Forest View Psychiatric Hospital

“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: 29955 Based on observation and interview, the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code”

“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: 29955 Based on interview and record review the facility failed to follow policy to provide transfer to an Emergency Room for SANE (Sexual Assault Nurse Exam) exam to 1 (P-1) of 1 patients reviewed for the allegation of rape resulting in the loss of a patient right to care in a safe setting. Findings include: On 10/28/2025 at 1525 during an interview with P-1 she alleged that she had been raped. P-1 was unable to establish if she had been raped at the facility or at another facility but stated she was raped by several males. P-1 stated that she had told staff that she had been raped, but that she had not allowed nursing staff to examine her out of embarrassment. P-1 stated that she had been sodomized and was very “torn up.” P-1 agreed to a SANE (Sexual Assault Nurse Exam) when asked if she wanted to be examined on 10/19/2025. On 10/28/2025 at 1610 during an interview with RN staff P she revealed that she had become aware of P-1’s report of rape on the morning of 10/19/2025. Staff P stated that she had called staff A Director of Risk to inform her of P-1’s allegation. Staff P also stated that she had called a local community facility to schedule a SANE exam, and they were closed. When asked when P-1 received a SANE exam, staff P stated she had been told that the exam took place on the next day, Monday (10/20/2025) when the local community facility was open. On 10/28/2025 at 1650 staff A Director of Risk was asked why P-1 was not taken to the hospital for a SANE exam. Staff A stated that the hospital would direct the facility to take a patient to the local community center for a SANE exam even if P-1 had been taken to the hospital. Staff A stated that the local police were called when P-1 had reported that she had been raped. Staff A stated the local police found no merit in P-1’s allegation. Staff A was asked if P-1 would have been taken to the hospital if the police had felt P-1’s claim was legitimate. Staff A stated that local police have taken patients to the hospital in the past if they felt the claims were legitimate and have also confiscated clothing for evidence in those cases. Staff A was queried why P-1 was not taken to the hospital. Staff A stated that video footage was reviewed from 1700 to 0800 for Friday night to Saturday morning (10/17/2025 to 10/18/2025). Staff A stated that the police did not feel that P-1 was credible and that no other person was seen going in and out of the room other than P-1 and there was not immediacy to get P-1 examined based on the findings. On 10/30/2025 at 0930 a review occurred of the policy titled, “Sexually Acting Out Precautions,” policy #18986316, dated 10/2025. The policy revealed the following: “D. RESPONSE: 1. Upon report or discovery of an allegation of sexual behavior between patient/patient, staff/patient or stranger/patient the Charge Nurse and facility leadership: e. Prepares patient(s) for transport to the ER for trauma evaluation for cases involving non-consent, allegation of force, assault/rape;” and, “E. NOTIFICATION: 1. Person discovering the incident/event shall immediately notify the Charge / Supervising Nurse who will report the incident to the House Supervisor; 2. The House Supervisor shall immediately notify the Attending Psychiatrist(s), Director of Nursing, Risk Manager, Administrator and / or Administrator On Call; 3. The House Supervisor will obtain orders for: a. Evaluation via ER, including testing for STD/HIV testing for Chlamydia, Gonorrhea, HIV, Hepatitis B, C and Pregnancy, etc.; b. Plan B / Morning After Pill reviewed and offered by the ER, as appropriate; c. Implementation of any appropriate Sexual Aggression and/or Victimization Precautions as outlined above; d. Implementation of increased level of monitoring, as required” The policy failed to refer to a local community facility for the purpose of obtaining a SANE exam.”

“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: 47415 Based on interview and record review, the facility failed to protect 1 (P-2) of 1 patients reviewed for restraints resulting in loss of a patient’s right to be free from abuse. Findings include: On 10/20/25 at 1355, P-2 was refusing the administration of a tube feeding through a nasal gastric tube. The physician staff L was notified and ordered P-2 to be placed in a physical hold to administer the tube feeding. P-2 was held down (in the hallway) by multiple staff members and the tube feeding was administered. There was no court order to administer medications. The mother (guardian) was not notified of the plan to place P-2 in a physical hold to administer the tube feeding. P-2 was in a physical hold for over an hour. On 10/28/25 at 1540, an interview with P-2 revealed that the episode caused emotional stress and made her feel guilty. P-2 reported she was lying flat during the tube feeding. On 10/29/25 1120, Provider Staff L was interviewed and initiated the conversation by stating that it was poor judgement on his part to order the hold for the tube feeding for P-2, and that it was inappropriate. A tube feeding policy was requested at time of survey, and staff stated they did not have one. The Lippincott standard of practice, aligned with national guidelines (American Society for Parenteral and Enteral Nutrition (ASPEN) requires maintaining a patient’s head of bed at a 30 - 45-degree angle during tube feeding to minimize the risk of aspiration. Record review of the policy titled, “Proper Use & Monitoring of Physical/Chemical Restraints & Seclusion,” dated last approved 08/2025, revealed, “It is the policy ...to support each patient’s right to be free from restraint ...and therefore limit the use of these intervention to emergencies in which there is an imminent risk of a patient physically harming him/herself or others ...The patient has a right to be free from restraint ...imposed as a means of coercion ...punishment, discipline, convenience or retaliation by staff ...The patient’s rights, dignity, privacy, safety and well-being will be supported and maintained.””

