Brightwell Behavioral Health

“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: 48030 Based on document review and interview, the facility failed to have an effective process to identify and address patient grievances resulting in an increased risk of untimely and ineffective grievance resolution for all 22 patients currently served by the facility. Findings include: On 11/5/2025 at 1000 an interview with the Director of Patient Rights (Staff L) was conducted. A list of complaint and grievances for the facility was requested upon arrival to the facility and Staff B explained that Staff L was unable to provide the list but would be willing to review the list. During an interview with Staff L it was revealed she is not responsible for complaints and grievances but is the responsibility of the Recipient Right’s Director. Staff L explained that patient complaints are put into box located in the milieu and the Recipient Rights staff will remove them all and treat everything a Recipient Right’s investigation. When queried if she knew the difference between a complaint and a grievance, Staff L said, no. On 11/5/2025 at 1200 an interview with the Human Resources and Complaint and Grievance Manager (Staff U) was conducted. Staff U explained that she is the Human Resources Manager but she is also responsible for complaints and grievances for the facility. When queried if she could provide a list of complaints and grievances for the facility, Staff U revealed they have not received any in the last 6 months and had actually not received any since 2024. When queried how complaints and grievances are identified at the facility, Staff U said they have signs posted, a box located in the patient milieu and a contact phone number on their website. When queried who is responsible for answering the phone number it was revealed they are answered by the Regional Human Resources Director but they have only received 1 complaint and it was an employee complaining about another employee. When queried if it was possible the Recipient Rights Director may be getting complaints and grievances in their box and unable to identify the difference, Staff U said, yes that is possible. On 11/5/2025 at 1215 an interview with the Chief Executive Officer (Staff A) was conducted and revealed that he agreed the Complaint and Grievance process for the facility was not adequate and that the facility was still transitioning after being acquired by another company in January. Staff A explained that complaints and grievances were handled by the Human Resource Manager and they have not changed that yet. Staff A queried whether it would be appropriate for the Recipient Rights Director to also manage complaints and grievances, and then decided this could be a conflict of interest. Staff A agreed it is unlikely there were no complaints or grievances for the facility since 2024 and that maybe they have all been handling them incorrectly. Review of the facility policy titled, “Grievance Policy”, policy #BH 0755 last revised on 9/16/2025, under Policy “All patients treated at [facility] are expected to be treated according to the standards set forth in 482.13 Condition of Participation: Patient Rights. A hospital must protect and promote each patient’s rights. The hospital allows the patient and their family members to voice complaints and recommend changes freely without being subject to coercion, discrimination, reprisal, or reasonable interruption of care. This establishes a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.””

“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 interview and record review, the facility failed to provide 1:1 observation for 1 (P-2) of 12 patients as prescribed by the physician resulting in an altercation and subsequent injury to another patient (P-1). Findings include: Review of the medical record for P-2 revealed was a 71-year-old male who was admitted to the facility 10/11/2024-1/7/2025 with a diagnosis of bipolar disorder, current episode depressed, severe, without psychotic features, generalized anxiety disorder, post-traumatic stress disorder (PTSD) unspecified, and unspecified intellectual disabilities. P-2 had an extensive psychiatric hospital admission history and was known to exhibit aggressive behavior toward staff and other patients. He was often non-compliant with medications and would display erratic behaviors and paranoia. P-1 was described as being “territorial” and “protective.” He did not like anyone invading his space, his room, or touching his belongings. On 10/12/2024, P-2 was on 1:1 status after verbalization of suicidal tendencies. Review of the medical record for P-1 revealed she was a 73-year-old female who was admitted to the facility 12/6/2024-12/11/2024 with a diagnosis of dementia with unspecified severity with psychotic disturbance and unspecified dementia with unspecified severity with other behavior disturbance. P-1 was admitted to the facility with “severe agitation, combativeness, altered mental status, and psychosis...She was also experiencing paranoia, delusions, and visual hallucinations.” Physician notes indicated her symptoms would worsen with increased confusion. P-1 was a low fall risk, and her level of observation was for checks every 15 minutes. Nursing notes dated 12/10/2024 stated P-1 was “ambulating about the common area (milieu) attempting to go into other patients (sic) rooms. patient (sic) requiring redirection...” Review of internal facility documentation revealed a discrepancy in events between the 12/10/2024 incident report and the undated root cause analysis (RCA). The incident report stated, “(P-1) was intrusive with another pt (P-2). Other pt (P-2) closed his door and she (P-1) put herself on the floor and said she fell.” The RCA stated, “”(P-1) attempted to go into another patient’s bedroom. The occupant of the bedroom (P-2) grabbed her wrists and told her that it was his bedroom and attempted to move her to the side. (P-1) yelled and put herself on the floor landing on her right side...” After experiencing increasing pain in the right hip area, an x-ray was obtained and showed a fracture of the ischium (pelvis). On 1/6/2025 at 1445, during review of P-2’s medical record, Staff B stated P-2 had been ordered to have 1:1 observation status; however, the investigation found he was not being monitored as he was supposed to be. Staff B explained that had P-2 been monitored appropriately, the staff could have redirected P-1 prior to her trying to enter P-2’s room and/or could have informed P-1 they would take care of the situation relieving him of the responsibility. “This (incident) should never have happened.” Facility policy #CC.13 titled “Suicide Precautions” issued 4/2019 states, “All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior. The levels are as follows... 1-to-1 observation at all times: This is the most restrictive toward the patient and involves continuous monitoring and phsycial proximity to the patient at all times. Staff must be within arm’s reach or 3 feet at all times including toileting and showering. Nursing staff must maintain a continuous log which indicates the patient’s location every 15 minutes and documents the patient’s thoughts and behaviors throughout each shift. Patients on this level are considered highest risk and documentation must reflect the need for continued 1-to-1 or improvement in behaviors and thoughts.