in the general population with the other patients. On 9/22/25 at 1441 Recipient Rights and Patient Advocate, Staff K, explained that an incident report is created for all alterations between patients. The incident reports are then reviewed by Staff K and are discussed daily with the appropriate leadership. Staff K explained that if there is an altercation between patients, the staff will meet to discuss the patients’ switching rooms or switching units entirely. Staff K explains that when the patients are adolescents’ separation is harder because the facility does not have another adolescent unit to move the patient to so other interventions may be needed. Staff K was queried regarding the incident involving P-2’s altercation with a peer. At the time of this interview Staff K did not recall the situation but stated they would look into it and produce the incident report file. On 9/23/25 at 1256 the Director of Risk, Staff M, was interviewed regarding the altercation involving P-2 and explained that there was no investigation into the incident since there was no harm but that there would be an incident report completed for any patient-to-patient altercation regardless of harm status. On 9/23/25 at 1329 Recipient Rights and Patient Advocate, Staff K provided a letter to P-2’s guardian regarding the altercation. The letter dated 8/18/2025 revealed the following: “your child was involved in a physical altercation with a peer. Staff separated your child and the peer immediately and additional precautions were taken to ensure their safety and wellbeing.” Staff K was queried regarding what additional precautions were taken and where the precautions were documented. Staff K explained that any precautions would be documented throughout the chart but was unable to provide specific details. On 9/23/25 at 1415 the Adolescent Unit Charge Nurse, Staff G, was queried regarding the altercation involving P-2. Staff G explained that they were present for the incident and recalled the incident involving P-2 on 8/18/25. Staff G explained that P-2 had gotten into another altercation with the same patient the night prior. Staff G recalled that the two patients had gotten into a fight on 8/17/25 and that the staff separated them into different day rooms so they would not interact. Staff G explained that on 8/18/25 P-2 and the other patient were together in the hall and the other patient assaulted P-2 and pulled P-2’s hair out. Staff G identified the other patient as P-12. Staff G explained that one of P-2’s braids was ripped out of her scalp, P-2 then had to receive some medication and went to lie down. The letter to P-2’s guardian was reviewed with Staff G and staff G was queried about what additional precautions where implemented and where they were documented. Staff G explained that they would normally be separated and be put on one-to-one observation and confirmed that those precautions were not taken with P-2 or P-12. On 9/25/25 at 1218 Physician Assistant, Staff N, explained that when there is a new patient with violent behaviors admitted they observe them for a few days to determine their triggers and then the triggers are mitigated. Staff N explained that if another patient is a trigger then the two patients should be kept separated for their safety. The staff provides solitary space or quiet space, so the patients are not triggered. Sometimes one-to-one observation is initiated to ensure they remain calm. Staff N explains that restraints and pharmaceuticals are used as a last resort. Staff N was queried regarding the definition and procedure for homicidal precautions. Staff N explained that a patient on homicidal precautions should be watched more closely and placed on one-to-one observation. Staff N explained that a homicidal patient should be removed from the general activity and would engage in one-on-one activity with a staff member present at all times. Staff N was queried regarding P-2. Staff N recalled that P-2 was triggering the other patients in the unit. Staff N explained that P-2 would trigger others and for the safety of others P-2 needed to be isolated from the other patients to keep everyone safe. A review of the observation sheets for both P-2 and P-12 revealed they were never on one-to-one supervision during their hospitalization. 