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 29955 Based on observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include: See the individually and below cited K-tags dated October 29, 2025 for survey event ID SWPV21. K-0222 K-0321 K-0324 K-0325 K-0353 K-0374 K-0920”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36887 Based on interview and record review, the facility failed to protect and promote the rights of 2 (P-1, P-2 ) of 2 patients resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: See Specific Tags: A-118 Failure to establish procedure for written or verbal grievance A-123 Failure to investigate and report to patient regarding their grievance A-144 Failure to provide a safe setting for care”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to develop and implement policy and/or procedure regarding a written grievance submitted to the Office of Recipient Rights that was outside it’s jurisdiction for 1 (P-1) of 5 cases reviewed resulting in the loss of patient rights and the potential for unsatisfactory outcomes for all patients submitting grievances to the office of recipient rights. Findings include: Review of the Office of Recipient Rights (ORR) Log from 3/2025-present revealed 5 complaint entries (25-5-4, 25-6-41, 25-6-54, 25-6-69, and 25-7-66) for P-1. Review of complaint #25-6-69 included a form titled “Recipient Rights Complaint” on which P-1 had hand-written concerns that his “anxiety, suicidal and self-harm thoughts, medical concerns [sic]) were not being addressed. He requested a transfer to another nearby psychiatric facility for “better quality care.” The complaint also had a form letter attached which indicated the submitted complaint did not fall under ORR jurisdiction as follows: “Your case has been classified as a/an: Outside ORR Jurisdiction [sic] For explanation on what this designation entails, see below... Outside RR [recipient rights] Jurisdiction: Your complaint is Outside Jurisdiction of the [facility name] Recipient Rights Office. (The complaint issues did not occur under the purview of [facility name], but maybe at another provider, police department, hospital. Often there are other avenues to follow up your claim, usually directly with the other party.) No other documentation was present regarding an investigation or referral to the complaint/grievance staff. Further review of the ORR Log revealed the complaint was closed with no date provided as to when it was closed. On 9/11/2025 at 1515, ORR Staff P was queried as to if this complaint was handed off to the person/people responsible for complaints and grievances within the facility to which he stated it was not. He stated sometimes complaints were handed off verbally, but he did not document verbal handoffs to other staff. On 9/11/2025 at 1550, Interim CEO Staff J was queried as to his expectation of events if a complaint made to the ORR fell outside ORR jurisdiction. Staff J stated the expectation would be to “document what was discovered and to whom it was handed off to. It should be forwarded to the complaints and grievances staff.” On 9/11/2025 at 1436, a policy was requested regarding the process of what to do with a complaint that does not fall under ORR jurisdiction. No policy was found.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to investigate and report back to the patient/patient representative in 2 (25-6-54 and 25-6-69) of 5 complaints/grievances for P-1 made to the facility resulting in the loss of patient rights and the potential for poor patient outcomes for all patients submitting grievances to the office of recipient rights. Findings include: Review of complaint #25-6-54 revealed a form titled “Recipient Rights Complaint” on which P-1 complained of harassment, slander, and being placed in a room with a patient of the opposite sex. P-1 made a request to talk with a supervisor and be transferred to another area psychiatric facility. P-1 dated the form 6/17/2025. Attached to the complaint was a form letter dated 6/23/2025 indicating the “case has been classified as a/an: Investigation [sic] For further explanations on next steps: The complaint has been assigned for investigation. Under most circumstances, the investigation will be completed within 90 days and a report of findings sent to the Executive Director of the Hospital. Once the investigation is complete, you will have the right to request mediation to resolve the problem. You will be advised of the results, in writing, at the conclusion of the investigation.” No documentation was provided for complaint #25-6-54 as to the investigation or results of the investigation. Further review of the ORR log revealed this entry was considered closed. No date was present as to when the complaint was closed. On 9/11/2025 at 1515, ORR Staff P was queried as to documentation for complaint #25-6-54 to which he stated by the time he was going to address it, the patient had already been moved so there was nothing for him to do. He further stated he did not document everything that might relate to the case. Review of complaint 25-6-69 revealed the “Recipient Rights Complaint” form on which P-1 stated he did not feel his concerns of anxiety, suicidal and self-harm thoughts, as well as medical concerns were being addressed. Additionally, he stated he did not feel his safety was being taken seriously. He again requested transfer to another area psychiatric facility. P-1 dated this complaint 6/21/2025. Attached to the complaint was a form letter indicating the complaint was outside of ORR jurisdiction. “Outside RR [recipient rights] Jurisdiction: Your complaint is Outside Jurisdiction of the [facility name] Recipient Rights Office. (The complaint issues did not occur under the purview of [facility name], but maybe at another provider, police department, hospital. Often there are other avenues to follow up your claim, usually directly with the other party.)” No documentation was present regarding a hand-off to the complaints/grievance staff at the facility. On 9/11/2025 at 1515, ORR Staff P was queried as to documentation for complaint #25-6-69 to which he stated that some things are handed off to the complaint/grievance staff, “but not everything.” Staff P stated he did not document verbal hand-offs to other staff. On 9/11/2025 at 1550, Interim CEO Staff J was queried as to his expectation of events if a complaint made to the ORR fell outside ORR jurisdiction. Staff J stated the expectation would be to “document what was