Capitol Park Mental Health Hospital

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 48300 Based on interview and document review, the hospital failed to ensure the patient provided written notice related to the facility’s policy regarding the decision to not implement patient DNR (do not resuscitate) advanced directives included the minimum required clear, precise, and valid statement of limitations related to this facility policy. Findings include: During an interview on 7/16/2026 at 9:55 a.m., registered nurse (RN)-A stated during the admission process the patient was notified that the facility did not follow DNR code status and expressed, “I think it’s because of suicide.” While at the facility, all patients were full code (CPR - cardiopulmonary resuscitation was used if a patient’s heart stopped beating). If a patient insisted on DNR, RN-A would inform the chief nursing officer (CNO). During an interview on 7/16/2026 at 11:19 a.m., the CNO stated during admission to the facility all patients were required to be a full code status. If a patient was adamant about remaining DNR, the facility would attempt to transfer the patient to a facility that would accept the DNR status. During an interview on 7/16/2026 3:09 p.m., the chief medical officer (CMO) stated all patients were treated as full code while admitted to the facility. According to the facility policy, a patient could not be DNR. The Conditions of Admission/Admission Consent form signed by all patients or their legal guardian included the following: “Do Not Resuscitate Order. I understand that in the event of a medical emergency, the facility will not honor a patient’s DNR, and facility staff will initiate CPR and contact 911. I understand that if I demand that my DNR be honored, my attending physician and the facility staff shall make a reasonable effort to arrange my transfer to a facility that will honor my DNR order.” This form lacked, at minimum, clarifying information between institution-wide conscience objections to the patient’s DNR status versus those that may be raised by individual physicians and/or other practitioners and lacked any identification of the State legal authority that permits such an objection, nor does the form describe the range of medical conditions or procedures that is affected by this conscience objection. The Advance Directive policy dated 9/2025 instructed, “The Facility will recognize and comply with a legally valid Advance Directive to the extent permitted under state law except as set forth in this policy below. In the event of a medical emergency, the Facility will not honor a patient’s Do Not Resuscitate order (DNR) and Facility staff will initiate CPR and contact 911. If a patient or their legal representative demands that their DNR be honored, the patient’s attending physician, and the Facility staff shall make a reasonable effort to arrange the patient’s transfer to a facility that will honor the patient’s DNR.” The policy lacked, at minimum, clarifying information between institution-wide conscience objections to the patient’s DNR status versus those that may be raised by individual physicians and/or other practitioners and lacked any identification of the State legal authority that permits such an objection, nor does the policy describe the range of medical conditions or procedures that is affected by this conscience objection. Review of the hospital’s admission packet on 7/16/2026 found patients were provided information regarding their right to formulate advance directives and the process to accomplish this. However, the admission packet lacked the Advance Directive policy or a written statement that identified a clear, precise, and valid statement that the hospital would not honor a patient’s DNR advanced directive during a medical emergency because of conscience objection and the minimum requirements.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47264 Based on interview and document review, the facility failed to prevent, investigate, and analyze abuse for 6 of 10 patients (P1, P2, P4, P5, P6, P7, and P10) reviewed when P1 assaulted P2, and P4 assaulted P5, P6, P7, and P10 over a period of several days. See A-0145 for additional information. Based on interview and document review, the facility failed to review and update the plan of care to reflect the use of restraints for 3 of 10 patients (P3, P4, P5) reviewed. See A-0166 for additional information. Based on interview and document review, the facility failed to perform a one-hour face-to-face assessment for the use of restraints for 1 of 10 patients (P4) reviewed when P4 was placed into restraints without adequate documentation. See A-0184 for additional information. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47264 Based on interview and document review, the facility failed to develop and keep current nursing care plans, within an interdisciplinary plan, in response to abuse and assessment of the patient to ensure nursing care was provided to meet the patient specific needs for 4 of 10 patients (P1, P2, P3, P4) when P1 assaulted P2, and P4 assaulted four other patients. Care plans did not address or provide interventions to prevent abuse towards other patients, protect patients from abuse, self-injurious behavior, the use of restraints or seclusion, and foreign body ingestion as applicable. See A-0395 for additional information. As a result, the hospital was found out of compliance with the Condition of Participation Nursing Services at 42 CFR 482.23.”

“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: 47264 Based on interview and document review, the facility failed to prevent, investigate, and analyze abuse for 6 of 10 patients (P1, P2, P4, P5, P6, P7, and P10) reviewed when P1 assaulted P2, and P4 assaulted P5, P6, P7, and P10 over a period of several days. Findings include: Video footage from 3/23/26 at 6:15 p.m., was reviewed on 4/29/26 at 12:34 p.m. with the director of risk. Multiple patients, including P1 and P2, registered nurse (RN)-A and behavioral health assistant (BHA)-A were seen walking in the hallway. The fire alarm lights were flashing throughout the unit as the building fire alarm had been pulled for a drill. P1 was walking towards the end of the hallway with P2 following a few feet behind him. P2 followed P1 the entire length of the hallway while gesticulating. At the end of the hallway, P1 turned around and punched P2 in the face. P2 fell to the ground. Behavioral health associate (BHA)-A immediately stepped between the patients with his arms raised as P1 continued to posture and raise his fist towards P2. Eventually P1 was redirected and walked with BHA-A down the hall. RN-A passed them and provided medical care to P2. P1’s medical record review indicated P1 was a 39-year-old male who admitted to the facility on 3/19/26 at 11:33 a.m. from community treatment facility via residential treatment staff for psychosis. P1’s relevant diagnoses included substance use disorder and schizoaffective disorder. P1 had a history of assault. P1’s intake dated 3/19/26 at 12:35 p.m. indicated P1 was admitted for treatment on a voluntary basis. A nursing assessment dated 3/19/26 at 4:21 p.m. indicated P1’s triggers included hearing voices, increased noise, and being touched. P1’s interdisciplinary treatment plan signed by a registered nurse (RN) on 3/20/26 at 5:43 a.m. indicated P1’s problems included disturbed thought processes, anxiety, and altered sleep pattern. Long and short-term goals were identified. No nursing interventions were identified. There was no further interdisciplinary treatment plans included in P1’s medical record. P1’s nursing note dated 3/22/26 at 5:53 p.m. indicated P1 was agitated and yelling at another patient. Aggression was noted. P1 needed redirection and 1:1 time with staff to deescalate. P1’s nursing note dated 3/26/26 at 2:12 p.m. indicated P1 was agitated about another patient. P1 needed oral as needed (PRN) medications to deescalate. P1’s discharge summary dated 3/27/26 indicated P1 discharged to a community treatment facility. An untitled and undated form was provided on 4/28/26 indicated P1 had punched P2 in a targeted event. P2 had been speaking with P1 repeatedly throughout the shift about personal events, and P1 had attempted to disengage by walking away. P2 had followed P1 and continued speaking to him, resulting in P1 turning around and punching P2 in the face. Staff immediately separated the patients. P1 was taken to the quiet room for further de-escalation; P2 was provided with nursing care for his injury. Video footage was reviewed. Staff present at the time of the incident were interviewed. The form stated, “Education re: situational awareness, responding to codes, verbal de-escalation,” without further explanation. A mandated report for patient physical abuse was made on 3/24/26 at 4:40 p.m. P2 was a 60-year-old male who admitted to the facility on 3/18/26 at 5:52 p.m. from an outside hospital’s emergency room (ER) via medical transport for mania. P2’s relevant diagnoses included anxiety, tremors, and alcohol use disorder. P2’s intake dated 3/18/26 at 8:27 p.m. indicated P2 was admitted for voluntary treatment. P2’s progress note dated 3/23/26 at 7:45 p.m. indicated P2 was punched on the right side of his face by P1 while walking in the hallway. Medical care was provided, and the provider and leadership were notified. P2’s progress note dated 3/23/26 at 7:46 p.m. indicated P2 was discharged to the community in a psychiatrically stable condition. An incident report form dated 3/26/26 at 6:30 p.m. indicated at approximately 6:15 p.m., P1 punched P2 on the right side of the face. First aid was provided, and PRN pain medication was offered and refused. P2 suffered a black eye and experienced pain of 8/10. The severity of the incident was classified as level 3 (levels 1 and 2 are sentinel events/comprehensive root cause analysis review and notification to corporate risk management immediately, levels 3 and 4 are internal reviews). The incident form signed and reviewed by the facility risk manager on 3/26/26. P4 was a 27-year-old female who presented to the facility on 3/19/26 at 11:33 a.m. via medical transport from an external ED for psychosis. P4’s relevant diagnoses included schizoaffective disorder, bipolar type, post-traumatic stress disorder (PTSD), and psychoactive substance dependence with withdrawal. P4 was living in the community at a managed care facility while on provisional discharge. P4’s intake form dated 3/19/26 at 12:35 p.m. indicated P4 was admitted for involuntary treatment. An order dated 3/20/266 at 4:25 p.m. indicated P4 was a high suicide risk. An order dated 3/20/26 at 4:26 p.m. indicated P4 was placed on every 15-minute observation. This order was discontinued on 3/21/26 at 2:02 p.m. An order dated 3/21/26 at 10:40 a.m. indicated P4 was placed on every 15-minute observation. This order was discontinued on 4/4/26 at 2:02 p.m. An order dated 3/22/26 at 1:31 p.m. indicated P4 was on assault precautions. P4’s psychiatric progress note dated 3/22/26 at 1:44 p.m. indicated a psychiatric emergency was declared for P4 on 3/23/26 at 1:31 p.m. due to assaultive behavior. Safety precautions were noted to be every 15-minute checks for suicide risk, and assault precautions. P4’s progress note dated 3/22/26 at 3:59 p.m. indicated P4 engaged in verbal altercations with an unnamed patient multiple times throughout the shift. Staff had to separate and deescalate the patients each time. During the second verbal altercation with the patient, P4 threw hot coffee at the patient, but hit staff instead. P4 required 1:1 de-escalation following this event. P4’s progress note dated 3/23/26 at 7:59 p.m. indicated P4 assaulted a staff member and pulled the fire alarm. An incident report form dated 3/23/26 at 5:48 p.m. indicated P4 assaulted staff when she attempted to elope from the facility. P4 struck at a staff member and then spat on them. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 3/24/26. P4’s progress note dated 3/28/26 at 1:55 p.m. indicated P4 attempted to assault an unnamed patient when she threw food and drink at them during lunch. An incident report form dated 3/28/26 at 1:20 p.m. indicated on 3/28/26 at 1:16 p.m. P4 threatened to harm another patient and threw food at them during lunch. The projectiles did not strike the patient. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 3/30/26. P4’s progress note dated 3/31/26 at 12:51 a.m. indicated on 3/30/26 at 9:10 p.m., P4 had been dysregulated and fought another unnamed patient. Staff attempted to intervene and were assaulted by P4 as well. An incident report dated 4/3/26 at 9:50 p.m. indicated P4 assaulting a staff member. A narrative explanation was not included. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 4/6/26. P4’s progress note dated 4/4/26 at 1:52 a.m. indicated on 4/3/26 at 9:15 p.m., P4 assaulted P5 by throwing water in her face. A staff member attempted to intervene, and P4 assaulted the staff by punching them in the face. P4 then returned to P5 and punched the patient multiple times in the head. A manual hold was initiated, during which P4 continued to assault staff. P4 threatened to kill P5 and the staff. P4 was placed in seclusion from 9:57 p.m. - 10:15 p.m. Then at approximately 11:00 p.m., P4 punched P10 in the face. P4 was escorted to her room by staff. P4’s progress note dated 4/4/26 at 12:56 p.m. indicated P4 assaulted staff. P4’s progress note dated 4/4/26 at 12:59 p.m. indicated the chief medical officer was contacted by the chief nursing officer and nursing staff regarding P4’s repeated assaults on staff and patients. Medications were adjusted to address these behaviors. An order dated 4/4/26 at 2:02 p.m. indicated P4 was placed on every minute observation. This order was discontinued on 4/9/26 at 8:38 a.m. An incident report form dated 4/6/26 at 26 at 11:10 a.m. indicated on 4/4/26 at approximately 11:10 a.m., P4 struck staff multiple times, resulting in a bloody nose. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 4/6/26. P4’s provider note dated 4/7/26 at 11:42 a.m. indicated P4 had assaulted multiple patients and staff over the weekend of 4/4/26, however not had any further assaultive behaviors. An order dated 4/9/26 at 8:39 a.m. indicated P4 was placed on every 15-minute observation. P4’s provider note dated 4/9/26 at 12:29 p.m. indicated P4 had continued without assaultive behaviors since the weekend of 4/4/26. As a result, observation frequency was decreased and P4 was allowed to eat off unit with the other patients. P5 was a 30-year-old female who presented to the facility on 3/18/26 at 12:39 p.m. via medical transport from an external ED for psychosis. P5’s relevant diagnoses included schizoaffective disorder, PTSD, obsessive compulsive disorder, major depressive disorder, and polysubstance abuse. P5’s intake dated 3/18/26 at 1:45 p.m. indicated P5 was admitted involuntarily. P5 had been on provisional discharge from a mentally ill and chemically dependent (MICD) commitment at the time of hospitalization. An order dated 3/18/26 at 2:05 p.m. indicated P5 was on every 15-minute observations. An incident report form dated 3/22/26 at 1:15 p.m. indicated P5 was assaulted when P4 threw hot coffee at her and staff jumped in the way. Staff separated P4 and P5, and it was not specified which patient was placed on 1:1. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 3/30/26. P5’s progress note dated 3/24/26 at 3:50 a.m. indicated P5 yelled at an unnamed patient. Staff intervened and separated the patients and sat between them. P5 then threw the deck of cards at the other patient. P5’s progress note dated 3/25/26 at 6:25 a.m. indicated P5 was verbally aggressive towards an unnamed patient. Staff intervened and separated the patients. P5’s progress note dated 3/26/26 at 22:33 indicated P5 was verbally aggressive towards an unnamed patient. Staff intervened and de-escalated the patients. When staff were not looking, P5 then went to the noisy activity room and engaged in an unspecified “fight episode” with the same unnamed patient. Staff intervened again and separated the patients. P5 was moved to a different room away from this patient. P5’s progress note dated 3/27/26 at 1:56 p.m. indicated P5 had been hit in the face the previous day when fighting with the other patient. P6 was a 49-year-old female who presented to the facility on 3/30/26 at 11:35 a.m. via medical transport from an external ED for psychosis. P6’s relevant diagnoses included schizoaffective disorder, BPPD, borderline personality disorder, anxiety, depression, and traumatic brain injury. P6’s intake dated 3/30/26 at 11:56 a.m. indicated P6 was admitted voluntarily. An order dated 3/30/26 at 1:23 p.m. indicated P6 was on every 15-minute observations. An incident report form dated 3/30/26 at 9:50 p.m. indicated at 9:10 p.m. P6 was involved in an altercation with P4. The summary of the event was deferred to the progress note within P6’s chart. Interventions by staff were identified as PRN medications, increased visual observations, verbal de-escalation, staff separating patients, and patient room changes. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 4/1/26. P6’s progress note dated 3/31/26 at 5:00 p.m. indicated on 3/30/26 at 9:10 p.m., P6 and another patient were found to be throwing food at each other. Staff intervened and separated the patients. While escorting P6 to another space, the other patient attacked P6, pulling on her hair while punching and kicking. Staff intervened and the patients were separated again. P6 was given medical attention and found to be without serious injury. The level of increased observation was not noted. A discharge summary dated 4/10/26 at 8:37 a.m. indicated P6 requested a discharge to continue care in the community. P6 was no longer exhibiting symptoms of mania and was able to contract for safety. P6 was discharged in an improved condition. P7 was 50-year-old female who presented to the facility on 4/2/26 at 1:40 p.m. via private car from the community for mania. P7’s relevant diagnoses included bipolar personality disorder with psychotic features, obsessive compulsive disorder, and anxiety. P7’s intake dated 4/2/26 at 7:29 p.m. indicated P7 was admitted voluntarily. P7 had been on a stay of commitment and living in stable housing at the time of hospitalization. An order dated 4/2/26 at 4:51 p.m. indicated P7 was on every 15-minute observations. This order was discontinued on 4/8/26 at 9:00 p.m. An incident report form dated 4/3/26 at 9:50 p.m. indicated P7 was involved in an altercation with P4. The summary of the event was deferred to the progress note within P6’s chart. Interventions by staff were identified as increasing visual observation, verbal de-escalation, and separating patients. The incident was classified as a level 3 incident. The form was reviewed by the director of risk management on 4/6/26. P7’s progress note dated 4/4/26 at 2:22 a.m. indicated on 4/3/26 at 9:15 p.m. P7 had water thrown in her face by another patient. When staff attempted to intervene, they were assaulted. The other patient then assaulted P7, striking her 3-4 times in the head. P7 was given medical treatment and PRN medications for pain medication. Family was updated per P7’s request. A discharge summary dated 4/8/26 at 12:26 p.m. indicated P7 was discharged to the community upon her request. P7 was psychiatrically stable, and outpatient services were arranged. P10 was admitted to the facility on 4/2/26 at 10:31 a.m. from the community via self for suicidality. P10’s relevant diagnoses included BPPD, PTSD, anxiety, substance abuse, and Crohn’s disease. An intake dated 4/2/26 at 11:36 a.m. indicated P10 was admitted voluntarily for treatment of suicidal ideation in the setting of substance abuse relapses. P10 had been on living independently in the community at the time of hospitalization. An order dated 4/2/26 at 2:14 p.m. indicated P10 was on every 5-minute observations. This order was discontinued on 4/3/26 at 9:27 a.m. A discharge care plan and home medication form dated 4/22/26 at 11:24 p.m. indicated P10 discharged from the facility on 4/22/26 at 11:30 a.m. to a shelter. During an interview on 4/28/26 at 10:46 a.m. RN-A stated the staff prevent abuse by completing regular 15-minute rounds and reviewing information about patients in schedule safety huddles. Safety huddles are nursing lead meetings held at regular 4-hour intervals where interdisciplinary staff discuss patient precautions and behaviors seen on the shift. If a patient is highly suicidal, they may utilize 1:1 or 5-minute visual checks. If abuse occurs, it should be documented in the medical record and then put in the safety huddles so the information can be passed to the next shift easily. Intervention for each patient is case-dependent. Patients may be labeled as needing a single-occupancy room, or they may need two staff members whenever interacting with them. If patients abuse other patients, staff will move their rooms or transfer them to a different unit. If they are transferred to a different unit, the staff are given reports and will monitor them clearly. They do occasionally try to have the patients work on conflict resolution together as it is a life skill. RN-A stated she was working the night of 3/23/26 when P1 assaulted P2. Prior to the incident, the fire alarms in the building were blinking because a patient, P4, had pulled the alarm. RN-A believes this agitated P1 because the alarms were sounding for such a long time. After the incident occurred, RN-A spoke with P1 about the reason for the incident, and he reported he was overwhelmed by P2 talking to him while the fire alarms were activated. RN-A stated after the incident, staff performed more frequent checks on P1. During an interview on 4/28/26 at 