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide an appropriate order for seclusion for 2 (P-2, P-11) of 2 patients reviewed according to facility policy resulting in the potential for adverse patient outcomes and loss of patient rights. Findings include: Review of the medical record for P-2 revealed he was placed into seclusion 12/19/2024 for being a danger to himself and others. Review of the seclusion order revealed an area titled “Maximum Duration.” In the section was a box marked with a hand-written time frame of 0946-1104. The order was signed 12/19/2024 at 0946. On 1/6/2025 at 1600, Staff B was queried as to the specific time frame in the order to which she stated it was the start and stop time of the seclusion. Staff B was then queried as to how the practitioner would know the patient would only need 1 hour and 18 minutes of seclusion at the time the order was written to which she stated they would not know that. Staff B agreed that documentation of the seclusion with the exception of the patient monitoring section was most likely completed at some time after the seclusion had been discontinued. On 1/7/2025 at 1357, Staff N stated the nurse fills out the 6-page restraint/seclusion document, including the orders, and gets signatures in the appropriate areas from the provider. Whomever would be monitoring the patient during restraint/seclusion would fill out that portion separately. Review of the medical record for P-11 revealed she was placed into seclusion 11/18/2024 for being a danger to herself and others. Review of the seclusion order revealed the “Maximum Duration” was hand-written in as “eight minutes.” The seclusion was initiated at 0635 and discontinued at 0643. The order was signed “11/18” at 0635. On 1/7/2025 at 0950, Staff B was queried how the practitioner could have known the patient would only need 8 minutes of seclusion to which she stated, “They couldn’t.” Facility policy #NU 20 titled “Restraints/Seclusion) last revised 11/2024 states, “Physical restraint...Seclusion: is the involuntary confinement of a patient alone in a room, which the patient is physically prevented from leaving, for any period of time. Seclusion may only be used for the management of violent or self-destructive behavior. This type of intervention requires a physician/provider order...ORDERS FOR RESTRAINTS... Restraint orders are time-limited and specific to the patient’s assessed status, and are never written as a PRN (as needed) order. 3. Restraint orders include the following components: Date and time the order is written, Type of restraint to be used, Reason for restraint, Alternatives considered, Length of time the patient is to be restrained, Behavioral criteria for the release from restraints/seclusion...Behavioral restraint orders must be written every four (4) hours...Notify the attending physician/provider as soon as possible after restraint instituted... In an emergency, if a patient presents an immediate danger to self or others, a restraint may be applied by or under the supervision of a registered nurse who is responsible for documenting the circumstances requiring the restraint/seclusion and immediately notifying the physician. The RN must document the justification for the emergency application of restraints, including measures taken to address behavior prior to the decision to apply restraints, type of restraint applied, name of the physician called, and the time of the call. A written order must be obtained prior to or immediately after application of restraint or seclusion.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 28042 Based on observation, interview, and record review, the facility failed to protect and promote the rights of 6 (P-1, 2, 3, 4, 5, 11) patients out of 11 patients observed and reviewed, resulting in the loss of dignity, injury, and delayed life saving interventions and the potential for harm for all patients served by the facility. Findings include: See specific tags: 0143 - Failure to protect patient privacy 0144 - Failure to provide care in a safe setting 0145 - Failure to protect patients from abuse”

“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: 28042 Based on observation, interview, and record review, the facility failed to protect the privacy, dignity and respect of 2 patients (P-2, 3) on the psychiatric unit of the facility, resulting in the loss of privacy, dignity and mental anguish. Findings include: During the initial tour of the facility on 11/04/2024 at 0940, patients were observed sitting in the main social area of the facility which was called the “milieu” by the Director of Nursing (Staff B). Patient rooms extended off the milieu, with the nursing work area, medication area and breakroom at the front of the milieu. The milieu was observed to have multiple tables with chairs, a television on the wall, and a small alcove with windows. During the tour, Staff F (Mental Health Technician) was observed assisting P-2 out of bed, into a wheelchair and into the milieu to a table. Staff F did not offer the restroom, provide any hygiene assistance or clothing to P-2. Staff F parked P-2 in the wheelchair wearing a patient gown, with one sock on, at a table with one other patient. P-2’s wheelchair did not have a wheelchair foot brace for either foot, resulting in the potential for injury to the patient’s feet or dislodgement from the wheelchair. On 11/07/2024 at 0930, review of P-2’s medical record revealed she was a 67-year-old female admitted to the facility on 11/02/2024. Nursing admission assessment on 11/02/2024 revealed she was a high fall risk with interventions to include line of sight while awake, alarms, brace for foot drop in wheelchair, and nonslip socks. These interventions were not in place at the time of observation. On 11/07/2024 at 0940, review of P-3’s medical record revealed he was a 78-year-old male admitted to the facility on 11/01/2024. His initial history and physical (H&P) dated 11/01/2024 indicated he had diagnosis to include dementia and depressive disorder. Nursing admission safety assessment indicated he was a high fall risk due to being confused with an unsteady gait with provider safety orders dated 11/01/2024 to be line of sight while awake. During an observation on 11/04/2024 at 0950, P-3 was observed walking on the milieu in a patient gown, without pants, with an incontinence brief visible through the back of his gown. P-3 had a dried brown substance around the edges of his mouth and lips. P-2, P-6,and P-5 were observed in the milieu watching P-3 walking in his gown with his incontinence brief exposed. During an observation on 11/06/2024 at 1130, P-3 was again observed walking on the milieu in only a patient gown that was open in the back. His gown was tucked into an incontinence brief exposing his bottom half, incontinent brief, and bare legs. He was observed to have one sock on and one sock off. P-2, P-4, P-5 and P-6 were observed in the milieu watching P-3 walking around with his bottom exposed. During an observation on 11/06/2024 at 1410, P-3 was observed continuing to walk on the milieu in a patient gown, without pants, with his gown tucked into incontinent brief, exposing his bottom half, incontinent brief, and bare legs. He was observed to have one sock on and one sock off. P-2, P-4, P-5 and P-6 were observed in the milieu watching P-3 walking in his gown exposed. In an interview on 11/06/2024 at 1415, Staff G (Mental Health Tech) stated the facility usually has scrub pants to provide to patients. However, she thought they were out of them. In an interview on 11/06/2024 at 1420, Staff B (Director of Nursing) confirmed it was a concern that P-3 was walking around the milieu in a gown with his brief showing. Staff B then went into the linen supply room to look for scrub pants for P-3 and was unable to locate any pants to fit him. Staff B confirmed this was a concern.”