discovered and to whom it was handed off to. It should be forwarded to the complaints and grievances staff.” Facility policy #18137272 titled “Patient Complaint and grievance Process” last revised 9/2025 states, “Grievances involving situations that place patients in immediate danger or allege abuse or neglect must be investigated immediately...Hospital will acknowledge, review, investigate and resolve each grievance within seven (7) days. Occasionally a grievance may be complicated and may require an extensive investigation. If it will not be resolved or if the investigation is not or will not be completed within seven (7) days, the Hospital will inform the patient/patient representative, in writing, that [facility name] is continuing to work to resolve the grievance and that they will receive a written response of resolution within 30 days... Following resolution, a member of the Hospital staff will provide the patient/patient representative with written notice of the decision. This written notice will be in a manner easily understood by the patient/patient representative and shall include the following: 1. The name of the contact person 2. The steps taken to investigate the grievance 3. The results of the grievance process (i.e. how was the grievance resolved)[sic]””

“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: 36887 Based on observation, interview, and record review, the facility failed to provide an environment that was safe for 1 (P-2) of 7 adolescent males in the adolescent male unit resulting in bodily injury of P-2 which required emergency care and the potential for injury to other patients and staff on the unit. Findings include: Review of the medical record for P-2 revealed he was a 15-year-old male admitted to the facility 8/5/2025 for unspecified mood disorder, autistic spectrum disorder, oppositional defiant disorder, and cannabis use. It was noted he had been threatening and assaultive toward emergency department staff and required the use of restraints prior to his transfer to the current facility. Multiple instances of physical and chemical restraint within this facility, which would have triggered a Code Yellow (need for additional staff assistance) for each event, were found in the medical record as follows: 8/5/2025 2330 Physical hold with chemical restraint 8/6/2025 1822 Physical hold with chemical restraint 8/9/2025 0954 Physical hold with chemical restraint 8/12/2025 1652 Physical hold with chemical restraint 8/15/2025 1455 Physical hold with chemical restraint 8/16/2025 2009 Physical hold with chemical restraint 8/17/2025 1830 Physical hold with chemical restraint 8/22/2025 1129 Physical hold 8/22/2025 1205 Physical hold with chemical restraint 8/28/2025 1438 Physical hold with chemical restraint 8/28/2025 1515 Physical hold with chemical restraint 8/30/2025 1515 Physical hold with chemical restraint 8/30/2025 1540 Physical hold with chemical restraint 9/9/2025 1520 Physical hold with chemical restraint 9/10/2025 1455 Physical hold with chemical restraint 9/10/2025 1535 Physical hold with chemical restraint On 9/9/2025 between 1045-1700, 5 Code Yellow events were paged overhead for the male adolescent unit. On 9/10/2025 at 0910, the 10-bed male adolescent unit was entered. Current census on the unit was 7 patients. There was 1 registered nurse (RN) and 1 mental health technician (MHT) scheduled and working on the unit. On 9/10/2025 at 0922, MHT Staff M stated a Code Yellow meant there was “imminent danger to self or others.” She denied having worked on 9/9/2025, but stated, in general, if there was a fight, de-escalation was attempted followed by a physical hold if that did not seem to be working. If a physical hold was used, the patient would usually be given medication. The physical hold consisted of two staff holding each arm and each leg. There were few men in the facility to assist with this. Staff M stated a physical hold and/or chemical restraint was not necessarily used for each Code Yellow that was called. She further stated a Code Yellow had occurred on the previous evening and no additional staff had reported. On 9/10/2025 at 0934, RN Staff N, who had been working 0700-2300 the previous day, stated for the past 4-5 months the unit had been staffed with 1 RN and 1 MHT because they were the smallest unit on the campus “and staff to patient ratios and all that.” Staff N said all of the Code Yellows the previous day were for P-2 except for 1. During the last Code Yellow, at approximately 1810 on 9/9/2025, P-2 was upset and had pulled off a piece of the door frame, went over “smashed” the window, then took pieces of glass and cut his arm. It appeared P-2 would need stitches, so he was sent to the local acute care hospital’s emergency room for further care. Staff N further stated a Code Yellow had been paged overhead and only the house supervisor had responded. As P-2’s behaviors had continued, another Code Yellow was called for additional help; however, no additional help came. Staff N stated P-2 “surrendered on his own after cutting himself. Staff N was queried as to why security was not involved and what the next steps would have been if P-1 had not “surrendered.” Staff N answered it was “always in the back of my mind that if something goes bad, it’s very bad. There is no back up plan that I’m aware of.” He further stated there was no security at the facility and he was not sure what he would have done had P-2 not surrendered. He admitted police had responded to the unit “at the beginning of May” when the facility lost control of the unit. Staff N felt the incident in May was different because a lot of staff were present and staff recognized the patients had weapons - broken toothbrushes, etc. They also realized the patients were not attacking staff or each other but were intent on destroying the facility/property. Staff N further stated no mechanical restraints were used at the facility and that seclusion was only used as a last resort. On 9/10/2025 at 1540, review of video documentation confirmed the statements of Staff N showing P-2 slamming the door very hard twice, removing a piece of the doorway and going back into the room, then coming out into the hallway and showing the staff his wounds. MHT Staff V held pressure on the wounds with towels, which were switched out three times, until she was sent to watch over the other patients. The video further showed lack of additional staff on the unit. On 9/15/2025 at 0859, House Supervisor Staff R stated he