11:18 a.m., RN-B stated when patients abuse each other, they transfer the aggressing patient to a different unit or restrict them to unit-only privileges. Unit-only means they cannot go to the shared dining space for meals. Nursing will then notify social work, and they will make a behavior plan for the patient. The aggressing patient may be increased to every 5-minute monitoring if needed. During an interview on 4/28/26 at 11:47 a.m. RN-C stated abuse is prevented by staff watching patients. If staff notice one patient is harassing another, she will separate the patients and keep them distanced. If the patients continue to harass each other, she will have one of the patients transferred to another unit. RN-C stated this information is put into the safety huddles so all staff can be aware of patient behavioral issues. If patients abuse each other, nursing is to separate the patients, provide medical care, and offer PRN medications for pain or agitation. Staff must always complete an incident report for instances of abuse. During an interview on 4/28/26 at 3:33 p.m. behavioral health associate (BHA)-B stated they prevent abuse on the units by using safety huddles. During safety huddles they can review each patient’s precautions, unit restrictions, and observation frequencies. A patient who has been aggressive to others, patients or staff, are given assault precautions. Assault precautions serve as a warning to staff this patient is more dangerous. During an interview on 4/28/26 at 3:54 p.m., social worker (SW)-A stated the treatment team is notified if a patient has abused other patients via the electronic medical record. Patients who are on assault precautions are labeled with an A in their system, and clinicians note this for their own safety when engaging with the patient. SW-A stated the nursing staff also utilize safety huddles. Safety huddles are typically nurses and BHAs, but any staff may join. During an interview on 4/28/26 at 4:05 p.m., MD-A stated staff prevent abuse by monitoring the milieu and de-escalating situations with their training. Staff should be attempting de-escalation whenever possible to avoid any physical interventions. During an interview on 4/29/26 at 9:45 a.m., BHA-A stated he learns about each patient in shift hand off and safety huddles. If a patient assaulted another patient, they would typically transfer them to another unit or place them on increased observations because “if they have a behavior or punch another resident, they could punch the next patient” too. BHA-A stated he was working on the evening of 3/23/26 when P1 assaulted P2. BHA-A was walking down the halls after dinner and unlocking doors to let patients back into their rooms. Behind him, he heard P1 yell “You’re a terrorist,” at P2 and when he turned around P2 was on the ground. BHA-A separated the patients and walked P1 to a private room to help him calm down. BHA-A stated P1 had been previously threatening to beat up other patients. BHA-A stated he had been approached by P1 previously and P1 had confided he had been wanting to hit people because he was overwhelmed by the fire alarm going off overhead. BHA-A stated staff had been monitoring P1 because he had a random aggressive outburst on 3/22/26. BHA-A stated they had not received any reeducation. During an interview on 4/29/26 at 10:11 a.m. RN-D stated they ensure patients are safe from abuse by completing their regular every 15-minute rounds, or every 5-minute rounds as applicable. The rounds are typically completed by the BHAs, but any floor staff can do them. They utilize an electronic charting system on tablets, which give small symbols to indicate what kind of precautions each patient is on. Assault precautions do not result in higher observation frequency unless noted by an observation order and are used for staff awareness. RN-D stated she was present when P1 assaulted P2. She was preparing a room for admission when she walked past P2, who was following P1 and talking. Then, she heard someone yell “What the hell!” and turned around to see P2 on the ground. RN-D provided care to P2 while RN-A and BHA-A moved P1 to a different space. RN-D stated earlier in the shift on 3/23/26, P1 had been aggressive towards another patient. P1 had been “getting in someone’s face” in the day space, and staff had to intervene to de-escalate the situation. RN-D stated she did not receive any reeducation. During an interview on 4/29/26 at 10:53 a.m., the director of risk stated she reviews all incident reports written by staff. Incident reports can be classified into three four levels with one as the most severe and four as the least severe. If an incident rises to level two or one, their regional team is consulted, and they will perform a root cause analysis. If an incident is level three or four, they will have an internal review. She will review documents and camera footage, and interview staff to determine what happened. Education for internal reviews is disseminated via monthly newsletters. If the issue is necessary, they will do real-time retraining on the floor with staff. No education was provided for staff prior to the survey. The director of risk stated that when reviewing P1 and P2’s incident, they reviewed camera footage and interviewed staff. Leadership had a conversation with P1 after the incident about the rules and expectations while admitted to inpatient. The director of risk stated that when reviewing P4’s multiple incidents, there was no root cause analysis done because they were all level three incidents. During an interview on 4/29/26 at 11:13 a.m., the nurse manager stated there are safety huddles held every four hours each day starting at 3:00 a.m. During the safety huddles, staff review precautions, behaviors, safety risks, and anticipated challenges for the shift. They will also assign a staff member to watch for specific patients specific behaviors. The safety huddles are not part of the medical record, and nurses are responsible for transcribing nursing-related information on the safety huddle sheets into the medical record. During an interview on 4/29/26 at 1:55 p.m., the chief nursing officer stated they prevent abuse by using safety huddles because this is the shift-to-shift plan of care for the patients. The safety huddles are not part of the medical record. If patient’s abuse each other, the nursing staff should separate the patients and try to determine what caused the altercation. Interventions may include increasing levels of observation and transferring patients to a different unit. Night shift nurses should add information on the safety huddles sheet, including altercations, to the interdisciplinary treatment plan. However, any staff from any discipline may add information into the safety huddle and interdisciplinary treatment plan as needed. The chief nursing officer stated she did not have a clear memory of the altercation between P1 and P2. The chief nursing officer stated P4 was assaulting patients and staff because she was under the impression law enforcement would become involved and she would be able to leave the facility. After the chief nursing officer explained to her this would not occur, P4 has not assaulted anyone. An email dated 4/29/26 at 2:28 p.m. the chief executive officer indicated the facility did not have a policy guiding the creation or process for safety huddles. A facility policy titled “Precautions, Assault,” dated 5/2025 indicated if a patient is placed on assault precautions, risk of assault and interventions will be addressed in the interdisciplinary treatment plan. A facility policy titled “Abuse and Neglect” dated 9/2025 indicated that if patient-to-patient abuse occurs, the registered nurse will place the aggressing patient on every 5-minute observation or 1:1 observation. The policy indicated investigation of incidents should be reviewed by the risk manager or another designee. The procedure for investigation outlined how interviews may be conducted. A facility policy titled “Patient Rights” dated 9/2025 indicated that the patient has a right to be protected from physical, verbal, and emotional abuse and neglect while admitted to the hospital.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 47264 Based on interview and document review, the facility failed to review and update the plan of care to reflect the use of restraints for 3 of 10 patients (P3, P4, P5) reviewed. Findings Include: P3 was a 21-year-old female who was admitted to the hospital on 4/19/26 at 2:09 p.m. via medical transport for suicidality. P3’s relevant diagnoses included major depressive disorder (MDD), post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), anxiety, attention deficit hyperactivity disorder (ADHD), and an unspecified eating disorder. P3 was living in the community at a managed care facility while on commitment. An order provided in P3’s medical record was reviewed and did not include observation status orders. P3’s intake dated 4/19/26 at 3:09 p.m. indicated P3 was admitted involuntarily for suicidal ideation after multiple failed suicide attempts, including strangulation, self-injurious behavior, and attempting to run into traffic. P3’s progress note dated 4/20/26 at 2:21 p.m. indicated P3 was found in her room with her paper scrub pants tied around her neck in the private bathroom. Her face was blue with discolored lips. Medical care was provided, and the provider was updated. An order was placed for 1:1 observation and as needed (PRN) medications were administered. An incident report form dated 4/20/26 at 11:54 a.m. indicated P3 had attempted to strangle herself in the bathroom with her pants. Medical care was provided, and the provider was updated. An order was placed for 1:1 observation and PRN medications were administered. An interdisciplinary treatment plan dated 4/21/26 at 2:28 p.m. indicated P3 problems included: depressed mood without psychosis, anxiety, altered elimination related to constipation, skin integrity related to superficial wounds, altered nutrition related to heartburn, altered sleep pattern related to insomnia, altered tissue perfusion related to hypertension, and altered comfort related to acute pain and skin itchiness. Goals were identified for each problem. Nursing interventions were not identified. No further interdisciplinary treatment plan updates were provided in P3’s medical record. P3’s progress note dated 4/22/26 at 4:13 a.m. indicated P3 presented to the nursing station with a wound on her right arm. The origin of the wound was not specified. Medical care was provided. P3’s nursing note dated 4/22/26 at 6:55 p.m. indicated P3 received upsetting news from staff, walked into the bathroom, and began banging her head against the wall repeatedly. P3 was given multiple alternatives by staff and refused all options. P3 was placed into a manual hold to administer an emergency intramuscular (IM) PRN to prevent further self-harm. P3 