“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: 28042 Based on observation, interview, and record review, the facility failed to provide a safe environment for all 17 patients on the psychiatric unit resulting in a failed emergency response for P-1, falls with injury for P-4, patient to patient assault between P-5 and P-11, and the potential for continued patient harm. Findings include: P-4: On 11/07/2024 at 0930, review of P-4’s medical record revealed she was an 85-year-old female admitted to the facility on 10/27/2024. Review of initial history and physical (H&P) dated 10/28/2024 revealed she had a past medical history significant for dementia (general term that represents a group of diseases that affect thinking, memory, reasoning, personality, mood and behavior), hyperlipidemia (high blood cholesterol), and hypertension (high blood pressure) who presented from the emergency department for dementia with behaviors. Review of provider progress note dated 11/06/2024 documented P-4 had an additional fall overnight unwitnessed. Placed P-4 on 1:1. 10/27/2024: History and Physical for P-4 documented that shortly after arrival, P-4 fell backwards hitting the back of her head fairly hard with immediate large sized hematoma (a collection of blood that pools outside a blood vessel, usually caused by an injury or trauma)over the occipital region and severe pain. P-4 was sent to the ED (emergency department) for evaluation and returned with report of negative CT (computed tomography) head scan. Assessment and plan by provider included psychiatry to treat dementia with behaviors, fall precautions in place with bed and chair alarms and line of sight monitoring. Review of provider non-medication orders for P-4 revealed 10/27/2024: Perform Activity check Line of Sight While Awake. Review of Patient Monitoring Rounds Sheets for P-4 revealed documentation: 10/27/2024: fell at 0545 and to be in line of sight while awake observation for high fall risk. Review of facility incident report for P-4 dated 10/27/2024 at 0540 indicated type of incident: unwitnessed fall; location: patient room; summary: Staff heard P-4 yell out from room, she was found sitting on floor holding head. P-4 stated she fell. Hematoma noted to posterior head. Did not appear to have LOC (loss of consciousness), alert and oriented times 1 (baseline), not on thinners (blood thinning medications). P-4 sent to ED. P-4 was not within line of sight monitoring by staff when P-4 fell. No monitoring or activity changes noted for P-4 post fall. 11/03/2024: Review of provider non-medication orders revealed line of sight and alarms for safety with no change from 10/28/2024 until 11/03/2024. Review of nursing daily assessment for P-4 dated 11/03/2024, shift 0700-1900 revealed she was a high fall risk, with level of observation to be in line of sight while awake. Nursing progress note 11/3/2024 at 4:34pm documented P-4 was walking in milieu next to a table when another patient got up and pushed P-4, when she fell backwards hitting her head. P-4 sent to the hospital for evaluation. Review of facility incident report for P-4 dated 11/03/2024 at 1545 indicated type of incident: patient injured by another patient; location: milieu; summary: P-4 was walking in milieu and walked by another patient’s table. The other patient got up and pushed P-4, she fell backwards and hit her head. P-4 was transferred to an acute care hospital for evaluation of hematoma to back of head. 11/06/2024: Review of facility incident report for P-4 dated 11/06/2024 at 0115 indicated P-4 had a 3rd fall at the facility (2nd unwitnessed and while the facility was not monitoring her within line of sight). The fall on 11/06/2024 was an unwitnessed fall; location: another patient’s room (110); summary: Heard loud noise coming out of room 110. Observed P-4 lying on floor on left side. It was not until after this 3rd fall that patient monitoring orders were increased to include, neuro-checks, chair alarm, and 1:1 monitoring. P-5: During the initial tour of the facility on 11/04/2024 at 0940, patients were observed sitting in the main social area of the facility which was called the “milieu” by the Director of Nursing (Staff B). Patient rooms extended off the milieu, with the nursing work area, medication area and breakroom at the front of the milieu. The milieu was observed to have multiple tables with chairs, a television on the wall, and a small alcove with windows. Patients were observed walking around the milieu in hospital gowns, sitting at tables, and in their individual patient rooms. During the tour, Staff B stated there were three nurses (RN’s) and three mental health techs on staff at that time. One male patient (P-5) was observed sitting at a table against the wall of the milieu yelling at staff and other patients as they walked by his vicinity. At times P-5 would stand and chase other patients away from his area swinging at them. P-5 was also observed yelling and swinging his arms, making verbal threats of physical violence toward staff members. In an interview on 11/04/2024 at 1040, Staff B (Director of Nursing) was queried as to the interventions in place for P-5. Staff B stated P-5 preferred to be by himself, so that is what they do, and it has worked so far. When asked about the incident the day prior, Staff B said a lady (P-4) wandered by and P-5 shoved her to the ground. When queried if there had been any new interventions put into place for P-5 after that occurred, Staff B stated no. During an observation on 11/04/2024 at 1250, P-5 was again observed yelling, walking around the milieu, making verbal threats to harm patients and staff, swinging his arms and getting close to patients and staff. On 11/07/2024 at 0950, review of P-5’s medical record revealed he was a 71-year-old male admitted to the facility on 10/10/2024. Review of initial history and physical (H&P) dated 10/11/2024 revealed he had a past medical history significant for depression, and hypertension who presented from the ED (emergency department) for exacerbation of underlying psychiatric condition. Review of psychiatric initial evaluation revealed P-5 had a long-standing history of bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), PTSD (post-traumatic stress disorder), anxiety and intellectual disability. The provider note indicated P-5 had multiple admissions with previously exhibited aggressive behavior towards staff and non-compliant with medication. Review of provider progress notes: 10/26/2024: P-5 had severe outburst on 10/25/2024 where he was tipping over tables and chairs, required injectable medication for acute agitation. P-5 threatening to kill peers, is unpredictable, impulsive with low frustration tolerance. 