was not only the house supervisor on the night of 9/9/2025, he was also the primary nurse on the 300 unit (unit which housed patients who were bipolar, manic, and had psychosis). He was the only one to respond after two calls for Code Yellow. He stated he didn’t arrive “on time” to the Code Yellow as he was trying to ensure the safety of the patients on his own unit after a newly arrived patient was found to have razor blades on her person. Staff R arrived after P-2 had injured himself. He stated he had sent MHT Staff V to watch over the other patients as P-2 was making multiple threats to harm her. Staff R admitted that he had been assaulted multiple times in the past, but never severely. He further stated there have been approximately 4-5 Code Yellows over the past 6 months in which no one had responded. He stated he feels much safer on the day shift. After 1600, the number of staff goes way down. On 9/10/2025 at 1003, Staff A was queried as to if any record were kept of Code Yellow events to which she stated, “No.” On 9/10/2025 at 1523, a Code Yellow was observed on the male adolescent unit involving physical and chemical restraint. No concerns were noted. On 9/11/2025 at 1040, Physician Staff Y voiced concerns over the door frames on both the adolescent female and adolescent male units. “(P-2) has shown us as well as all of the other male adolescent patients how easily this can be removed.” He showed the surveyor the door frames were loose and held in place with “1/2-inch screws.” He additionally voiced concern the facility would not address the issue with urgency. Observation of the door frame further revealed the metal had jagged edges and the screw was partially exposed the whole length making it possible for a patient to remove. The cutting and jagged edge of the door frame was done post-manufacture. Facility policy titled “Code Yellow-Physically Acting Out Patient Response Plan” last revised 6/10/2025 states, “PURPOSE This plan prepares the facility to safely manage a patient who is acting out and has become a physical risk to self and others. PROCEDURE Points to Remember: Human Life Is Always Top Priority Remain calm Announce “Code Yellow” location via house-wide overhead paging Walk-do not run Follow the direction of the responding team leader Reassure patients and visitors Use common sense Maintain dignity and respect for all patients at all times Always seek to de-escalate any such situation before attempting to physically manage any patient RESPONSE: I. NOTIFICATION The hospital is alerted to activate the “Code Yellow” by way of a staff member identifying a patient who is in imminent risk of harming self or others. II. ACTIVATING THE CODE YELLOW PLAN A. Upon identification of an escalating patient, the identifying staff member will page a hospital-wide page announcing “Code Yellow __________ (location).” B. Notification may be made by way of depressing one of many “Code Yellow” buttons located throughout the facility. C. All staff are to ensure that all patients remain safe and monitored at all times during a Code Yellow response. D. All attempts to verbally De-Escalate the situation should be made in order to avoid laying hands on patients unless all other options have been exhausted. E. All assigned staff trained in Handle with Care (HWC), are to report to the area of the code. F. One single staff member that will act as the team leader in the response. G. The team leader is the only person who should talk to the patient. H. The team leader may assign another person to communicate with the patient. I. Staff responding should ensure they are not posturing themselves such that the patient will feel threatened. J. The team leader delegates others to: 1. Contact the Doctor; 2. Prepare a Quiet Room, if indicated and ordered; 3. Prepare Medication, if indicated and ordered; 4. Direct staff away from the area to avoid creating a threatening situation as perceived by the patient; 5. Call the code, or repeat the announcement, if needed; 6. Care for other patients by removing them from the immediate area, starting a group, reassuring them and providing support. III. RECOVERY If the Code Yellow occurred in conjunction with any damage to the building, i.e., broken windows, furniture, etc., arrangements for repairs will be coordinated by the Administrator on Call or designee. Debriefings of patients and staff will be completed by nursing staff to ensure any medical or emotional needs are addressed, if applicable. Complete all incident reporting forms and present to the Risk Manager. Outpatient Staff are required to use Verbal De-escalation techniques as the first line of intervention when responding to escalating patient behavior in our outpatient facility. Any physical intervention would have to comply with local laws and regulations. “ The policy did not define what a Code Yellow was, did not indicate who was to respond, did not specify how patients would be kept safe, and it did not specify what “laying hands on the patient” meant, or who would determine if and/or when “laying hands on the patient” should occur.”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 29955 Based on observation, interview, and record review the facility failed to provide adequate staffing to ensure one-to-one monitoring occurred as ordered for five (P-1, P-3, P-4, P-5, and P-8) of five patients reviewed, failed to administer medications as scheduled for eight (P-9, P-10, P-11, P-12, P-13, P-14, P-15, and P-16) of ten patients reviewed resulting in the potential for less than optimal outcomes for all patients receiving care at the facility. Findings included: See specific tag A-1704 - Adequate Staffing”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 29955 Based on observation, interview, and record review, the facility failed to protect the privacy, dignity and respect of three patients (P-6, P-7, and P-16) of three patients reviewed on the adult psychiatric unit resulting in the loss of privacy, dignity, and potential for mental anguish. Findings include: On 6/2/2025 at 1145 during the initial tour of the facility on unit 2-5 it was observed that the unit was crowded and patients were sitting on the hallway floor. Patients were observed in gowns in the hallway. On 6/3/2025 at 0845 during an interview with (confidential informant) CI-17 it was revealed that patients (P-6, P-7, and P-16) were admitted to the 2-5 unit on the prior day without open beds being available due to pending discharges not being