continued 1:1 observation. Education was provided to increase fluids to address constipation. The care plan portion indicated P3’s problem with goals. P3’s seclusion/restraint packet dated 4/22/26 at 4:42 p.m. indicated P3 was placed into a physical restraint given two chemical restraints for threat of immediate harm to self. The order was obtained on 4/22/26 at 3:50 p.m. from a provider. The first chemical restraint was administered at 3:50 p.m., and when it was ineffective, a manual hold was initiated at 4:10 p.m. to prevent further harm to self. P3 continued to self-harm, scream, and bang her head, and was given a second chemical restraint at 4:29 p.m. The manual hold was discontinued at 4:29 p.m. when P3 was able to contract for safety. Less restrictive interventions attempted included 1:1 verbal de-escalation, and team support. An RN completed the face-to-face assessment. A full assessment of the patient was completed. Monitoring was completed by a registered nurse (RN) in intervals shorter than 15 minutes. No changes were made to the treatment plan; orders were to keep P3 on 1:1 observation. An incident report dated 4/27/26 at 10:00 a.m. indicated on 4/24/26 at 11:00 a.m. P3 swallowed a marker cap and was transported to the ED for further evaluation. P4 was a 27-year-old female who presented to the facility on 3/19/26 at 11:33 a.m. via medical transport from an external ED for psychosis. P4’s relevant diagnoses included schizoaffective disorder, bipolar type, post-traumatic stress disorder (PTSD), and psychoactive substance dependence with withdrawal. P4 was living in the community at a managed care facility while on provisional discharge. P4’s intake form dated 3/19/26 at 12:35 p.m. indicated P4 was admitted for involuntary treatment. P4’s initial interdisciplinary treatment plan was not included in the medical record provided. An order dated 4/3/26 at 9:37 p.m. indicated P4 was placed into physical restraints for immediate harm to others. P4’s progress note dated 4/4/26 at 1:52 a.m. indicated on 4/3/26 at 9:15 p.m., P4 assaulted P5 by throwing water in her face. A staff member attempted to intervene, and P4 assaulted the staff by punching them in the face. P4 then returned to P5 and punched the patient multiple times in the head. A manual hold was initiated, during which P4 continued to assault staff. P4 threatened to kill P5 and the staff. P4 was placed in seclusion from 9:57 p.m. - 10:15 p.m. P4’s interdisciplinary treatment plan updated dated 4/6/26 at 9:30 a.m. indicated P4 had one episode of seclusion, two episodes of physical restraint, and two episodes of chemical restraints while hospitalized. P4’s interdisciplinary treatment plan updated dated 4/16/26 at 9:30 a.m. indicated P4 had the same number of restraint and seclusion episodes as the update on 4/6/26. P4’s interdisciplinary treatment plan updated dated 4/28/26 at 9:30 a.m. indicated P4 had the same number of restraint and seclusion episodes as the update on 4/6/26. Orders from P4’s admission through 4/29/26 were reviewed and no further orders for restraint or seclusion were identified. Documentation from P4’s hospital admission was reviewed and no further documentation for restraints or seclusion was identified. P5 was a 20-year-old female who presented to the facility on 3/18/26 at 12:39 p.m. via medical transport from an external ED for psychosis. P5’s relevant diagnoses included schizoaffective disorder, PTSD, obsessive compulsive disorder, major depressive disorder, and polysubstance abuse. P5’s intake dated 3/18/26 at 1:45 p.m. indicated P5 was admitted involuntarily. P5 had been on provisional discharge from a mentally ill and chemically dependent (MICD) commitment at the time of hospitalization. P5’s progress note dated 3/25/26 at 7:41 p.m. indicated P5 was placed in a manual hold at 3:37 p.m. - 3:47 p.m. due to risk of harm to others. A seclusion/restraint packet dated 3/25/26 at 3:45 p.m. indicated P5 was placed in a physical restraint for threat of immediate harm to others. The order was obtained on 3/25/26 at 3:37 p.m. from a provider. The physical restraint was discontinued at 3:47 p.m. after P5 was able to contract for safety. Less restrictive interventions attempted including relaxation activity, PRN medication, distraction, and the comfort room. An RN completed the face-to-face assessment. A full assessment of the patient was completed. Monitoring was completed by a registered nurse (RN) in intervals shorter than 15 minutes. No additional orders were placed. P5’s interdisciplinary treatment plan update dated 3/28/26 at 9:30 a.m. indicated P5 did not have any episodes of restraint or seclusion. P5’s interdisciplinary treatment plan update dated 4/5/26 at 9:30 a.m. indicated P5 did not have any episodes of restraint or seclusion. P5’s interdisciplinary treatment plan update dated 4/10/26 at 9:30 a.m. indicated P5 did not have any episodes of restraint or seclusion. P5’s interdisciplinary treatment plan update dated 4/19/26 at 9:30 a.m. indicated P5 did not have any episodes of restraint or seclusion. P5’s interdisciplinary treatment plan update dated 4/27/26 at 9:30 a.m. indicated P5 did not have any episodes of restraint or seclusion. During an interview on 4/28/26 at 10:46 a.m., RN-A stated the only physical restraints used in the facility are physical restraints or manual holds. During an interview on 4/28/26 at 11:18 a.m., RN-B stated when using a physical restraint, they must complete a seclusion/restraint packet and upload it to the medical record. The occurrence of restraints and seclusion are not added to the treatment plan. Nursing documents in the packet, in a progress note, and a nursing note. During an interview on 4/28/26 at 4:05 p.m., the chief medical officer stated if nursing needed to add something to the treatment plan, they would discuss with the treatment team. During an interview on 4/29/26 at 1:55 p.m., the chief nursing officer stated the director of risk completes audits on the use of restraints at the facility. Any time there is a use of restraints, the incident must be reviewed. Hospital leadership must seek to eliminate the use of restraints through multiple avenues, including effective treatment planning. A facility policy titled “Restraint” dated 9/2025 indicated if restraints are used on a patient, the treatment plan shall be updated to include measures to prevent further use of restraint. The treatment plan shall be reviewed if the patient requires multiple episodes of restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 47264 Based on interview and document review, the facility failed to perform a one-hour face-to-face assessment for the use of restraints for 1 of 10 patients (P4) reviewed when P4 was placed into restraints without adequate documentation. Findings include: P4 was a 27-year-old female who presented to the facility on 3/19/26 at 11:33 a.m. via medical transport from an external ED for psychosis. P4’s relevant diagnoses included schizoaffective disorder, bipolar type, post-traumatic stress disorder (PTSD), and psychoactive substance dependence with withdrawal. P4 was living in the community at a managed care facility while on provisional discharge. P4’s intake form dated 3/19/26 at 12:35 p.m. indicated P4 was admitted for involuntary treatment. P4’s initial interdisciplinary treatment plan was not included in the medical record provided. An order dated 4/3/26 at 9:37 p.m. indicated P4 was placed into physical restraints for immediate harm to others. A progress note dated 4/4/26 at 1:52 a.m. indicated on 4/3/26 at 9:15 p.m., P4 assaulted P5 by throwing water in her face. A staff member attempted to intervene, and P4 assaulted the staff by punching them in the face. P4 then returned to P5 and punched the patient multiple times in the head. A manual hold was initiated, during which P4 continued to assault staff. P4 threatened to kill P5 and the staff. P4 was placed in seclusion from 9:57 p.m. - 10:15 p.m. P4’s interdisciplinary treatment plan updated dated 4/6/26 at 9:30 a.m. indicated P4 had one episode of seclusion, two episodes of physical restraint, and two episodes of chemical restraints while hospitalized. P4’s interdisciplinary treatment plan updated dated 4/16/26 at 9:30 a.m. indicated P4 had the same number of restraint and seclusion episodes as the update on 4/6/26. P4’s interdisciplinary treatment plan updated dated 4/28/26 at 9:30 a.m. indicated P4 had the same number of restraint and seclusion episodes as the update on 4/6/26. Orders from P4’s admission through 4/29/26 were reviewed and no other orders for restraint or seclusion were identified. Documentation from P4’s hospital admission was reviewed and no other documentation for restraints or seclusion was identified. During an interview on 4/28/26 at 10:46 a.m., RN-A stated the only physical restraints used in the facility are physical restraints or manual holds. An RN must complete an assessment of the patient within 1 hour of the use of restraint or seclusion. During an interview on 4/28/26 at 11:18 a.m., RN-B stated when using a physical restraint, they must complete a seclusion/restraint packet and upload it to the medical record. The one-hour face-to-face documentation is documented in the packet. The purpose is to determine how they can improve and avoid the use or restraints in the future. During an interview on 4/28/26 at 11:47 a.m., RN-C stated when using restraints or seclusion, the nurse must do a complete assessment on the patient. Nursing must determine if the patient is appropriate during and after restraints. During an interview on 4/29/26 at 11:13 a.m., the nursing manager stated nursing must complete as assessment of each patient placed in a physical restraint or seclusion. During an interview on 4/29/26 at 1:55 p.m., the chief nursing officer stated the director of risk completes audits on the use of restraints at the facility. Any time there is a use of restraints, the incident must be reviewed. In an email titled “packets” dated 4/29/26 at 2:00 p.m., the chief executive officer provided restraint documentation for P5 and P9. Additional restraint documentation was not provided for P4. A facility policy titled “Restraint” dated 9/2025 did not provide outlines for the documentation of face-to-face assessments.