10/27/2024: P-5 continued to be unpredictable and impulsive. 10/28/2024: P-5 attempted to punch a peer “last night”. P-5 is paranoid and delusional. 10/30/2024: Peer found in P-5’s bed, at which time P-5 removed him. 11/04/2024: P-5 very agitated, with poor impulse control, gesturing, posturing, swinging his arms and making threats. Plan to make medication changes. 11/05/2024: Continues to posture, verbally threaten staff and peers, has required multiple IM (intramuscular) injections for being combative, overturning tables and throwing chairs. 11/06/2024: Medication changes made. P-5 calmer, using coloring and music as coping skills. No posturing, not making homicidal threats. 1:1 continued for unpredictable behavior. 10/29/2024: Provider note dated 10/29/2024: P-5 having increased outbursts frequency and intensity, physically aggressive with staff and peers. Provider non-medication orders for P-5 revealed on 10/29/2024 P-5’s monitoring to be “Line of Sight While Awake.” Review of nursing progress notes: 10/29/2024 at 6:00pm indicate P-5 did not interact well with staff or other patients, stated he would kill anybody that came near his door. Another patient walked by P-5’s room, he got in the patient’s face raising his fists, also swinging at staff and patient. The note indicated P-5 was threatening to kill patients walking by his table. 6:00 pm: Wandering patient went into P-5’s room, got into his bed and was dragged out by P-5. Review of Patient Monitoring Rounds Sheets for P-5 on 10/29/2024 noted P-5 was “calm” when observed every 15 minutes from 1800 to 1915 and “calm or asleep” from 1930 to 0700. The monitoring sheets contained inconsistent documentation with P-5’s aggressive behavior noted at 1800. Review of facility incident report for P-5 dated 10/29/2024 at 1815 indicated type of incident: patient attacked another patient; location: patient room; summary: P-5 grabbed P-11 by the foot and dragged him off the bed. Assessment section, notification section and signature sections of form were all blank. 11/03/2024: Review of P-5’s medical record revealed on 11/02/2024: increasingly aggressive toward peer, threatening to choke him. Angry with staff. 11/03/2024: Provider received a message that P-5 pushed a peer down due to being by his room. P-5 was suicidal and homicidal when he was upset and is easily triggered. P-5 remained agitated, aggressive physically and verbally, impulsive, and unpredictable. The note indicated P-5 needed a higher level of care due to his level of violence that continued to escalate. 11/03/2024 at 1330: P-5 jumping up whenever another patient was too close and threatened to “knock his ass out”. 1545: P-5 sitting at table when another patient walked by (P-4), P-5 got up and shoved her (P-4) backwards and she fell to the floor. P-4 was sent to the hospital for evaluation. Review of Patient Monitoring Rounds Sheets for P-5 revealed documentation inconsistencies. On 11/03/2024 the record indicated P-5 was “calm” from 1430 to 1915 which included the timeframe P-5 pushed P-4 down. On 11/06/2024 at 1510, review of the facility video recording of patient-to-patient event between P-4 and P-5 on 11/03/2024 revealed 1626, P-5 at table near wall and P-4 stood from chair in the middle of the milieu, walked into patient room next to P-5. No staff are observed near P-4 or P-5 to have them in line of sight. P-4 is observed walking around end of bed in room with no staff present until exiting at 1635. P-4 exited room next to where P-5 was sitting at 1635 when P-5 stood up, yelled at P-4 and pushed her to the ground. No staff were near P-4 or P-5 when this occurred. Review of nursing daily assessment notes for P-5 indicated P-5 was not placed on 1:1 observation until the afternoon of 11/04/2024. The facility failed to protect other patients from P-5’s known impulsive and aggressive behaviors until therapeutic medications and treatments were achieved. P-11: On 11/07/2024 at 1000, review of P-11’s medical record revealed he was a 76-year-old male admitted to the facility on 10/25/2024. Review of provider note dated 10/29/2024 indicated a capacity evaluation was completed for P-11 with him unable to demonstrate any appropriate decision making or the ability to answer questions appropriately. Provider non-medication orders for P-11 indicated 10/26/2024: line of sight while awake plus alarms for safety. No change in orders. Nursing notes for P-11 documented: on 10/29/2024 the note at 0600 indicated at 2030 P-11 walked near another patient’s table (P-5) who became agitated. Both patients became agitated and attempted to hit each other, with P-5 hitting P-11’s left shoulder. Review of Patient Monitoring Rounds Sheets for P-11 revealed documentation inconsistencies on 10/29/2024 P-11 was noted as “calm or asleep” when observed every 15 minutes from 1430 to 1915 and “calm or asleep” from 1930 to 0700 which was the timeframe for the altercation between P-5 and P-11. Review of facility incident report for P-11 dated 10/29/2024 (no time) indicated type of incident: patient attacked another patient; location: patient room; summary: P-11 was dragged off the bed by his foot by P-5 onto the floor. The witness, nursing assessment, notification and signature sections of the form were blank. In an interview on 11/04/2024 at 1015, Staff F (Mental Health Tech) stated when a patient is to be line of sight observation they are to always be in line of sight of staff. In an interview on 11/06/2024 at 1500, Staff G stated there were 3 techs on staff with 11 patients who had orders to be direct line of sight and 2 patients who were 1:1 supervision. Staff G said they do not have enough staff to possibly be able to supervise the patients as ordered. In an interview on 11/07/2024 at 1115, Staff B stated staff were not observing patients according to the orders and policy of line of sight. Staff B stated P-4 had an unwitnessed fall in another patient’s room during the night of 11/06/2024. If staff had been observing her like they should, P-4 would not have been in that room, in the dark and would not have fallen. On 11/07/2024 at 1030, review of assignment sheets revealed: 11/04/2024 10 patients who were to be in line of sight while awake and one patient with 1:1 observation, with 2 nurses and 4 mental health techs. 