completed prior to the new patients being brought to the unit. CI-17 stated that new admissions were often admitted to the units with pending discharges although the pending discharges had not taken place at the time the new admissions arrived on the unit. On 6/3/2025 at 1100 an interview occurred with staff M, the Chief Executive Officer. Staff M was asked if he was aware that new admissions were being brought to specific units where were patients pending discharge (but the discharge had not occured yet). Staff M replied, “No one has let me know that this has happened.” On 6/3/2025 at 1325 an interview occurred with staff L, the Director of Admissions. Staff L was queried about newly admitted patients being brought to the adult psychiatric units without a clean and ready bed for the new admission. Staff L stated new admissions were not brought to adult units unless there was a bed ready and available for the newly admitted patient. Staff L further stated that new admissions were kept in the admissions area until a bed was available and ready on the unit. Staff L stated there were three rooms in which a patient could be held in the admissions area that were monitored by admissions staff. Staff L stated that admissions are staggered at approximately a two hour period between patients admitting to the facility. On 6/3/2025 at 1415 an interview occurred with staff O, registered nurse. Staff O was queried about admissions from 6/2/2025. Staff O was asked if new admits were assigned to rooms that were open. Staff O stated, “No, not necessarily. Staff O was then asked if newly admitted patients are assigned to beds that may not be open due to a pending discharge not being complete. Staff O stated, “Yes...Discharges are pending and may not happen that day.” Staff O was then asked if the newly admitted patients are kept in the admissions area until the previous patient in that bed has discharged and the room has been cleaned and is ready for the patient. Staff O answered, “No...we never keep patients in the admissions area...” On 6/3/2025 at 1440 an interview occurred with staff P, registered nurse. Staff P was queried about the admissions process. Staff P explained that new patients were brought through the admissions department and then sent to the assigned units. Staff P was queried if there was an open bed on the unit for a new patient to go to once on the unit. Staff P responded, “Not always.” Staff P was asked to explain her response. Staff P clarified that new admissions were actually assigned to go to a unit and not a “bed.” Staff P stated there isn’t always a bed available on the unit because discharges may be delayed or not happen at all that day. Staff P was then asked if new admissions were spaced apart in order to not have a unit receive new patients closely together. Staff P stated, “No...If there is a patient to put in a unit we are instructed to put the patient in the unit.” Staff P was then queried if she would be aware of discharges pending or that had not happened yet that day. Staff P stated that the white board in the intake office designates which patient is pending a “possible” discharge, but that discharges often may be delayed or not happen that day as expected. Staff P stated that the facility was only concerned with keeping beds filled at all times. Staff P explained that she often saw patients admitted with a documented history of violence, and aggressive and/or sexual behaviors, with patients and staff and banned from other facilities. Staff P then stated she often felt bad for the nurses on the floor because she would take admission after admission to a unit knowing that there may not be enough staff to cover the acuity of the patients that were being admitted. On 6/3/2025 at 1640 a list for 6/2/2025 admissions times was provided by staff L, the Director of Admissions. According to the list provided P-16 was admitted to the adult 2-5 unit on 6/2/2025 at 0900, P-6 was admitted to the 2-5 unit on 6/2/2025 at 0939, and P-7 was admitted to the 2-5 unit on 6/2/2025 at 1015. Staff L was queried if a two-hour spacing was provided between P-16, P-6, and P-7 admissions. Staff L stated, “No.” On 6/4/2025 at 1030 an interview was conducted with P-6. P-6 was queried if she had a bed available when she arrived on the 2-5 unit. P-6 stated, “No...they told me that I would have to wait for a bed because people were being discharged.” P-6 was asked how long she had waited for a bed to become available. P-6 responded, “A couple of hours.” P-6 was then queried about where she waited during that time and how did it make her feel while she waited. P-6 stated, “I waited in the hallway near the nurse’s station...It didn’t make me feel safe because I was in a hospital gown and men were walking past me...I didn’t feel safe because I was recently assaulted.” A record review of P-6’s medical record on 6/4/2025 at 1500 revealed P-6 was sexually assaulted two weeks prior according to documentation. On 6/4/2025 at 1050 an interview was conducted with P-7. P-7 was queried if she had a bed available when she arrived on the 2-5 unit. P-7 replied, “No there wasn’t a bed available...they told me they had to clean up the room after a patient who was supposed to be discharged left the unit.” P-7 was then asked how long she waited for a bed to become available. P-7 responded, “About an hour and a half or more.” P-7 was asked where she waited during that time and how did she feel about waiting. P-7 stated, “I was sitting in a chair at the nurse’s station. I didn’t feel very good about it.” An attempt to interview P-16 was made on 6/4/2025 at 1110. P-16 was unable to be interviewed at the time. Staff V, registered nurse, was interviewed on 6/4/2025 at 1115. Staff V was asked if she was working on 6/2/2025 on the 2-5 unit at the time of P-6, P-7, and P-16 being brought to the unit for admission. Staff V replied, “Yes. I was working on 6/2/2025 on the morning shift.” Staff V was queried if a bed was available for P-16 at the time when P-16 arrived to the unit. Staff V responded, “No...we were waiting on discharges to occur.” Staff V was then asked if this was routine practice. Staff V stated, “Unfortunately yes. I know that there is a projection of how many patients are to be discharged but the projection doesn’t always happen or discharges are delayed. If a patient hasn’t discharged then a new admit will have to wait for the discharge of another patient and for the room to be cleaned...sometimes that is hours.””