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47264 Based on interview and document review, the facility failed to develop and keep current nursing care plans, within an interdisciplinary plan, in response to abuse and assessment of the patient to ensure nursing care was provided to meet the patient specific needs for 4 of 10 patients (P1, P2, P3, P4) when P1 assaulted P2, and P4 assaulted four other patients. Care plans did not address or provide interventions to prevent abuse towards other patients, protect patients from abuse, self-injurious behavior, the use of restraints or seclusion, and foreign body ingestion as applicable. Findings include: Video footage from 3/23/26 at 6:15 p.m. was reviewed on 4/29/26 at 12:34 p.m. with the director of risk. Multiple patients, including P1 and P2, registered nurse (RN)-A and behavioral health assistant (BHA)-A were seen walking in the hallway. The fire alarm lights were flashing throughout the unit as the building fire alarm had been pulled for a drill. P1 was walking towards the end of the hallway with P2 following a few feet behind him. P2 followed P1 the entire length of the hallway while gesticulating. At the end of the hallway, P1 turned around and punched P2 in the face. P2 fell to the ground. BHA-A immediately stepped between the patients with his arms raised as P1 continued to posture and raise his fist towards P2. Eventually P1 was redirected and walked with BHA-A down the hall. RN-A passed them and provided medical care to P2. P1 was a 39-year-old male who admitted to the facility on 3/19/26 at 11:33 a.m. from community treatment facility via residential treatment staff for psychosis. P1’s relevant diagnoses included substance use disorder and schizoaffective disorder. P1’s intake dated 3/19/26 at 12:35 p.m. indicated P1 was admitted for treatment on a voluntary basis. P1’s nursing note dated 3/19/26 at 3:28 p.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns; nursing interventions were not documented. The care plan portion was left blank; nursing intervention responses were not documented. A nursing assessment dated 3/19/26 at 4:21 p.m. indicated P1’s triggers included hearing voices, increased noise, and being touched. P1’s interdisciplinary treatment plan signed by a registered nurse (RN) on 3/20/26 at 5:43 a.m. indicated P1’s problems included disturbed thought processes, anxiety, and altered sleep pattern. Long- and short-term goals were identified. No nursing interventions were identified. There was no further interdisciplinary treatment plans included in P1’s medical record. P1’s nursing note dated 3/20/26 at 12:39 a.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns. The care plan portion indicated P1 had disturbed though process with interventions for therapists; nursing interventions were not documented; nursing intervention responses were not documented. P1’s nursing note dated 3/20/26 at 5:37 p.m. indicated P1 received education on “12 hours intended to discharge.” The narrative portion indicated P1 had an uneventful shift. The care plan portion identified problems of disturbed thought processes, anxiety, and altered sleep pattern, each with goals, interdisciplinary interventions, and nursing interventions. Nursing intervention responses were not documented. P1’s nursing note dated 3/21/26 at 5:37 a.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns. The care plan portion identified problems of disturbed thought process with goals. Nursing interventions were not documented; nursing intervention responses were not documented. P1’s nursing note dated 3/21/26 at 5:07 p.m. indicated no new education on the shift. The narrative portion indicated P1 had become agitated with another patient and required 1:1 regulation time from a nurse; a PRN medication was administered. The care plan portion indicated multiple problems with goals and nursing interventions listed. P1’s nursing note dated 3/22/26 at 6:59 a.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns. The care plan portion indicated P2 had altered sleep; nursing interventions were not documented; nursing intervention responses were not documented. P1’s nursing note dated 3/22/26 at 5:53 p.m. indicated P1 was agitated and yelling at another patient. Aggression was noted. P1 needed redirection and 1:1 time with staff to deescalate. No new education was provided. The care plan portion identified problems with goals and nursing interventions. P1’s nursing note dated 3/23/26 at 6:01 a.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns. The care plan indicated P1 had disturbed thoughts; nursing interventions were not documented; nursing intervention responses were not documented. P1’s nursing note dated 3/23/26 at 4:56 p.m. indicated no new education on the shift. The narrative portion was blank. The care plan portion listed P1’s problems; nursing interventions were not documented; nursing intervention responses were not documented. P1’s nursing note dated 3/23/26 at 7:50 a.m. indicated P1 was educated on boundaries with peers. The narrative portion indicated P1 was remorseful about striking another patient. The care plan portion listed P1’s problems; nursing interventions were not documented; nursing intervention responses were not documented. P1’s nursing note dated 3/24/26 at 8:43 p.m. indicated P1 was educated on his safety plan. The narrative portion indicated P1 did not have any behavioral concerns. The care plan portion listed P1’s problems; nursing interventions were not documented; nursing intervention responses were not documented. P1’s nursing note dated 3/25/26 at 5:59 a.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns. The care plan portion listed P1’s problems; nursing interventions were not documented; nursing intervention responses were not documented. P1’s nursing note dated 3/25/26 at 8:27 p.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns. The care plan portion listed P1’s goals without problems or nursing interventions; nursing intervention responses were not documented. P1’s nursing note dated 3/26/26 at 5:29 a.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns. The care plan portion listed one of P1’s problems without nursing interventions; nursing intervention responses were not documented. P1’s nursing note dated 3/26/26 at 2:14 p.m. indicated no new education on the shift. The narrative portion indicated P1 became agitated at another patient during the shift and required PRN medication. The care plan portion indicated P1’s problems with nursing interventions noted. The PRN medication was noted to be effective. P1’s nursing note dated 3/27/26 at 6:09 a.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns. The care plan portion listed one of P1’s problems without nursing interventions documented; nursing intervention responses were not documented. P1’s discharge summary dated 3/27/26 indicated P1 discharged to a community treatment facility. P2 was a 60-year-old male who admitted to the facility on 3/18/26 at 5:52 p.m. from an outside hospital’s emergency room (ER) via medical transport for mania. P2’s relevant diagnoses included anxiety, tremors, and alcohol use disorder. P2’s intake dated 3/18/26 at 8:27 p.m. indicated P2 was admitted for voluntary treatment. P2’s nursing note dated 3/19/26 at 7:09 a.m. indicated P2 received education on multiple items. The narrative portion indicated P1 did not have any behavioral concerns. The care plan portion indicated P2 was at risk for falls and had goals listed without nursing interventions; nursing intervention responses were not documented. P2’s nursing note dated 3/19/26 at 4:25 p.m. indicated no new education on the shift. The narrative portion indicated P2 did not have any behavioral concerns. The care plan portion was blank; nursing interventions were not documented; nursing intervention responses were not documented. P2’s nursing note dated 3/20/26 at 6:14 a.m. indicated no new education on the shift. The narrative portion indicated P1 did not have any behavioral concerns. The plan of care portion included goals without nursing interventions; nursing intervention responses were not documented. P2’s nursing note dated 3/20/26 at 5:51 p.m. indicated no new education on the shift. The narrative portion indicated P2 did not have any behavioral concerns. The plan of care portion listed P2’s problems with goals and nursing interventions; nursing intervention responses were not documented. P2’s nursing note dated 3/21/26 at 5:38 a.m. indicated no new education on the shift. The narrative portion indicated P2 did not have any behavioral concerns. The plan of care portion listed P2’s problem with goals and no nursing interventions recorded; nursing intervention responses were not documented. P2’s nursing note dated 3/21/26 at 3:52 p.m. indicated no new education on the shift. The narrative portion indicated P2 had an episode of confusion and his discharge was delayed. The plan of care portion listed P2’s problems with goals and nursing interventions; nursing intervention responses were not documented. P2’s nursing note dated 3/22/26 at 6:58 a.m. indicated no new education on the shift. The narrative portion indicated P2 did not have any behavioral concerns. The plan of care portion included P2’s problem without nursing interventions listed: nursing interventions responses were not documented. P2’s nursing note dated 3/22/26 at 5:57 p.m. indicated no new education on the shift. The narrative portion indicated P2 did not have any behavioral concerns. The plan of care portion listed P2’s problems with goals and nursing interventions; nursing interventions responses were not documented. P2’s nursing note dated 3/23/26 at 6:00 a.m. indicated no new education on the shift. The narrative portion indicated P2 did not have any behavioral concerns. The plan of care portion listed P2’s problem and goals without nursing interventions; nursing intervention responses were not documented. P2’s nursing note dated 3/23/26 at 5:11 p.m. indicated no new education on the shift. The narrative portion was blank. The plan of care portion listed P2’s problem without goals or nursing interventions; nursing intervention responses were not documented. P2’s progress note dated 3/23/26 at 7:45 p.m. indicated P2 was punched on the right side of his face by P1 while walking in the hallway. Medical care was provided, and the provider and leadership were notified. P2’s progress note dated 3/23/26 at 7:46 p.m. indicated P2 was discharged to the community in a psychiatrically stable condition. P3 was a 21-year-old female who was admitted to the hospital on 4/19/26 at 2:09 p.m. via medical transport for suicidality. P3’s relevant diagnoses included major depressive disorder (MDD), post-traumatic stress disorder (PTSD), obsessive control disorder (OCD), anxiety, attention deficit hyperactivity disorder (ADHD), and an unspecified eating disorder. P3 was living in the community at a managed care facility while on commitment. Orders provided in P3’s medical record were reviewed and did not include observation status orders. P3’s intake dated 4/19/26 at 3:09 p.m. indicated P3 was admitted involuntarily for suicidal ideation after multiple failed suicide attempts, including strangulation, self-injurious behavior, and attempting to run into traffic. P3’s nursing note dated 4/20/26 at 7:33 a.m. indicated P3 was on every 5-minute observation due to continuous self-injurious behavior. P3 continuously picked at scabs on her arm with the intention to make herself bleed. Wound care was applied to the areas to