48772 P-3: This 14-year-old male was voluntarily admitted to the facility on 8/9/25 for suicidal ideation, disruptive mood regulation disorder, auditory hallucinations, and insomnia. P-3 has a history of autism spectrum disorder and attention deficit hyperactivity disorder. Record review indicated that on 8/18/25, an incident report stated P-3 was slapped in the face when a peer said he was sitting in his chair. The peer was removed. The report stated, “no injury noted. Face reddened, ice pack applied.” The adolescent unit charge nurse (Staff G) was interviewed on 9/22/25 at 1353. When queried on preventing altercations between residents, Staff G stated they try to eliminate stressors and try to figure out what is going on. Staff G stated they will make changes to room assignments or seating charts for group sessions if there are issues between patients. Staff G stated if altercation becomes physical, they will intervene immediately, separate the individuals, assess for harm, and notify physician and parents/guardians. The adolescent unit charge nurse (Staff G) was re-interviewed on 9/23/25 at 1410. Staff G was queried if she recalled the altercation involving P-3 on 8/18/25. She stated it happened very quickly with no indication. Staff G stated the alleged perpetrator and P-3 were far apart in age, that they were not roommates. During an interview with the Chief Nursing Officer (Staff D) on 9/23/25 at 1345, Staff D stated the incident with P-3 happened so close to discharge that the parent/guardian was already on route to pick him up from the facility so the event couldn’t be addressed in real time. Staff D stated P-3’s guardian was informed of the incident at discharge. A review of the facility’s policy titled “Identifying and Reporting Abuse and Neglect” dated 11/2024 revealed the following: “Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish ...Procedure a. All employees, volunteers and agents of (facility’s name) shall: i. Safeguard recipient from abuse and/or neglect and act to obtain treatment for observed injuries and to prevent additional harm.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document according to policy for 9 (P-1, 2, 3, 4, 6, 7, 8, 9, 10) of 10 records reviewed, resulting in the potential for unrecognized and unmet care needs and increased risk for negative outcomes. Findings include: See tags: A-0396 Failure to update care plans A-0398 Failure to document nursing assessments”

“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: 48772 Based on interview and record review, the facility failed to maintain and update an individualized care plans for 6 (P-1, P-2, P-3, P-4, P-6, P-8) of 10 records reviewed, resulting in the potential for unmet care needs and negative outcomes for these patients. Findings include: P-2: This 45-year-old male was admitted to the facility on 2/21/25 with a diagnosis of major depressive disorder. During record review on 3/31/25, it was noted that the patient had an unwitnessed fall and hit his head on 2/23/25 and was transferred to the emergency department for evaluation. The master treatment plan failed to indicate the patient fall on the acute medical problems list. In addition, the daily nurse progress notes failed to include observations or interventions related to the treatment plan or progress toward meeting the goals for all days except 2/27/25, where the nurse documented “patient is working towards goals.” P-3: This 22-year-old female was admitted to the facility on 2/25/25 with a diagnosis of paranoid schizophrenia. During record review on 3/31/25, it was noted that the daily nurse progress notes failed to include observations or interventions related to the treatment plan or progress toward meeting the goals. It was also noted that the treatment plan failed to include a date where goals were achieved or discontinued. P-4: This 59-year-old male was admitted to the facility on 1/15/25 with a diagnosis of major depressive disorder. During record review on 3/31/25, it was noted that the patient had fallen in his room, hit his head, and was transferred to the emergency department for evaluation. The master treatment plan failed to indicate the patient fall on the acute medical problems list. It was also noted that the daily nurse progress notes failed to include observations or interventions related to the treatment plan or progress toward meeting the goals. It was also noted that the treatment plan failed to include a date where goals were achieved or discontinued. P-6: This 28-year-old female was admitted to the facility on 3/21/25 with a diagnosis of major depressive disorder. A medical consult was conducted on 3/23/25 regarding a fasting blood sugar of 111. The physician ordered an 1800 calorie diet and Metformin 500mg twice daily. During record review on 3/31/25, it was noted that the master treatment plan failed to include diabetes on the acute medical problems list. These findings were reviewed and acknowledged by the assistant chief nursing officer (Staff-L) during an interview on 3/31/25 at 1215. 