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 29955 Based on observation, interview, and record review the facility failed to provide adequate staffing to ensure monitoring occurred as ordered for five (P-1, P-3, P-4, P-5, and P-8) of five patients reviewed, and failed to administer medications as scheduled for eight (P-9, P-10, P-11, P-12, P-13, P-14, P-15 and P-16) of ten patients reviewed resulting in the potential for less than optimal outcomes for all patients receiving care at the facility. Findings included: On 6/3/2025 at 1400 a review of P-1’s medical record occurred. According to the record P-1 was admitted to the facility as an involuntary admission on 4/22/2025. P-1 was a 48-year-old homeless male who was petitioned by the emergency department of the sending hospital. P-1 reported he had suicidal thoughts and attempts, with voices telling him to walk into traffic to “kill himself.” The record also noted that P-1 was assaultive towards others. P-1 also reported current substance abuse including alcohol and cocaine. P-1 was documented as currently being on parole. The record also contained the following documentation located in documents provided from the transferring hospital, “There are reports of sexually inappropriate behavior towards staff at other facilities.” Further record review revealed an order for special precautions for sexual behaviors and aggressive behaviors on 4/22/2025. Orders also revealed observation level for every 15-minute intervals. Behaviors listed included threatening, assaultive, sexual acting out. P-1 was discharged on 4/30/2025. During review of the medical record, staff N, the assistant Director of Nursing was unable to locate documentation to support 15-minute checks were conducted during P-1’s hospitalization. On 6/4/2025 at 1330 a review of P-3’s medical record occurred. According to the record P-3 was admitted to the facility on 4/18/2025. According to P-3’s medical record P-3 was described as a 31-year-old female “with history of multiple psychiatric hospitalizations and self-harming behaviors, including several suicide attempts, reportedly through intentional overdoses.” According to the justification for hospitalization it states, “...dangerous to self, others, or property with a need for structured environment, psychiatric drug therapy, requires 24-hour supervision...emotional or behavioral conditions and complications requiring 24-hour medical and nursing care.” According to the “Risk Assessment” documentation revealed “current suicidal ideation: Yes,” and “current assessment of capacity to harm self: significant, describe: banging head on the wall.” A verbal order dated 4/27/2025 for one-to-one monitoring was found in the medical record. During review of the medical record, staff N, the assistant Director of Nursing was unable to locate documentation to support one-to-one monitoring prior to 5/29/2025. Staff N was queried if one-to-one documentation was to be kept in the medical record. Staff N stated, “Yes.” On 6/4/2025 at 1355 a review of P-4’s medical record occurred. According to the record P-4 was admitted to the facility on 4/10/2025. According to P-4’s medical record P-4 was a 15-year-old male with a history of a past suicide attempt. P-4 was admitted to the facility for leaving his home and telling his mother, “I am goin [SIC] to kill myself.” P-4 was stated to be aggressive with his mother prior to admission. P-4’s past history also included physical abuse by father and sexual abuse at the age of 9 by parent’s significant others son. P-4 was also documented as being on parole with P-4’s mother stating P-4 breaks into cars and homes. P-4 was discharged on 4/22/2025. During P-4’s hospitalization it is documented that P-4 was “often redirected due to making inappropriate sexual comments to unit staff. (P-4) also made sexually aggressive comments, threatened to walk around naked, and tried to elope from unit. A nurse’s note on 4/15/2025 revealed, “1:1 while awake....” Staff N was unable to locate documentation to support one-to-one monitoring during P-4’s hospitalization. On 6/3/2025 at 1545 a review of P-5’s medical record occurred. According to the record, P-5 was admitted to the facility on 6/2/2025 at 1635. P-5 was described as a 40-year-old female admitted to the facility on a court order. P-5 had “made suicidal statements, locked herself in the bathroom, cut her wrist and took 2 Xanax.” P-5 at the time of admission was unable to participate in her admission and had received a “B-52 (5mg Haldol and 2mg Ativan) with 50mg of Benadryl” at the transferring hospital at 1149 and arrived at the facility for admissions at 1635. Due to P-5 not being able to participate in the admission process and a skin check not being able to be conducted one-to-one observation was ordered. Documentation for one-to-one observation started on 6/2/2025 at 1635 and was documented through 6/3/2025 at 0945. On 6/4/2025 at 1420, staff N was asked to locate documentation for 15 minute observation checks from 6/3/2025 at 0945 to current. Staff N was unable to provide documentation for 15 minute observation checks after 6/3/2025 at 0945. On 6/4/2025 at 1445 a review of P-8’s medical record occurred. According to the record, P-8 was admitted to the facility on 5/28/2025. P-8 was admitted to the facility for major depressive disorder after swallowing five magnets that had to be removed. P-8’s diagnoses included generalized anxiety disorder, bipolar disorder, and eating disorder. Documentation also revealed P-8 had suicidal ideation without a plan and self-injurious behavior. During record review staff N was unable to locate documentation for 15 minute observation checks from the start of admission to the time of record review. On 6/4/2025 at 1015 during an interview with staff V, registered nurse it was revealed the facility failed to meet the needs of patients requiring one-to-one observation. Staff V stated, “I have had to make the decision of whether I put a mental health worker with a one-to-one patient or keep a mental health worker on the floor to conduct group activities...We (the facility) has been so short staffed since agency was canceled. Staff is constantly mandated overtime with the threat of being fired if it is refused by a staff member. Medications are also not being passed as ordered because only one medication nurse