prevent further self-injury. The care plan portion listed P3’s problems; goals were listed. P3’s progress note dated 4/20/26 at 2:21 p.m. indicated P3 was found in her room with her paper scrub pants tied around her neck in the private bathroom. Her face was blue with discolored lips. Medical care was provided, and the provider was updated. An order was placed for 1:1 observation and PRN medications were administered. An incident report form dated 4/20/26 at 11:54 a.m. indicated P3 had attempted to strangle herself in the bathroom with her pants. Medical care was provided, and the provider was updated. An order was placed for 1:1 observation and PRN medications were administered. P3’s progress note dated 4/20/26 at 2:24 p.m. indicated this was a late entry. The note indicated P3 had attempted to strangle herself by tying her scrub pants around her neck, resulting in her almost losing consciousness with a dark blue/purple face. P3 told staff she would not stop trying to kill herself. Medical care was provided, and the provider was updated. An order was placed for 1:1 observation and PRN medications were administered. P3’s nursing note dated 4/20/26 at 5:41 p.m. indicated P3 had exhibited self-injurious behavior during the shift and was educated to notify staff of suicidal thoughts. The narrative portion identified nursing would continue with 1:1 observation and would monitor her condition. The care plan portion included P3’s goals. An activities assessment dated 4/20/26 at 3:09 p.m. indicated P3 reported she swallowed objects as a means of coping and a means to attempt suicide. P3’s nursing note dated 4/21/26 at 1:41 p.m. indicated P3 had a plan to kill herself including hanging herself, swallowing objects, and cutting herself. The note indicated P3 exhibited self-injurious behavior and had recently cut herself on her arms. The narrative portion indicated P3 was on 1:1 observation due to high suicidality. The plan of care portion was blank. P3’s interdisciplinary treatment plan dated 4/21/26 at 2:28 p.m. indicated P3 problems included: depressed mood without psychosis, anxiety, altered elimination related to constipation, skin integrity related to superficial wounds, altered nutrition related to heartburn, altered sleep pattern related to insomnia, altered tissue perfusion related to hypertension, and altered comfort related to acute pain and skin itchiness. Goals were identified for each problem. Nursing interventions were not identified. No further interdisciplinary treatment plan updates were provided in P3’s medical record. P3’s progress note dated 4/22/26 at 4:13 a.m. indicated P3 presented to the nursing station with a wound on her right arm. The origin of the wound was not specified. Medical care was provided. P3’s nursing note dated 4/22/26 at 6:26 a.m. indicated P3 verbalized if she were not on a 1:1, she would attempt to kill herself again. The care plan portion listed P3’s problem with goals and therapist interventions. Nursing interventions were not listed; nursing interventions response was not listed. P3’s nursing note dated 4/22/26 at 6:55 p.m. indicated P3 received upsetting news from staff, walked into the bathroom, and began banging her head against the wall repeatedly. P3 was given multiple alternatives by staff and refused all options. P3 was placed into a manual hold to administer an emergency IM PRN to prevent further self-harm. P3 continued 1:1 observation. Education was provided to increase fluids to address constipation. The care plan portion indicated P3’s problem with goals. P3’s nursing note dated 4/23/26 at 6:27 a.m. indicated no new education in the shift. The narrative portion indicated P3 continued 1:1 observation without event. The plan of care portion listed P3’s problems without goals or nursing interventions; nursing intervention responses were not documented. P3’s nursing note dated 4/23/26 at 7:30 p.m. indicated no new education in the shift. The narrative portion was blank. The plan of care portion indicated P3 was depressed and anxious without any goals or nursing interventions documented; nursing intervention responses were not documented. P3’s nursing note dated 4/24/26 at 6:03 a.m. indicated P3 was educated to notify staff with any concerns. The narrative portion indicated P3 remained on 1:1 observation. The care plan portion indicated P3’s problem without goals or interventions; nursing intervention responses were not documented. An incident report dated 4/27/26 at 10:00 a.m. indicated on 4/24/26 at 11:00 a.m. P3 swallowed a marker cap and was transported to the ED for further evaluation. P4 was a 27-year-old female who presented to the facility on 3/19/26 at 11:33 a.m. via medical transport from an external ED for psychosis. P4’s relevant diagnoses included schizoaffective disorder, bipolar type, post-traumatic stress disorder (PTSD), and psychoactive substance dependence with withdrawal. P4 was living in the community at a managed care facility while on provisional discharge. P4’s intake form dated 3/19/26 at 12:35 p.m. indicated P4 was admitted for involuntary treatment. P4’s nursing note dated 3/20/26 at 5:23 a.m. indicated no new education in the shift. The narrative portion indicated P4 was isolated and withdrawn. The care plan portion was blank; nursing interventions were not documented; nursing intervention responses were not documented. An order dated 3/20/266 at 4:25 p.m. indicated P4 was a high suicide risk. An order dated 3/20/26 at 4:26 p.m. indicated P4 was placed on every 5-minute observations. This order was discontinued on 3/21/26 at 2:02 p.m. An order dated 3/21/26 at 10:40 a.m. indicated P4 was placed on every 15-minute observation. This order was discontinued on 4/4/26 at 2:02 p.m. P4’s nursing note dated 3/21/26 at 11:36 a.m. indicated no new education in the shift. The narrative portion indicated P4 believed she was pregnant. The care plan portion was blank; nursing interventions were not documented; nursing intervention responses were not documented. P4’s nursing note dated 3/22/26 at 6:38 a.m. indicated P4 was educated to request PRN medication as needed. The narrative portion indicated P4 was hyperverbal. The care plan portion indicated one of P4’s problems without goals; nursing interventions were not documented; nursing intervention responses were not documented. P4’s nursing note dated 3/22/26 at 10:17 a.m. indicated P4 was educated on menstrual hygiene due to her bleeding on furniture. P4 was noted to be agitated, yelling/screaming, oppositional, and labile. Aggression was noted to be present with P4 threatening to “beat a bitch.” The care plan portion was blank; nursing interventions were not documented; nursing intervention responses were not documented. An order dated 3/22/26 at 1:31 p.m. indicated P4 was on assault precautions. P4’s psychiatric progress note dated 3/22/26 at 1:44 p.m. indicated a psychiatric emergency was declared for P4 on 3/23/26 at 1:31 p.m. due to assaultive behavior. Safety precautions were noted to be every 15-minute checks for suicide risk, and assault precautions. P4’s progress note dated 3/22/26 at 3:59 p.m. indicated P4 engaged in verbal altercations with an unnamed patient multiple times throughout the shift. Staff had to separate and deescalate the patients each time. During the second verbal altercation with a patient, P4 threw hot coffee at the patient, but hit staff instead. P4 required 1:1 de-escalation following this event. P4’s nursing note dated 3/22/26 at 7:16 a.m. indicated P4’s education was “angry, uncooperative.” P4 was noted to be agitated and had angry outbursts. The care plan portion indicated one of P4’s problems without goals.; nursing interventions were not documented; nursing intervention responses were not documented. P4’s nursing note dated 3/23/26 at 1:02 p.m. indicated no new education in the shift. P4 was yelling/screaming and was exhibiting physical aggression. The narrative portion indicated was seen pacing and verbally aggressive with staff. P4 spit on staff and went to the quiet room to deescalate. The care plan portion was blank; nursing interventions were not documented; nursing intervention responses were not documented. An incident report form dated 3/23/26 at 5:48 p.m. indicated P4 assaulted staff when she attempted to elope from the facility. P4 struck at a staff member and then spat on them. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 3/24/26. P4’s nursing note dated 3/24/26 at 5:49 a.m. indicated no new education in the shift. The narrative portion indicated P4 attempted to elope from the facility. The care plan portion included P4’s problems and goals; nursing interventions were not documented; nursing intervention responses were not documented. P4’s nursing note dated 3/24/26 at 6:57 p.m. indicated no new education in the shift. The narrative portion indicated P4 had threatened to assault a patient. The care plan portion indicated P4’s problems with goals and interventions. An incident report form dated 3/28/26 at 1:20 p.m. indicated on 3/28/26 at 1:16 p.m. P4 threatened to harm another patient and threw food at them during lunch. The projectiles did not strike the patient. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 3/30/26. P4’s nursing note dated 3/28/26 at 1:55 p.m. indicated no new education in the shift. The narrative portion indicated P4 attempted to assault an unnamed patient when she threw food and drink at them during lunch. P4’s mood was documented as appropriate. The care plan portion indicated P4’s problems with goals; nursing interventions were not documented; nursing intervention responses were not documented. P4’s initial interdisciplinary treatment plan was not included in the medical record provided. P4’s interdisciplinary treatment plan updated dated 3/30/26 at 8:35 a.m. indicated P4’s problems included: disturbed thought process, anxiety, tobacco use, altered sleep pattern related to difficulty falling asleep, and ineffective airway management related to chronic cough. Each problem was accompanied by goals for P4. The comment portion indicated P4 had not been aggressive on the shift and required frequent monitoring to redirect her negative behaviors. Nursing interventions were not identified. P4’s nursing note dated 3/31/26 at 5:27 a.m. indicated no new education in the shift. The narrative portion indicated P4 assaulted another patient. Aggression was documented as present with punching, kicking, and throwing drinks at another patient. The care plan portion identified problems without goals; nursing interventions were not documented; nursing intervention responses were not documented. P4’s progress note dated 3/31/26 at 12:51 a.m. indicated on 3/30/26 at 9:10 p.m., P4 had been dysregulated and fought another unnamed patient. Staff attempted to intervene and were assaulted by P4 as well. P4’s progress note dated 4/4/26 at 1:52 a.m. indicated on 4/3/26 at 9:15 p.m., P4 assaulted P5 