50585 P-1 was admitted to the facility on 2/13/2025 for hallucinations, delusions and agitation. On 2/16/2205 at 1220, P-1 fell while in the cafeteria. P-1’s nursing fall treatment plan was initiated on 2/16/2025. Three short term goals were included on the treatment plan and they included “Patient will report fall related pain/injury immediately to staff,” “Patient will participate in review of possible fall causes,” and “Patient will demonstrate use of fall prevention measures included in fall precautions.” The plan revealed that only the “Patient will report fall related pain/injury immediately to staff” was documented as initiated with a target date of 2/26/25. There was no other documentation or target dates for the other two goals. P-1’s master treatment plan was updated on 2/16/2025 with the word “Fall” and there was no other documentation about the date resolved and no additional updates were documented on subsequent days relating to the fall. P-8 was admitted on 12/31/2025 for major depression that included seizure disorder. P-8’s history and physical revealed that the plan for P-8 was to start P-8 on Keppra 750 mg twice a day. On 1/2/2025 at 0800, P-8 had a consult for seizure disorder with the plan “Patient will be given Keppra 1500 twice a day.” P-8’s initial master treatment plan created on 1/3/2025 did not have any documentation about seizure disorder. On 1/6/2025 at 0800, P-8 had a consult for “Patient states that (they) had a seizure for 10 minutes.” The consult note revealed that “per staff nurse, it was not a seizure, Pt sleeping, will reevaluate in am.” On 1/7/2025 at 0900, P-8 had a consult for the seizure disorder and the plan included “Patient will continue with the Keppra. We will consult the neurologist.” According to P-8’s master treatment plan, there was no documentation about seizure disorder from 1/3/2025 to 2/4/2025. On 2/5/2025, P-8’s master treatment plan revealed “no seizure activity noted.” On 4/1/2025 at 1200, Staff C acknowledged the findings and confirmed the medical treatment plans should be updated as needed in real time. Staff C also expected staff to complete all sections of the nursing progress notes. CNO Staff C was queried if they expected staff to follow policies and procedures and they said “absolutely.” According to the facility’s policy “Nursing Process,” dated 6/2024, “The nurse, in collaboration with the treatment team, develops a plan of care by integrating each step of the nursing process. The plan of care is revised and updated as needed, and acts as a written guide for the documentation of the patient’s care.” The policy also revealed that “The nurse adds the revisions to the plan of care to the original document and records the rationale for the revisions in the medical record.” According to the facility’s policy “Interdisciplinary Treatment Plan for Inpatient Services,” dated 2/2025, “The Master Treatment Plan is reviewed and updated as frequently as necessary, but at a minimum, is reviewed every seven (7) days.””

“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: 50585 Based on interview and record review, the facility failed to document required nursing assessments for 6 (P-1, P-2, P-3, P-7, P-9, P-10) of 10 patients reviewed, resulting in the increased likelihood of negative outcomes for the patients. Findings include: P-1 was admitted on 2/13/2025 for hallucinations, delusions, and agitation. On 2/16/2205 at 1220, P-1 fell while in the cafeteria. On 2/17/2025 at 0600, P-1’s post fall nursing progress note revealed that P-1 had a pain score of 5 and location included “L shoulder, ribs, elbow, hip, knee.” There was no correlating nursing medical note documented in P-1’s daily nurse progress note for the 1900-0700 shift. On 2/18/2025, P-1’s daily nurse progress note revealed that P-1 reported a pain score of 9 and then reassessed at 1000 with a score of 4 (0700-1900 shift). There was no correlating nursing medical note documented for the 1900-0700 shift. On 2/19/2025, P-1’s daily nurse progress note for the 1900-0700 shift revealed that P-1 reported chronic dull pain to left shoulder. However, no pain score was documented at that time. On 2/20/2025 P-1’s daily nursing progress note for the 0700 to 1900 shift revealed that P-1 had pain but