is expected to pass medications for 25 to 27 patients, with administering medications like insulin that requires a second nurse to verify doses, and to also help with charting...It was manageable when there were two nurses passing medications. We (staff) also had a minimum of three nurses and two mental health workers. Now we have two nurses on average...the charge nurse also acts as the team nurse who handles all admissions and most of the daily charting for 25 to 27 patients. The mental health workers are usually on one-to-one assignments.” On 6/4/2025 at 1025 an interview was conducted with staff U, registered nurse. Staff U was asked to provide a list of patients whose medications were late. Staff U provided a list of patients who were in red (red indicating that medication was overdue) on the electronic medication administration record for 6/4/2025 at 1030. The following patients were noted as being late receiving medications at the 0900 medication pass on 6/4/2025 at 1345: P-9’s medication administration record revealed the following: cariprazine 6 mg once daily scheduled at 0900 was administered at 1029 on 6/3/2025, and 1027 on 6/4/2025, docusate sodium 200 mg twice daily scheduled at 0900 was administered at 1030 on 6/3/2025, and 1028 on 6/4/2025, escitalopram tablet 15 mg once daily scheduled at 0900 was administered at 1030 on 6/3/2025, and 1027 on 6/4/2025, gabapentin capsule 800 mg three times daily scheduled at 0900 was administered at 1030 on 6/3/2025, and 1028 on 6/4/2025, hydroxyzine pamoate 50 mg three times daily scheduled at 0900 was administered at 1030 on 6/3/2025, and 1028 on 6/4/2025, omeprazole capsule 20 mg once daily scheduled at 0900 was administered at 1030 on 6/3/2025, and 1027 on 6/4/2025, risperidone tablet 0.5 mg twice daily scheduled at 0900 was administered at 1027 on 6/4/2025. P-10’s medication administration record revealed the following: benztropine tablet 1 mg twice daily scheduled at 0900 was administered at 1011 on 6/3/2025, cetirizine tablet 10 mg once daily scheduled at 0900 was administered at 1008 on 6/3/2025, chlorpromazine tablet 50 mg three times a day scheduled at 0900 was administered at 1008 on 6/3/2025, fluoxetine 60 mg once daily scheduled at 0900 was administered at 1009 on 6/3/2025, gabapentin capsule 300mg daily scheduled at 0900 was administered at 1009 on 6/3/2025, lidocaine topical patch 5% daily scheduled daily at 0900 was administered at 1002 on 6/3/2025, lorazepam tablet 1mg twice daily scheduled at 0900 was administered at 1008 on 6/3/2025, and nicotine patch 14mg once daily scheduled at 0900 was administered at 1006 on 6/3/2025. P-11’s medication administration record revealed the following: brexpiprazole tablet 2mg daily scheduled at 0900 was administered at 1022 on 6/3/2025, brexpiprazole tablet 3mg daily scheduled at 0900 was administered at 1039 on 6/4/2025, buspirone tablet 15mg twice daily was administered at 1042 on 6/2/2025, 1023 on 6/3/2025, and 1039 on 6/4/2025, certirizine tablet 10mg daily scheduled at 0900 was administered at 1042 on 6/2/2025, 1022 on 6/3/2025, and 1039 on 6/4/2025, fluoxetine capsule 60mg daily scheduled at 0900 was administered at 1042 on 6/2/2025, 1022 on 6/3/2025, and 1039 on 6/4/2025, fluticasone nasal spray every morning scheduled at 0900 was administered at 1043 on 6/2/2025, 1023 on 6/3/2025, and 1039 on 6/4/2025, lidocaine 5% patch daily scheduled at 0900 was administered at 1046 on 6/2/2025, and 1043 on 6/4/2025. P-12’s medication administration record revealed the following: aripiprazole 15mg tablet daily scheduled at 0900 was administered at 1026 on 6/2/2025, 1046 on 6/3/2025, and 1059 on 6/4/2025, buspirone tablet 15 mg three times daily scheduled at 0900 was administered at 1027 on 6/3/2025, 1046 on 6/3/2025, and 1058 on 6/4/2025, gabapentin capsule 100mg three times daily scheduled at 0900 was administered at 1027 on 6/3/2025, 1046 on 6/4/2025, and 1058 on 6/4/2025, and risperidone tablet 1mg twice daily scheduled at 0900 was administered at 1026 on 6/2/2025, 1047 on 6/3/2025, and 1059 on 6/4/2025. P-13’s medication administration record revealed the following: duloxetine capsule 30mg daily scheduled at 0900 was administered at 1129 on 6/3/2025, emtricitabine-tenofovir tablet 200mg/300mg scheduled at 0900 was administered at 1039 on 6/2/2025, 1132 on 6/4/2025, and 1050 on 6/4/2025, insulin aspart sliding scale three times daily scheduled at 0900 was administered at 1046 on 6/4/2025, lamotrigine tablet 150mg daily scheduled at 0900 was administered at 1035 on 6/2/2025, 1129 on 6/3/2025, and 1050 on 6/4/2025, levothyroxine tablet 75mcg daily scheduled at 0900 was administered at 1036 on 6/2/2025, 1133 on 6/3/2025, and 1050 on 6/4/2025, losartan tablet 25mg daily scheduled at 0900 was administered at 1038 on 6/2/2025, 1132 on 6/3/2025, and 1050 on 6/4/2025, olanzapine tablet 10mg daily scheduled at 0900 was administered at 1038 on 6/2/2025, 1131 on 6/3/2025, and 1050 on 6/4/2025, pantoprazole tablet 40mg daily scheduled at 0900 was administered at 1036 on 6/2/2025, 1130 on 6/3/2025, and 1050 on 6/4/2025, and tamsulosin capsule 0.4mg twice daily scheduled at 0900 was administered at 1037 on 6/2/2025, 1131 on 6/3/2025, and 1050 on 6/4/2025. P-14’s medication administration record revealed the following: aripiprazole tablet 7.5mg daily scheduled at 0900 was administered at 1017 on 6/2/2025, and 1107 on 6/3/2025, aripiprazole tablet 10mg daily scheduled at 0900 was administered at 1053 on 6/4/2025, divalproex sodium tablet 500mg twice daily scheduled at 0900 was administered at 1018 on 6/2/2025, and 1106 on 6/3/2025. P-15’s medication administration record revealed the following: duloxetine capsule 30mg twice daily scheduled at 0900 was administered at 1014 on 6/2/2025, and 1035 on 6/4/2025, magnesium chloride tablet 64mg twice daily scheduled at 0900 was administered at 1014 on 6/2/2025, and 1035 on 6/4/2025, multivitamin tablet daily scheduled at 0900 was administered at 1014 on 6/2/2025, and 1035 on 6/4/2025, thiamine tablet 100mg daily scheduled at 0900 was administered at 1013 on 6/2/2025, and 1034 on 6/4/2025. P-16’s medication administration record revealed the following: mupirocin topical 2% three times daily scheduled at 0900 was administered at 1007 on 6/2/2025. On 6/4/2025 at 1530 an interview occurred with staff N, the Assistant Director of Nursing. Staff