by throwing water in her face. A staff member attempted to intervene, and P4 assaulted the staff by punching them in the face. P4 then returned to P5 and punched the patient multiple times in the head. A manual hold was initiated, during which P4 continued to assault staff. P4 threatened to kill P5 and the staff. P4 was placed in seclusion from 9:57 p.m. - 10:15 p.m. Then at approximately 11:00 p.m., P4 punched P10 in the face. P4 was escorted to her room by staff. P4’s progress note dated 4/4/26 at 12:56 p.m. indicated P4 assaulted staff. P4’s progress note dated 4/4/26 at 12:59 p.m. indicated the chief medical officer was contacted by the chief nursing officer and nursing staff regarding P4’s repeated assaults on staff and patients. Medications were altered to address these behaviors. An order dated 4/4/26 at 2:02 p.m. indicated P4 was placed on every 5-minute observation. This order was discontinued on 4/9/26 at 8:38 a.m. P4’s interdisciplinary treatment plan updated dated 4/6/26 at 9:30 a.m. indicated P4’s problems included: disturbed thought process, anxiety, tobacco use, altered sleep pattern related to difficulty falling asleep, and ineffective airway management related to chronic cough. Each problem was accompanied by goals for P4. Nursing interventions were not identified. Nursing comments indicated P4 had assaulted another patient. P4 was not identified as an elopement risk. P4’s nursing note dated 4/4/26 at 4:46 p.m. indicated no new education in the shift. The narrative portion was blank. Assaultive behavior was present as P4 assaulted staff and threatened to continue doing so. P4 was noted to be impulsive, yelling/screaming, aggressive, and angry. The care plan portion identified P4’s problems without goals; nursing interventions were not documented; nursing intervention responses were not documented. P4’s nursing note dated 4/5/26 at 6:16 a.m. indicated P4 was educated on requesting PRN medications. The narrative portion indicated the chief nursing officer interviewed P4, who agreed to stop assaulting people. The care plan portion indicated P4’s problem and goals. P4’s provider note dated 4/7/26 at 11:42 a.m. indicated P4 had assaulted multiple patients and staff over the weekend of 4/4/26, however not had any further assaultive behaviors. An order dated 4/9/26 at 8:39 a.m. indicated P4 was placed on every 15-minute observation. P4’s provider note dated 4/9/26 at 12:29 p.m. indicated P4 had continued without assaultive behaviors since the weekend of 4/4/26. As a result, observation frequency was decreased and P4 was allowed to eat off unit with the other patients. P4’s interdisciplinary treatment plan updated dated 4/16/26 at 9:30 a.m. indicated P4’s problems included: disturbed thought process, anxiety, tobacco use, altered sleep pattern related to difficulty falling asleep, and ineffective airway management related to chronic cough. Each problem was accompanied by goals for P4. Nursing interventions were not identified. P4’s interdisciplinary treatment plan updated dated 4/28/26 at 9:30 a.m. indicated P4’s problems included: disturbed thought process, anxiety, tobacco use, altered sleep pattern related to difficulty falling asleep, and ineffective airway management related to chronic cough. Each problem was accompanied by goals for P4. Nursing interventions were not identified. Social services commented P4 tended to be aggressive with staff and other patients. P5 was a 20-year-old female who presented to the facility on 3/18/26 at 12:39 p.m. via medical transport from an external ED for psychosis. P5’s relevant diagnoses included schizoaffective disorder, PTSD, obsessive compulsive disorder, major depressive disorder, and polysubstance abuse. P5’s intake dated 3/18/26 at 1:45 p.m. indicated P5 was admitted involuntarily. P5 had been on provisional discharge from a mentally ill and chemically dependent (MICD) commitment at the time of hospitalization. An order dated 3/18/26 at 2:05 p.m. indicated P5 was on every 15-minute observations. An incident report form dated 3/22/26 at 1:15 p.m. indicated P5 was assaulted when P4 threw hot coffee at her and staff jumped in the way. Staff separated P4 and P5, and it was not specified which patient was placed on 1:1. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 3/30/26. P5’s progress note dated 3/24/26 at 3:50 a.m. indicated P5 yelled at an unnamed patient. Staff intervened and separated the patients and sat between them. P5 then threw the deck of cards at the other patient. P5’s progress note dated 3/25/26 at 6:25 a.m. indicated P5 was verbally aggressive towards an unnamed patient. Staff intervened and separated the patients. P5’s progress note dated 3/26/26 at 22:33 indicated P5 was verbally aggressive towards an unnamed patient. Staff intervened and deescalated the patients. When staff were not looking, P5 then went to the noisy activity room and engaged in an unspecified “fight episode” with the same unnamed patient. Staff intervened again and separated the patients. P5 was moved to a different room away from this patient. P5’s progress note dated 3/27/26 at 1:56 p.m. indicated P5 had been hit in the face the previous day when fighting with the other patient. P5’s initial interdisciplinary treatment plan was not provided in the medical record. P5’s interdisciplinary treatment plan update dated 3/28/26 at 9:30 a.m. indicated P5’s problems included disturbed through process, altered elimination related to diarrhea, impaired metabolism related to diabetes, altered sleep pattern related to insomnia, altered nutrition related to dyspepsia, impaired skin integrity related to dry skin, altered comfort related to extrapyramidal side effects, and altered tissue perfusions related to hypertension. Each problem included multiple goals. The comments portion did not indicate P5 has been abused by another patient while hospitalized. The comments portion indicated P5 was inappropriate with peers and staff and not easily redirected. Nursing interventions were not documented. P5’s interdisciplinary treatment plan update dated 4/5/26 at 9:30 a.m. indicated P5’s problems included disturbed through process, altered elimination related to diarrhea, impaired metabolism related to diabetes, altered sleep pattern related to insomnia, altered nutrition related to dyspepsia, impaired skin integrity related to dry skin, altered comfort related to extrapyramidal side effects, and altered tissue perfusions related to hypertension. Each problem included multiple goals. The comments portion did not indicate P5 has been abused by another patient while hospitalized. The comments portion indicated P5 continued to be verbally aggressive with peers. Nursing interventions were noted to be PRN medication for agitation. P5’s interdisciplinary treatment plan update dated 4/10/26 at 9:30 a.m. indicated P5’s problems included disturbed through process, altered elimination related to diarrhea, impaired metabolism related to diabetes, altered sleep pattern related to insomnia, altered nutrition related to dyspepsia, impaired skin integrity related to dry skin, altered comfort related to extrapyramidal side effects, and altered tissue perfusions related to hypertension. Each problem included multiple goals. The comments portion did not indicate P5 has been abused by another patient while hospitalized. The comments portion indicated P5 continued to have angry outbursts towards peers and required redirection and PRN medications. P5’s interdisciplinary treatment plan update dated 4/19/26 at 9:30 a.m. indicated P5’s problems included disturbed through process, altered elimination related to diarrhea, impaired metabolism related to diabetes, altered sleep pattern related to insomnia, altered nutrition related to dyspepsia, impaired skin integrity related to dry skin, altered comfort related to extrapyramidal side effects, and altered tissue perfusions related to hypertension. Each problem included multiple goals. The comments portion did not indicate P5 has been abused by another patient while hospitalized. Nursing interventions were not documented. P5’s interdisciplinary treatment plan update dated 4/27/26 at 9:30 a.m. indicated P5’s problems included disturbed through process, altered elimination related to diarrhea, impaired metabolism related to diabetes, altered sleep pattern related to insomnia, altered nutrition related to dyspepsia, impaired skin integrity related to dry skin, altered comfort related to extrapyramidal side effects, and altered tissue perfusions related to hypertension. Each problem included multiple goals. The comments portion did not indicate P5 has been abused by another patient while hospitalized. The comments portion indicated P5 “socialized more, no outbursts.” Nursing interventions were not documented. P6 was a 49-year-old female who presented to the facility on 3/30/26 at 11:35 a.m. via medical transport from an external ED for psychosis. P6’s relevant diagnoses included schizoaffective disorder, BPPD, borderline personality disorder, anxiety, depression, and traumatic brain injury. P6’s intake dated 3/30/26 at 11:56 a.m. indicated P6 was admitted voluntarily. An order dated 3/30/26 at 1:23 p.m. indicated P6 was on every 15-minute observations. P6’s nursing note dated 3/30/26 at 7:14 p.m. indicated no new education in the shift. P6 was noted to be manic and anxious. The narrative portion indicated “work on boundaries.” The care plan portion was blank; nursing interventions were not documented; nursing interventions responses were not documented. An incident report form dated 3/30/26 at 9:50 p.m. indicated at 9:10 p.m. P6 was involved in an altercation with P4. The summary of the event was deferred to the progress note within P6’s chart. Interventions by staff were identified as PRN medications, increased visual observations, verbal de-escalation, staff separating patients, and patient room changes. The incident was classified as a level 3 incident. The director of risk reviewed the incident on 4/1/26. P6’s progress note dated 3/31/26 at 5:00 a.m. indicated on 3/30/26 at 9:10 p.m., P6 and another patient were found to be throwing food at each other. Staff intervened and separated the patients. While escorting P6 to another space, the other patient attacked P6, pulling on her hair while punching and kicking. Staff intervened and the patients were separated again. P6 was given medical attention and found to be without serious injury. The level of increased observation was not noted. P6’s nursing note dated 3/31/26 at 5:29 a.m. indicated no new education in the shift. P6 was noted to be manic and anxious. The narrative portion indicated P6 was verbally aggressive. The care plan portion indicated P6’s multiple problems; nursing interventions were not documented; nursing interventions responses were not documented. P6’s interdisciplinary treatment plan dated 4/1/26 at 8:32 a.m. indicated P6’s problems included