11/06/2024: 11 patients who were to be in line of sight while awake and two patients with 1:1 observation, with 3 nurses and 4 mental health techs. Review of facility “Patient Rounding” policy dated 04/01/2019 revealed, “Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period. A. The purpose of rounds is to check all aspects of security and safety while monitoring patient behavior and location.” Review of facility “Fall Prevention Protocol” policy dated 04/01/2019 revealed, “All patients admitted to this hospital will be placed on fall prevention protocol. All patients admitted demonstrate a self-care deficit, decreased mobility or an activity intolerance which places them at higher risk for falls.” 36887 Review of the medical record for P-1 revealed he was a 77-year-old patient who had been admitted involuntarily on 10/24/2024 for major depressive disorder, recurrent, severe with psychotic symptoms. Past medical history included atrial flutter (abnormal heart rhythm), hypertension (high blood pressure), hyperlipidemia (high fat content in the blood), schizoaffective disorder bipolar type (mental disorder), depression, anxiety, TIA (transient ischemic attack), CVA (cerebral vascular accident - stroke), atrial fibrillation (abnormal heart rhythm), orthostatic hypotension (low blood pressure that occurs from laying to sitting and/or sitting to standing), CKD stage 4 (chronic kidney disease stage 4), and peripheral neuropathy (nerve pain in extremities). He had a history of having an unsteady gait, used a walker, and a history of falls. P-1 was a full-code. Review of nursing documentation revealed shift notes were made by RN Staff I on 10/30/2024 at 1429. He documented, “0850-0900...Nurse entered Pt room to find Pt lying naked, as was reported by off going shift, on floor on left side in a recovery style position. Nurse viewed Pt to insure (sic) Pt was breathing...0910-0925...Pt had urinated on floor...0930-0935: Tech approached this nurse to inform nurse that Pt was cold. This nurse immediately proceeded to Pts room with tech. Pt was found in same position, left side. On evaluation, this nurse found Pt to be cold, nonresponsive with no chest movement. This nurse instructed tech to stay in room. This nurse then went to grab a stethoscope to listen for heart sounds. On way to retrieve stethoscope this nurse informed Charge Nurse of possible passing. (Unknown time): Nurse reentered room. Tech and nurse rotated Pt on to back. This nurse listened for any heart sounds, could not assess heart sounds. At this time, Dayshift Supervisor, DON, Admin and crash cart present. This nurse exited room to inform those present of event timeline. (Staff D) present in room preforming (sic) CPR.” No other code documentation was present nor was there a discharge summary present in the medical record. On 11/4/2024 at 1450, CEO Staff A provided a document titled “Timeline for the Death of (P-1) 10-30-24” which included the following: “8:30am (sic) approx.-Nurse (Staff I) pulled meds to give to (P-1), he was sleeping and placed meds back in the med room 9:00AM (sic)-Nurse (Staff I) went to look in on the patient and (P-1) was sleeping on the floor on his stomach on his left side snoring. 9:00am (sic)-MHT (Staff Q) was doing rounds and noticed (P-1) sleeping on the floor snoring 9:15am (sic) (Staff K)-PA went in to do her rounds on (P-1) and she noticed that there was urine on the floor and alerted the nurse (Staff I). He then told the MHT (Staff Q) that the room was in need of attention. 9:34am (sic) -MHT (Staff Q) entered the room and new (sic) something wasn’t quite right with (P-1) and she notified nurse (Staff I) immediately. 9:36am (sic) -Nurse (Staff I) entered the room and told MHT that he needed to go get his stethoscope, as he noticed that he was cold. 9:38am (sic) -Nurse (Staff I) and nurse (Staff P) went to enter the room due to the patient being cold and at that time he wasn’t breathing. 9:39am (sic) -Leadership was notified that we had an issue with (P-1). 9:39am (sic) -CPR was started and 911 was called. 9:45am (sic) -(oxygen) was administered with a high flow rate 9:50am (sic) -no vitals were registering 9:58am (sic) -EMS arrived 10:09am (sic) -EMS were calling (local acute care hospital) to see if a Physician would pronounce the patient deceased...” On 11/6/2024 at 1121, Physician Assistant (PA) Staff K stated she was doing her rounds and entered P-1’s room on 10/30/2024 at 0916. “I was unhappy with the way he was presented-naked on the floor with a large puddle of urine around him. A small bedsore was present.” She stated she did not do an assessment or touch the patient at that time. “I went to the desk and told (Staff I). He said, ‘I haven’t set eyes on him yet today.’ Twenty-five minutes later, I heard the patient was dead... (Staff I) said he was grabbing a stethoscope because he thought the patient was dead... I called 911... EMS asked if CPR had been started and (Staff I) said, ’ No. He’s too far gone. ’ He cannot declare anyone deceased. He should’ve started CPR, not gotten a stethoscope... No code was called.” When queried as to if she responded to the room, she stated all of the nurses were in there, so she went to the ambulance bay to await the EMS staff. PA Staff K failed to respond to the patient’s room and initiate CPR and/or coordinate resuscitative efforts upon hearing of P-1’s emergent medical condition. On 11/6/2024 at 1550, Mental Health Technician (MHT) Staff Q stated she was assigned to do rounding which occurred every 15 minutes. “When I got to Room 103, the patient’s color was changing. He was very white and was laying on his side. I got closer to the patient and realized he wasn’t breathing. I checked his wrists and neck for pulses - nothing. I threw down the clipboard and ran to get (Staff I). He was sitting behind the nurse’s station. I told him to come quickly to 103. I said, ’ I think he’s gone. ’ (Staff I) came quick (sic), then everybody was coming.” At that point, Staff Q stated she left Room 103 and returned to the milieu to keep other patients away from Room 103. Staff Q failed to initiate CPR and call for help upon finding P-1 not breathing and with no palpable pulses. Review of video documentation revealed the following: 09:36:01 MHT Staff Q rapidly walked from corner (by Room 103) to mid-milieu. Spoke to RN Staff I, he turned away and walked off camera. She walked to the nurse’s station and set her clipboard down. 09:36:25 RN (Registered Nurse) Staff I returned by the nurse’s station applying gloves. Both he and MHT Staff Q rapidly walked to the corner area appearing to go to Room 103. 