N was queried about the administration of medications. Staff N stated medications can be administered an hour before or an hour after the scheduled administration time. A request for medication administration policy was made on 6/4/2025. At the time of exit a policy titled, “Provision of Care” was provided but only referred to medication management. The policy failed to address the timeliness of medication administration. On 6/3/2025 at 1100 staff A, the Director of Risk was queried about short staffing. Staff A stated, “If we (facility) does not have enough staff how am I to keep the patients and staff safe?” At that time, Staff B acknowledged mandatory overtime was used frequently. Staff B, the Director of Nursing also acknowledged the staff shortage. Staff B stated the facility was actively interviewing candidates for positions. On 6/4/2025 at 1545 a review of the policy titled, “Mandatory Work Time,” policy number 11425554, dated 10/2022 with a next review date of 10/2023. According to the policy it revealed the following on page 1 under the subtitle “purpose,...In order to deliver quality care in a safe environment for staff and patients, employees may be required to work additional mandatory shifts, based on the staffing needs of the hospital.” The policy continued, “2. When the need to implement mandatory work time is established, the supervisor accesses the seniority list identifies the next least senior employee in the needed job classification who is presently on duty. This employee is contacted as soon as possible to notify them that they are mandated to work the required shift...F. An employee may not refuse to work a mandatory work shift. If after the supervisor clearly gives a direct order that the employee is being mandated to work and the employee refuses to work, the supervisor informs the employee that the refusal will result in disciplinary action based on “insubordination” by refusal to work a mandatory shift. If the employee still refuses to work, the following action will occur: First Refusal Formal Coaching, Second Refusal First Written Warning, Third Refusal Final Written Warning, Fourth Refusal Termination.””

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 28042 Based on interview and record review, the governing body failed to be accountable and aware of the conduct of the hospital and ensure the quality of care provided to one (P-1) of 10 sampled patients, resulting in delayed treatment and the potential for less than optimal outcomes. Review of the medical record for P-1 on 09/19/2024 at 1000 revealed he was a 40-year-old-male who was voluntarily admitted to the facility on 07/15/2024. Review of his psychiatric admission evaluation dated 07/15/2024 revealed justification for admission to include anxiety, depression, significant decline in functioning, dangerous to self, others, or property with a need for structured environment, psychiatric drug therapy, requires 24-hour supervision, failure of social or occupational functioning, inability to meet basic life and health needs, failure of treatment at a lower level of care, emotional or behavioral conditions and complications requiring 24-hour medical and nursing care, and that P-1 had a guardian. The note indicated P-1 no longer felt safe at home as he had been having suicidal ideations to drink bleach and does feel like he wants to die. Review of medical records from transferring facility for P-1 which were located in the receiving psychiatric facility’s chart for P-1 revealed a fax cover sheet dated 07/14/2024 at 10:10:02pm with P-1’s medical records. In an interview on 09/18/2024 at 1500, Staff D (Admission Nurse) stated she recalled when P-1 arrived via ambulance at the facility on the night of 07/14/2024. Staff D stated P-1 did not have his guardian with him to sign him in, so she had to send him back to the acute care hospital. Staff D stated P-1 had been accepted for admission, but a guardian must be present to physically sign the consent. Staff D stated she told the guardian who was on the phone, that P-1 could not be admitted without her physically present to sign the paperwork. A verbal consent cannot be given. She (Staff D) did make the ambulance crew take P-1 back to the acute care hospital and did not allow P-1 to be admitted to the facility that night. Staff D stated she checked with the Supervisor (Staff H), and he agreed with her. In an interview on 09/18/2024 at 1515, Staff H (RN Supervisor) stated he did not recall a patient being refused admission due to no guardian being present. Staff H said he would never do that, especially if the guardian was on the phone, because the facility policy allows for a verbal consent to be given with two staff member witnesses to sign the consent. In an interview on 09/19/2024 at 0955 Staff F (Chief Nursing Officer) stated she was not aware of the incident when P-1 was not allowed into the facility. It is her expectation that the admission nurse should have obtained a verbal consent and completed the admission. That is the facility policy. During the interview, Staff F reviewed the chart of P-1 and agreed that P-1 had been admitted to the psychiatric facility the next morning with admission paperwork signed by P-1’s guardian. In an interview on 09/19/2024 at 1020, Staff E (Chief Medical Officer) stated he was not sure what the policy was for obtaining consent. He had only been the medical director for one month and he didn’t feel he should comment on that. In an interview on 09/19/2024 at 1035, Staff B (Chief Executive Officer) stated he was not aware of a patient not being allowed into the facility for admission until now. Staff B stated it was his expectation that if anything abnormal happens, staff should be calling the leader of their department or the administrator on call with any questions. Staff B said a guardian does not need to be present for admission or to sign consent. A verbal consent is accepted per the facility policy. On 09/19/2024 at 1120, review of facility “Informed Consent to Treatment and Services” Policy dated 12/2022 revealed, D. When a legal parent or guardian is unavailable to physically sign the consent(s), a verbal consent, witnessed by 2 staff members and documented in the medical record, is permissible. Efforts will be made to obtain signed consent as soon as the responsible signatory becomes available.”