depressed mood with psychosis, anxiety, altered sleep pattern, and altered comfort related to chronic pain. Each problem included multiple goals. The comments portion did not indicate P6 had been abused by another patient while hospitalized. Nursing interventions were not documented. P6’s updated interdisciplinary treatment plans were not provided in the medical record. A discharge summary dated 4/10/26 at 8:37 a.m. indicated P6 requested a discharge to continue care in the community. P6 was no longer exhibiting symptoms of mania and was able to contract for safety. P6 was discharged in an improved condition. P7 was 50-year-old female who presented to the facility on 4/2/26 at 1:40 p.m. via private car from the community for mania. P7’s relevant diagnoses included bipolar personality disorder with psychotic features, obsessive compulsive disorder, and anxiety. P7’s intake dated 4/2/26 at 7:29 p.m. indicated P7 was admitted voluntarily. P7 had been on a stay of commitment and living in stable housing at the time of hospitalization. An order dated 4/2/26 at 4:51 p.m. indicated P7 was on every 15-minute observations. This order was discontinued on 4/8/26 at 9:00 p.m. An incident report form dated 4/3/26 at 9:50 p.m. indicated P7 was involved in an altercation with P4. The summary of the event was deferred to the progress note within P6’s chart. Interventions by staff were identified as increasing visual observation, verbal de-escalation, and separating patients. The incident was classified as a level 3 incident. The form was reviewed by the director of risk management on 4/6/26. P7’s progress note dated 4/4/326 at 2:22 a.m. indicated on 4/3/26 at 9:15 p.m. P7 had water thrown in her face by another patient. When staff attempted to intervene, they were assaulted. The other patient then assaulted P7, striking her 3-4 times in the head. P7 was given medical treatment and PRN medications for pain medication. Family was updated per P7’s request. A discharge summary dated 4/8/26 at 12:26 p.m. indicated P7 was discharged to the community upon her request. P7 was psychiatrically stable, and outpatient services were arranged. P7’s interdisciplinary treatment plan was not provided in the medical record. P10 was admitted to the facility on 4/2/26 at 10:31 a.m. from the community via self for suicidality. P10’s relevant diagnoses included BPPD, PTSD, anxiety, substance abuse, and Crohn’s disease. An intake dated 4/2/26 at 11:36 a.m. indicated P10 was admitted voluntarily for treatment of suicidal ideation in the setting of substance abuse relapses. P10 had been on living independently in the community at the time of hospitalization. An order dated 4/2/26 at 2:14 p.m. indicated P10 was on every 5-minute observations. This order was discontinued on 4/3/26 at 9:27 a.m. P10’s initial interdisciplinary treatment plan was not provided in the medical record. P10’s interdisciplinary team updated dated 4/12/16 at 9:30 a.m. indicated P10’s problems included depressed mood with psychosis, anxiety, altered comfort as evidence by a history of gastric esophageal reflux disease, ineffective airway management related to asthma, altered tissue perfusion related to chronic heart failure, altered sleep pattern related to insomnia, tobacco use, risk for injury, and altered nutrition related to nausea. Each problem included multiple goals. The comments portion did not indicate P10 has been abused by another patient while hospitalized. Nursing interventions were not documented. indicated P10’s problems included depressed mood with psychosis, anxiety, altered comfort as evidence by a history of gastric esophageal reflux disease, ineffective airway management related to asthma, tobacco use, risk for injury, and altered nutrition related to nausea. Each problem included multiple goals. The comments portion did not indicate P10 has been abused by another patient while hospitalized. Nursing interventions were not documented. P10’s interdisciplinary team plan updated dated 4/20/26 at 9:30 a.m. indicated P10’s problems included depressed mood with psychosis, anxiety, altered comfort as evidence by a history of gastric esophageal reflux disease, ineffective airway management related to asthma, altered tissue perfusion related to chronic heart failure, altered sleep pattern related to insomnia, tobacco use, risk for injury, and altered nutrition related to nausea. Each problem included multiple goals. The comments portion did not indicated P10 has been abused by another patient while hospitalized. Nursing interventions were not documented. A discharge care plan and home medication form dated 4/22/26 at 11:24 p.m. indicated P10 discharged from the facility on 4/22/26 at 11:30 a.m. to a shelter. During an interview on 4/28/26 at 10:46 a.m., registered nurse (RN) - A stated the nursing care plan is held within the interdisciplinary care plan. These plans are not updated daily. However, she charts on what she is doing for each patient daily in nursing notes and progress noted. During an interview on 4/28/26 at 11:18 a.m., RN-B stated the interdisciplinary treatment plan is created by the providers and social workers. Nursing adds the medications. Interventions are not listed in the interdisciplinary treatment plan. During an interview on 4/28/26 at 11:47 a.m., RN-C stated nursing contributes to the interdisciplinary treatment plan by adding medications. Nursing staff also help make goals for the patient. During an interview on 4/28/26 at 3:33 p.m., behavioral health assistant (BHA)-B stated she knows what interventions to do for patient’s based on the information she receives in verbal report and safety huddle. Safety huddle is used to discuss who is on assault precautions and what specific de-escalation tactics work well for the patient. While on the unit, she references her tablet to see who is on specific precautions. During an interview on 4/28/29 at 6:54 p.m., social worker (SW)-A stated interdisciplinary treatment plans are created and updated weekly by the treatment team. Each discipline is responsible for entering patient-specific interventions in the interventions section. The nursing interventions should be divided out and will identify what nursing intervention is expected for the patient. These nursing interventions are determined by whichever nurse is present during the daily treatment team meeting. This is decided by nursing staff and assigned to nurses on the board each morning. During an interview on 4/28/26 at 4:05 p.m., the chief medical officer (CMO) stated that interdisciplinary treatment team occurs every day in the morning. The treatment plan is discussed with the patient, and changes as the patient’s needs change. If there was an emergency where a patient’s treatment plan needed to be updated due to behaviors, nursing staff can call the providers and discuss adding it to the treatment plan. During an interview on 4/29/26 at 9:45 a.m., BHA-A stated he knows which patients are assaultive based on the information discussed in verbal shift hand-off. BHA-A stated the tablets are used for monitoring patients while doing observation assignments like every 15 minute and every 5-minute checks. During an interview on 4/29/26 at 10:11 a.m., RN-D stated she provides patient-specific care based on information she receives in hand-off. Once the patients have been admitted to the hospital long enough, staff begin to know their triggers and when something is wrong. Nursing interventions are documented in the initial and updated interdisciplinary treatment plans. For each problem identified, there should be goals, outcomes, and interventions identified. Changes to the treatment plan can be made by reaching out to the social worker or provider. Depending on what the change is, nursing may be able to make alterations as well. During an interview on 4/29/26 at 11:13 a.m., the nursing manager stated nursing interventions are documented in the nursing notes. Any changes to the interdisciplinary treatment plan would be reflected in the weekly interdisciplinary treatment plan update. Safety huddles are used every four hours to communicate patient needs to staff on shift. This would include precautions, behaviors, and anticipated challenges for the shift. A specific staff person would be assigned to observe each behavior, and there are specific instructions on how to address these behaviors. The information on the safety huddle sheets is not part of the medical record. Nursing staff are responsible for putting any nursing interventions listed on the sheets into the medical record. Any other information on the safety huddle sheet is transcribed into the medical record by social work. During an interview on 4/29/26 at 1:55 p.m., the CNO stated nursing is responsible for creating their interventions. If there was an incident with new behaviors, nursing should add a new problem or precautions to the treatment plan. This includes any incidents in the milieu, such as punching walls, or altercations. Nursing documents nursing interventions in nursing notes every shift. Not every intervention will be documented in the nursing note. The purpose of the interdisciplinary treatment plan updates is to document the progress a patient is making towards their goals. Information on the safety huddle sheets should be added to the interdisciplinary treatment plan by the night shift nurses, however any staff including social work of day shift nurses may as well. A facility policy titled “Observations, Patient” dated 4/2026 indicated if a patient is placed on 1:1, this information will be included in the interdisciplinary treatment plan. A facility policy titled “Precautions, Assault” dated 5/2026 indicated if a patient is placed on assault precautions, the information will be included in the interdisciplinary treatment plan. A facility policy titled “Treatment Planning” dated 9/2025 indicated nursing staff is responsible for developing the initial treatment plan within 8 hours of admission. The minimum contents of the interdisciplinary treatment plan should identify interventions to assist a patient in achieving their goals. The interventions must, as follows: i. Interventions shall identify the type, focus and frequency of treatment. ii. Interventions shall be individualized and specific to the patient involved. iii. Interventions shall address physical and functional factors, psychosocial factors, patient/family education, and patient discharge planning. A facility policy titled “Restraint” dated 9/2025 indicated if restraints are used on a patient, the treatment plan shall be updated to include measures to prevent further use of restraint. The treatment plan shall be reviewed if the patient requires multiple episodes of restraint. A facility policy titled “Patient Rights” dated 9/2025 indicated that the patient has a right to be protected from physical, verbal, and emotional abuse and neglect while admitted to the hospital.”