09:37:28 RN Staff I exited corner area flipped the door shut behind him and walked rapidly toward nursing station with MHT Staff Q close behind him. 09:38:30 Charge Nurse Staff P walked to corner area and appeared to be standing by the corner of the door, leaned and looked into the room before turning and walking away. 09:38:53 RN Staff I walked rapidly back to corner area while putting a stethoscope around his neck. 09:38:59 DON (Director of Nursing) Staff B ran across the milieu toward Room 103 coming from the conference room area. 09:39:03 Director of Clinical Services Staff D ran across the milieu toward Room 103 coming from the conference room area. 09:39:12 Director of Social Work ran across the milieu toward Room 103 coming from the conference room area. 09:39:23 CEO walked normal pace in front of the nurse ’ s station and speaks with staff member in purple scrubs before walking back toward Room 103. 09:39:33 DON Staff B exited corner area 09:39:34 Crash cart/AED moved across milieu toward Room 103. 09:39:39 Crash cart stopped in middle of milieu 09:39:44 RN Staff I exited corner area 09:40:53 RN Staff I talked with patient at nurse ’ s station who is on the phone 09:41:56 RN Staff I walked around milieu moving hands in the air around his head, standing around, talking with staff, and talking with DON Staff B 09:41:56 CEO Staff A walked over to talk with DON Staff B and RN Staff I 09:41:58 Crash cart to Room 103 09:43:19 CEO Staff A, DON Staff B, and RN Staff I all walk back to Room 103 09:55:14 EMS to Room 103 Charge Nurse Staff P failed to assess the patient, initiate CPR, and call for help on responding to P-1’s room, Room 103. On 11/6/2024 at 1419, P-1’s primary nurse, Staff I, stated he had come received report at 0700 that the patient wanted his clothes off and to sleep on the floor. Mats had been provided. At approximately 0850-0900, Staff I stated he obtained P-1’s meds and upon entering P-1’s room, found him lying on the floor, naked, laying on his left side and snoring. “I did a quick visual assessment.” When queried as to what he meant, Staff I stated he heard snoring, saw the rise and fall of the chest, and counted breaths to check for a normal rate. He confirmed this was not documented. Staff I then took the medications back to the med room to allow P-1 to sleep a little longer. Staff I was approached by PA Staff K regarding a wound on P-1’s coccyx. He “grabbed some gloves and went into the patient’s room and found urine on the floor. He did not recall the PA informing him of urine being on the floor. Staff I stated he found Mental Health Technician (MHT) Staff Q “to clean (P-1) up.” Staff I stated he did not notice P-1’s breathing, he thought the skin color was “pinkish”, and admitted again the assessment had not been documented. At approximately 0935, MHT Staff Q went into the patient room and came out to “grab” Staff I. On entering the room, Staff I stated he did “a more thorough assessment. There was no rise/fall of the chest, no carotid pulse. He left to get a stethoscope and instructed Staff Q to remain in the room. He stated he was unaware the patient had been a full code and there was no visual way to know code status without going to the nurse’s station and looking at “the board.” On his way to the nurse’s station, he informed the Charge Nurse Staff P he “thought the patient had passed.” Staff I stated Unit Clerk Staff J “called the code and everyone ran to the room and the code began. There was no monitor, and the defibrillator was not put on the patient. “We were just getting ready to do that when EMS arrived.” He described the patient as being pale pink in color and cool to the touch. Staff I was queried as to why the defibrillator was not attached to the patient. He stated he had not been trained on the AED (automated external defibrillator) in this facility. He stated there was no debrief or discussion of the event, but that was coming soon. “Most people here have never seen a code, my self included. We know the response needs work.” Staff I failed to know his patient’s code status, initiate CPR, call for assistance, coordinate the code response, and failed to use emergency equipment made available. Review of Staff I’s personnel file on 11/7/2024 at 1100 revealed current BLS (basic life support-CPR) certification. No skills/competency checklist was present indicating he had been precepted. This was confirmed by Nurse Consultant Staff C on 11/7/2024 at 1229. At that time, Staff C stated emergency equipment and response was presented by the preceptor once on the unit. In an interview on 11/4/2024 at 1112, Unit Clerk Staff J stated she was working on 10/30/2024, the day P-1 passed away. She was concerned because P-1 was a full code, a code was never called, and it was approximately 4 minutes before CPR (cardiopulmonary resuscitation) was started. Staff J stated she observed Staff I (the nurse for P-1) walk out of P-1’s room and say he was going to get his stethoscope because, “(P-1’s) dead. I said, “What do you mean? He ’ s a full code!” Staff J said she immediately ran to the conference room where the leadership team was having morning meeting to inform them of the situation. The Director of Clinical Services (Staff D), Director of Nursing (Staff B) and the CEO (Staff A) ran to P-1’s room. When queried as to why the code was not called overhead, Staff J stated to use the paging system, staff had to go to the front office. There was no way to quickly alert from the patient care area of an emergency without yelling for help and/or running for help. When interviewed on 11/4/2024 at 1301, DON Staff B she was in the conference room with other administrative staff for their daily morning meeting when the unit clerk ran in and said someone had died. “We ran out. (Staff D) started CPR. She yelled to grab the crash cart. The unit clerk went and got the crash cart. (Staff A) was documenting the code... The primary nurse was (Staff I). I directed him to put oxygen on the patient.” Staff B stated she was unsure how long CPR continued, but did admit that CPR was discontinued prior to EMS arrival. She was unsure why CPR was discontinued other than “maybe the patient had passed.” Staff B stated P-1 was not put on the monitor/defibrillator, and no shocks were administered. “(Staff I) said there was no pulse.” Staff B failed to assess the patient, initiate CPR, document the resuscitation efforts, coordinate resuscitation response, continue resuscitation efforts until EMS (emergency medical services) arrival, and failed to ensure her nursing staff had been adequately trained prior to termination of the preceptor education. On 11/4/2024 at 1335, Director of Clinical Services Staff D recounted that she was in the morning administrative meeting on 10/30/2024 when the “unit clerk came running in and stated, ’ I think someone’s dead.’ We all came running out of the meeting room. (P-1) was lying naked in urine. It looked like he had passed, and it may have been for some time.” When asked why she thought it had been “some time”, she stated it was because of the patient’s “color being pale, blue, and gray” and the “smells” in the room. She stepped back out of the patient’s room and called out, “Call 911, grab the pulse ox (oximeter-checks for oxygenation of the blood) and crash cart...None of those things were done by the nursing staff on the floor... When I saw (P-1), I got on my knees and started doing compressions. (Staff I) said, ’ He’s gone. He’s cold ’ and the unit clerk kept repeating, ’(P-1)’s a full-code.’” Staff D stated she repeatedly asked for the crash cart. “(P-1) was never placed on a monitor/defibrillator. At some point (Staff I) put an oxygen mask on the patient. (PA Staff K) called 911 because no one on the floor had called... Only a 4-minute delay in CPR. We could have saved his life... We have never had a mock code, just CPR training.” Staff D, who was also the head of staff education, failed to provide training and/or scenarios to staff preparing them for emergency response. On 11/4/2024 at 1450, CEO Staff A stated she was in the morning meeting when Unit Clerk Staff J “came in and stated, ‘We have an issue with Room 3.’ We dropped what we were doing and went to where the issue was... The crash cart was already there, and oxygen was placed on the patient. CPR was started at 0939 and stopped at 0950. Staff A stated she was unsure why it had stopped. “Two nurses were present and called the death: (Staff D) and (Staff C).” Staff A stated she was the scribe for the code. When asked why a nurse was not scribing, she stated, “I knew it had to be done so I did it.” Staff A admitted she was not trained in BLS. The code documentation titled “Timeline for the Death of (P-1) 10-30-24” was listed above. Staff A was asked if any type of education had been provided to staff following the death P-1. She stated there was mandatory education scheduled for 11/20/2024 that was “in person so we can express what has happened and learn from it... Verbal education was done by (DON Staff B) but it wasn’t recorded so I can’t provide it to you... We need to get better at calling a code. The code button is at the front door. In a perfect world, someone would run up front. There is no capability of calling overhead from the back where patient care is...EMS needs a straight shot to the patient, and we need to decide who is going to do what.” When queried regarding her expectation of staff when a code occurs, she stated, “If you see someone down, start CPR immediately, well, go look at the board and then start CPR.” Staff A failed to work within her scope of practice as a non-clinical administrator, failed to ensure a system of rapid communication/notification of emergent events, and failed to provide leadership in providing a debriefing of staff, investigation of the event, identification of concerns, development of a plan to prevent a like occurrence in the future, development of education to be provided, and documented training to staff. Facility policy titled “Medical Emergencies Code Blue Management” last revised 11/2024 states, “Code blue is an emergency announced in a hospital setting in which a patient is in cardiopulmonary arrest, requiring a team of providers to begin immediate resuscitative efforts within BLS standard procedures. POLICY: The Hospital maintains the following emergency equipment: Automated External Defibrillator (AED); Oxygen; Oxygen supplies, i.e., nasal cannula, face mask, ambu bag; Suction, suction tubing, yankauer; Staff are certified in BCLS (basic cardiac life support), BLS, or ACLS (advanced cardiac life support); Staff are trained in the use of an AED. PROCEDURE: When a patient is in cardiopulmonary arrest, the patients’ (sic) code status will be confirmed via the medical record and if a FULL CODE, the Code Blue is called, and procedure will be initiated. 1. The patient will be immediately assessed for an airway, breathing, and a pulse. 2. 911 will be called by an available staff member and this staff member will wait for first responders at ambulance bay doors. 3. CPR will be initiated, and a staff member will record the code if available. 4. The crash cart will be brought to the code site. 5. The AED will be applied to the patient per manufacture (sic) recommendations (AED will give verbal prompts) 6. The Code Blue will continue until the first responders arrive and assume care of patient. 7. Report will be given to the first responders, and the emergency room. 8. Notifications will be made to the family/POA (power of attorney)/Guardian, Facility, DON, Administrator, and others as needed. 9. The crash cart will be inventoried, restocked, locked. 10. A review of the code will be completed by the Chief Medical Officer, Director of Nursing, and the Quality Director.” Facility policy titled “Pronouncement of Death” issued 4/1/2019 states, “Determination and pronouncement of death may be performed by a physician unless otherwise specified by the local state/county regulations or guidelines. NOTE: It is the Hospital’s policy that only the physician can pronounce time of death. PROCEDURE: The designated staff person may determine and pronounce a person dead when, according to ordinary standards of medical practice, there is irreversible cessation of the person’s spontaneous respiratory and circulatory functions.””