there was no pain score documented. There was no medical note documented for the 1900 to 0700 shift. On 2/21/2025, P-1’s daily nursing progress note for the 0700 to 1900 shift revealed that P-1 had chronic pain to left shoulder, but no pain score was documented. There was no corresponding nurse medical note documented for the 1900 to 0700 shift. P-7 was interviewed on 3/31/2025 at 1000 and revealed a concern that they told their nurse their ankle hurt on 3/29/2025 and P-7 reported there has been no update. On 3/29/2025 at 1725, P-7’s daily nursing progress note revealed that “c/o of swelling to L ankle, pain 0/10.” On 3/30/2025 (no time recorded), P-7’s daily nursing progress note for one shift revealed “Pt is stable.” On 3/30/2025, there nurse medical note for the second shift was blank. On 3/31/2025, P-7’s daily nursing progress note revealed that a pain assessment was not documented on the 0700-1900 shift. On 3/31/2025 at 1235 Assistant Chief Nursing Officer (ACNO) Staff L confirmed that there was no order/consult generated by nursing to address P-7’s ankle and confirmed the nurse should have documented the sore ankle as a medical condition in the nursing medical notes. P-9 was admitted on 1/11/2025 with a history of psychosis. According to medical record review on 3/31/2025 at 1135, P-9 had missing pain assessments in the daily nursing progress notes on the following dates 2/11/2025 (0700-1900 shift), 1/12/2025 (0700-1900 shift), 1/13/2025 (0700-1900 shift), 1/20/2025 (0700-1900 shift), 1/21/2025 (0700-1900 shift), 1/23/2025 (0700-1900 shift), 1/25/2025 (0700-1900 shift), 1/26/2025 (0700-1900 shift), 1/27/2025 (0700-1900 and 1900-0700 shifts), 2/3/2025 (0700-1900 shift), 2/4/2025 (0700-1900 and 1900 - 0700 shifts), and 2/19/2025 (1900-0700 shift). ACNO Staff L confirmed the findings during an interview on 3/31/2025 at 1215. 48772 P-2: This 45-year-old male was admitted to the facility on 2/21/25 with a diagnosis of major depressive disorder. During record review on 3/31/25, it was noted that the daily nurse progress notes failed to include pain assessments on 2/22/25, 2/24/25, 3/1/25, and 3/4/25. It was also noted that the nursing medical assessment on 2/22/25, 0700-1900 was blank. P-3: This 22-year-old female was admitted to the facility on 2/25/25 with a diagnosis of paranoid schizophrenia. During record review on 3/31/25, it was noted that the daily nurse progress notes failed to include pain assessments on 2/27/25, 3/1/25, 3/3/25 (both shifts), and 3/6/25. It was also noted that the medical assessment on 3/6/25 (0700-1900) failed to include a nursing signature and the nursing medical assessment on 3/3/25 (1900-0700) was blank. It was also noted that P-3 had fallen out of bed on 2/27/25 at 0320. The post fall nursing progress note indicated post fall follow up every shift for 24 hours following the fall. Shift one completed the assessment on 2/27/25 at 0930. The second shift assessment was blank. In addition, the physician ordered neuro checks every 2 hours for 24 hours. The medical record indicated neuro checks began on 2/27/25 at 0400. The last neuro check documented was at 1800 on 2/27/25. There was no evidence of a physician order to discontinue the neuro checks after 14 hours. P-10: This 41-year-old female was admitted to the facility on 3/9/25 with a diagnosis of schizoaffective disorder. During record review on 3/31/25, it was noted that the daily nurse progress notes failed to include pain assessments on 3/11/25, 3/13/25, 3/14/25, 3/22/25, 3/23/25, and 3/24/25. These findings were reviewed and acknowledged by the assistant chief nursing officer (Staff-L) during an interview on 3/31/25 at 1215. The chief nursing officer (Staff C) stated all nursing staff are expected to follow policies and procedures during an interview on 4/1/25 at 1155. Policy-16241747, Nursing Assessment (Last revised 7/23). States, “ALL sections of the nursing assessment MUST be completed.” Policy-16790103, Pain Management (Last revised 10/24). States, “In order to provide for a common language throughout the System, intensity will be documented using designated pain scale.””

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 38269 Based on observation and interview, the facility failed to provide a safe and sanitary environment, resulting in the potential for harm and less than optimal outcomes to all 175 patients served by the facility. Findings include: See specific tags: A-701 Failure to provide safe environment. Ligature risk A-724 Failure to ensure furniture promoted safety. .”