“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: 36887 Based on interview and record review, the facility failed to identify abuse and protect 1 (P-1) of 11 vulnerable patients from abuse resulting in the loss of privacy, dignity, and respect. Findings include: Review of the medical record for P-1, the patient of concern, revealed he was a 77-year-old patient who had been admitted involuntarily on 10/24/2024 for major depressive disorder, recurrent, severe with psychotic symptoms. Past medical history included atrial flutter (abnormal heart rhythm), hypertension (high blood pressure), hyperlipidemia (high fat content in the blood), schizoaffective disorder bipolar type (mental disorder), depression, anxiety, TIA (transient ischemic attack), CVA (cerebral vascular accident - stroke), atrial fibrillation (abnormal heart rhythm), orthostatic hypotension (low blood pressure that occurs from laying to sitting and/or sitting to standing), CKD stage 4 (chronic kidney disease stage 4), and peripheral neuropathy (nerve pain in extremities). He had a history of having an unsteady gait, used a walker, and a history of falls. The initial psychiatric evaluation dated 10/25/2024 noted he was alert and oriented to himself only. “Presents with restricted affect, confusion, and disorientation. Displays disorganized and tangential thought processes...Cognition is grossly impaired due to confusion; insight is limited regarding his situation.” P-1 was insistent at being naked and sitting or laying on the floor. A mat was provided for the patient to lay on. On 11/4/2024 at 1355, Confidential Informant (CI) #1 stated on 10/29/2024, a video of P-1 naked in his room had been uploaded to a social media site that was accessible to the general public. Neither the family nor law enforcement were made aware of the video. On 11/6/2024 at 1004, Certified Recreational Therapeutic Specialist (CRTS) Staff O stated on 10/29/2024 she was in her office at the end of the day getting ready to leave and she scrolled through a social media site and noticed a post was present from a colleague, Mental Health Technician (MHT) Staff T. She stated, “I immediately recognized the setting as (facility name).” The video “did not show the face or the name of the patient, but I know my patients and could have guessed who it was.” When asked who she thought it was, Staff O identified P-1. Staff O immediately took the video to the Director of Nursing (DON) Staff B. Staff B requested and obtained a copy of the video. During an interview with DON Staff B on 11/4/2024 at 1644, she stated it was “toward the end of the day” on 10/29/2024 that she was approached by CRTS Staff O who said, “I need to show you something right now.” Upon seeing the video, Staff B went to MHT Staff T’s social media page and was able to access the video. Staff B stated, “I wasn’t even friends with him on the social media site. “I instructed (Staff O) to fill out a recipient rights form, then immediately reported the video to (CEO Staff A) and owner of the facility. The owner told (Staff T) to take it down immediately and that he was suspended pending investigation.” Staff B identified the patient in the video as P-1. Staff B also stated MHT Staff T contacted her via text wanting to send her the video, which he did, and asking how serious it was. “It was pretty cut and dry. It was on his (social media) page and he admitted to doing it... He was terminated.” Staff B said Staff T told her in the text he knew who had reported him and said he was “sorry for what I’m going to have to do.” Staff B stated, “That could mean anything. I felt obligated to warn (Staff O) and HR (human resources). Staff B confirmed the report of the video upload to the social media website had not been reported to family or law enforcement. “The ORR (office of recipient rights) and (CEO Staff A) were working on that.” When queried as to if any education had been provided to staff, Staff B stated the following day (10/30/2024) there was a verbal reminder to staff regarding phone usage. “I didn’t tell staff it was abuse. Anyone working in the medical field should know that... I just said, “Hey guys, you all know you shouldn’t have your phones on the unit.’” Review of the video and text conversation from MHT Staff T to DON staff B was reviewed. The video which is 11 seconds in total goes through the footage twice. It starts out showing the backside of a naked man from mid-back down to feet, ambulating across a hard surface floor toward a bed. At the beginning of the video, the upper left corner has MHT Staff T’s name, and across the bottom third of the video there is a label that states, “Tuesday 3:53 AM”, then underneath that is a banner which states, “The crazy shit I gotta deal with tonight.” The camera then swings to the patient bathroom showing the toilet bowl full of blue paper/cloth material that had been wadded up. The view is then turned to the shower before shutting off. During interview with CEO Staff A on 11/4/2024 at 1450 she stated the video had been brought to her attention 10/29/2024 by CRTS Staff O. “Staff T was suspended immediately pending investigation.” When queried about the investigation, Staff A stated the video had been viewed by Recipient Rights Officer Staff U and human resources. No interviews were conducted of other staff that had been working the night shift on 10/29/2024 as “everyone would’ve stuck up for him.” Staff T was terminated 10/30/2024. Staff A stated family and law enforcement had been notified by the DON on 10/30/2024. On 11/6/2024 at 1021, Recipient Rights Officer Staff U stated he was new to his position as of 8/2024 and had just completed basic recipient rights training “last month.” Staff U stated he had viewed the video and determined the facility was not identified, the patient’s face had not been seen nor had the patient been identified in the video, so he had determined no abuse had occurred. Facility policy “Recognizing and Reporting Suspected Abuse/Neglect/Exploitation” last reviewed 4/2020 states, “CEO, Director of Qulaity, Director of Patient Relations, Provider or Designee are responsible for convening, reviewing and discussing available evidence and documentation and making decision if the abuse or neglect allegation is legitimate... The investigation process will take different forms depending on the nature of the incident and information received by the DON or designee...Employee/s involved in the alleged abuse or neglect will be suspended pending the conclusion of the investigation per (human resources) policy and procedure...If it is determined that the allegation of abuse or neglect is legitimate, the Human Resources Director and department manager will convene and decide on the appropriate disciplinary action. Any disciplinary actions will be implemented in accordance to (human resources) policy and procedure.” The policy fails to define the meanings of abuse, neglect and exploitation and fails to mention reporting of abuse/neglect/exploitation to law enforcement and/or other agencies when necessary.”