“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: 38269 Based on observation and interview, the facility failed to maintain a safe and sanitary physical environment for all 173 patients at the facility at the time of observation, resulting in the potential for less than optimal outcomes and the potential for harm, including death. Findings include: On 11/27/2023 at 1120, during the facility tour on (adult co-ed) Unit E, patient room doors were noted to be a possible ligature risk. The Chief Operations Officer (COO), Staff C was queried about the patient room doors being “ligature free”. Staff C indicated that the doors were recognized as a risk to patient safety, and that new doors were on order. Staff C described the new doors as having a “piano hinge” (a solid closed hinge) and that the intent was to replace all patient doors. The Assistant Chief Nursing Officer (ACNO), Staff G, then pointed out one of the newer “ligature resistant” doors. On 11/27/2023 at 1130, room 514 was observed to have one of the new doors. Staff B, C, E, & G confirmed patient room (514), was fitted with a “ligature resistant door”. Staff G stated “these doors were vetted by the supplier as well as the state”. A 2X6 inch rectangular hole was observed in the doorframe above the new door. At 1131 this writer requested a flat sheet be brought to room 514. Staff G returned to room 514 with a flat sheet in hand. In less than one minute the sheet was used by the writer to secure a ligature point, strong enough to hold an adult off the floor. The excess sheet was then used to wrap securely around one’s neck resulting in the potential for asphyxiation. There was enough excess sheet that it could be tied in a loop and used around the neck, to induce suffocation while bending one’s knees, doing an alligator roll or hanging. While performing the above maneuvers, the door was in both the open and closed positions without visibility from the hallway staff or cameras. The lack of visibility was confirmed by facility Staff B, C, E, and G. All of the above above described activity was witnessed by, and confirmed by the COO, CNO, Director of Regulatory and the ACNO. A request was made for a tally of patient room doors, including hinge types. The tallys were as follows: Total patient room doors: 97 Piano hinged doors: 21 Multi-hinged doors: 76 An Immediate Jeopardy was called on 11/28/2023 at 1512. An additional ligature risk evaluation was completed on 11/29/2023, while patients were scheduled to be off the unit for activities. On 11/29/2023 at 1130, the Director of Plant Operations, Staff O, who is in charge of ordering and installing doors, the Director of Risk Management, Staff D, in charge of evaluating the environment for patient safety risks, and a state employed Engineer Surveyor were present during the evaluation. Both types of doors were evaluated and confirmed to be a potential ligature risk on 11/29/2023 at 1134. Twenty-one (21) doors with a solid hinge (Piano Hinge) and the concerning 2X6 inch holes were determined to be installed and in use. One of the piano hinged door frames was newly retrofitted with a metal cover plate, obstructing the 2 x 6 inch hole where the sheet was stuffed and anchored. Twenty (20) door frames remained with a 2 x 6 inch hole in the top frame. Seventy-Six (76) remaining patient rooms, still had the multi hinged doors, (previously recognized as a safety risk) by the facility. On 11/29/2023 at 1230, when queried, the Director of Risk Management, Staff D and Director of Plant Operations, Staff O, described the risk mitigation for multi-hinged doors, was to replace them with the solid hinged doors (piano hinge). 13069 On 11/29/2023 starting around 10:00 AM during a tour of the Unit D of the second floor and all following floors/units (including clean and dirty storage rooms), excessive build-up of lint and grime were observed on the floors specifically behind doors, on shelving units, on the walls, and on the ventilation grilles. Above findings were also confirmed by accompanying staff members C and D at the time of observation.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 13069 Based on observation and interview, the facility failed to provide furniture that promoted safety in the psychiatric setting on 4 (unit A, B, C, D) of 4 patient care units observed, resulting in the potential for harm to all patients on the four units. Findings include: On 11/29/2023 at around 10:00 AM during the tour of the second floor unit D, the facility completely or partially replaced heavyweight chairs with a lightweight (plastic) chairs in the unit’s activity room, quiet room, and dining room. The lightweight plastic chairs could be easily thrown and/or used as a weapon. The same observations were made on units A, B, and C. At the time of observation, accompanying staff members C and D confirmed the findings and agreed the lightweight chairs were not the best type of chair for the psychiatric setting.”